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Alternative technique of intubation retromolar, retrograde, submental and other technique
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Alternative technique of intubation retromolar, retrograde, submental and other technique



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  • 1. Alternative Technique OfIntubation Retromolar, Retrograde, Submental And Other Technique Under the Guidance Assistant Prof (Dr.) Adokshak Joshi Presented by Dr. Munesh Kumar Meena
  • 2. Fundamental of AirwayA. Difficult Airway : Clinical situation in which a conventionally trained anaesthesiologist experiences difficulty with mask ventilation, difficulty with tracheal intubation or both.B. Difficult mask ventilation: It occur when it is not possible for the unassisted anaesthesiologist to maintain oxygen saturation > 90% using 100% of oxygen and positive pressure mask ventilationC. Difficult Laryngoscopy: It occur when it is not possible to visualize any portion of the vocal cords with conventional laryngoscopy.D. Difficult Endotracheal intubation : It occur when proper insertion of tracheal tube with conventional laryngoscopy requires >3 attempts or >10 minutes.
  • 3. Anatomy of LarynxIt extend from the laryngeal inlet (C3-C4 in adults) to lowerborder of cricoid cartilage (c6 in adults). It moves vertically andanteroposterorly during swallowing and phonation. Larynxinclude cartilages, paired cartilage include arytenoidscorniculates and the cuneiforms and unpaired cartilageincludes thyroid, cricoid and epiglottisAccording to Sappey the average measurements of the adultlarynx are as follows: In males In females.Length 44 mm. 36 mm.Transverse diameter 43 mm. 41 mm.Antero-posterior diameter 36 mm. 26 mm.Circumference 136 mm. 112 mm
  • 4. Muscles.—The muscles of the larynx are extrinsic, passing betweenthe larynx and parts around these have been described in the sectionon Myology; and intrinsic, confined entirely to the larynx. Theintrinsic muscles are:Cricothyreoideus. Cricoarytænoideus lateralis.Cricoarytænoideus posterior. Arytænoideus. Thyroarytænoideus.
  • 5. Vessels and Nerves : The chief arteries of the larynx are thelaryngeal branches derived from the superior and inferior thyroid.The veins accompany the arteries; those accompanying thesuperior laryngeal artery join the superior thyroid vein whichopens into the internal jugular vein; while those accompanying theinferior laryngeal artery join the inferior thyroid vein which opensinto the innominate vein. The lymphatic vessels consist of twosets, superior and inferior. The former accompany the superiorlaryngeal artery and pierce the hyothyroid membrane, to end inthe glands situated near the bifurcation of the common carotidartery. Of the latter, some pass through the middle cricothyroidligament and open into a gland lying in front of that ligament or infront of the upper part of the trachea, while others pass to thedeep cervical glands and to the glands accompanying the inferiorthyroid artery.
  • 6. The nerves are derived from the internal and external branches ofthe superior laryngeal nerve, from the recurrent nerve, and fromthe sympathetic. The internal laryngeal branch is almost entirelysensory, but some motor filaments are said to be carried by it tothe Arytænoideus. It enters the larynx by piercing the posteriorpart of the hyothyroid membrane above the superior laryngealvessels, and divides into a branch which is distributed to bothsurfaces of the epiglottis, a second to the aryepiglottic fold, and athird, the largest, which supplies the mucous membrane over theback of the larynx and communicates with the recurrent nerve.The external laryngeal branch supplies the Cricothyreoideus.
  • 7. The recurrent nerve passes upward beneath the lowerborder of the Constrictor pharyngis inferior immediatelybehind the cricothyroid joint. It supplies all the musclesof the larynx except the Cricothyreoideus, and perhaps apart of the Arytænoideus. The sensory branches of thelaryngeal nerves form subepithelial plexuses, from whichfibers pass to end between the cells covering the mucousmembrane.
  • 8. Evaluation of the difficult laryngoscopy &Tracheal intubationAssessment of cervical atlanto occipital joint – Larygoscopyview becomes easier when the neck is flexed on the chest by25-35° and a-o joint is well extened (85°). Assess the firstmovement by asking the patient to touch his manubriumsternil with his chin. This assure neck flexion of 25-30°.Following this ask the patient to look at the ceiling withoutraising eyebrows to test a-o joint function.Reduction of a-o extensioni.No reductionii.1/3rd reductioniii.2/3rd reductioniv.Complete reduction
  • 9. 2/3rd or complete reduction of extesion at a-o joint is a clear pointerto difficult rigid laryngoscopy.Delilkan’s test: In this test patient is asked to look straight ahead.The head is held in the neutral position. The index finger of the lefthand of the clinician is placed under the tip of the jaw while theindex finger of the right hand is placed on the patient’s occipitaltuberosity. Patient is now asked to look at the ceiling. If the leftindex finger becomes higher than right, extension which considerednormal. If the left index finger is remains at the same level of theright or lower, extension is abnormal.In Diabetic Patient: Long term juvenile diabetes patients presentwith laryngoscopic difficulty due to “stiff joint syndrome”. In thispatient have difficulty approximating their palms and can not bendtheir finger backwards. If present, it should alert the laryngoscopyto the possibility of cervical spine involvement and limited a-omovement leading to difficult laryngoscopy and intubation.
  • 10. Assessment of termpromandibular joint (TMJ) function: Rotation ofthe condyle in the synovial cavity and forward displacement ofcondyle. The former is responsible for 2-3 cm mouth opening andthe latter for a further responsible for 2-3 cm mouth opening.Assessment of the mandibular space:Thyromental distance: >6.5cm no problem with laryngoscopy andintubation. 6-6.5cm difficulty in laryngoscopy and intubation butpossible. <6cm laryngoscopy may be impossible.Hyomental distance : Grade I - > 6cm Grade II - 4.0 – 6.0 cm Grade III - <4 cm.Grade III hyomental distance is usually associated with impossibleto laryngoscopy and intubation
  • 11. Assessment of Oropharynx for Laryngoscopy and Intubation:Mallampati Grading :Grade I - Faucial pillars, uvula, soft and hardpalate visible.Grade II - Uvula, Soft and hard palate visible.Grade III - Base of uvula or none, soft and hard palate visible.Grade IV - Only hard palate visible In Grade III and IV difficult laryngoscopy and intubation
  • 12. Indication of the Retrograde Intubation:1. Facial Anomalies a. Maxillary hypoplasia (Apert syndrome, Crouzon disease) b. Mandibular hypoplasia (Pierre Robin syndroem, Treacher Collins syndrome, Goldenhar syndrome) c. Mandibular hyperplasia (acrmegaly, cherubism)2. Temporomandibular joint pathology : Ankylosis or reduced movment(congenital traumatic, infective)3. Anomalies of the mouth and tongue: a. Microstomia (burns, trauma scarring) b. Diseases of the tongue (burns, trauma, Ludwig, angina) all lead to tongue swelling c. Tumors of the mouth and tongue (hemangioma, lymphangioma) d. Macroglossia (Down syndrome, hypothyroidism)4.Problem with teeth (missing left upper incisors, protruding upper incisors)5.Anomaly/pathology of the nose a. Choanal atresia b. Hypertrophic tubinates and deviated nasal septum
  • 13. Contraindication of retrograde intubationAbsolute : inability to open mouth and easily performed orotrachealintubation.Relative contraindication: Systemic coagulopathy, infection in theskin overlying the cricothyroid membrane.Complication of retrograde intubation: tracheal laceration,infection, mediastinitis. Injury to the larynx and vocal apparatus,recurrent laryngeal nerve injury may be occur.
  • 15. TECHNIQUE OF RETROGRADE INTUBATION• Retrograde intubation involves the passage of a malleable wire through a needle (Seldinger technique)• Indicated in the “can’t intubate, can oxygenate” scenario• Introduction of a needle at a 45 degree angle cephaladly through the cricothyroid membrane in to the trachea• Passage of wire through needle (Seldinger technique) in to the pharynx• Retrieval of malleable wire from posterior pharynx with forceps• Securing both ends of the wire
  • 16. TECHNIQUE OF RETROGRADE INTUBATION• Thread the wire through the Murphy eye (outside to inside)• Pass the appropriate sized endotracheal tube in to the airway guided by the wire• When the distal end of the ET tube meets resistance at the level of the cricothyroid membrane (against the wire), cut wire at puncture site, advance ET tube and remove remaining wire through tube
  • 17. TECHNIQUE OF RETROGRADE INTUBATIONSecure endotracheal tube and monitor end tidal carbon dioxideMaxillo facial surgeryDental SurgeryPlastic Surgery including rhinoplasty and Rhytidectomy
  • 18. TECHNIQUE OF SUBMENTAL INTUBATIONUnder sterile painting and draping of chin and mouth, 2 ml of 2%xylocaine with adrenaline infiltration and a small 1.5 cm transverseskin crease incision should be made in the medial region ofsubmental area, 2 cm behind the mental symphysis and adjacent tolower border of mandible. Blunt dissection through thesubcutaneous fat, platysma, cervical fascia, and anterior bellies ofdiagastric, geniohyoid, and genioglossus muscles is made to create atunnel. The mouth opening should be maintained using mouth gag.The floor of the mouth exposed by retracting the tongue.
  • 19. A closed artery forceps introduced through the submental skinincision and formed tunnel, until the tip of the artery forceps tentedthe mucosa of the floor of the mouth staying close to the lingualsurface of mandible in order to avoid injury to the submandibularduct and the lingual nerve. The tented oral mucosa incised to makea small opening and the blades of the artery forceps separate to adistance equal to the diameter of the tube. The endotracheal tubethen disconnected from the breathing circuit and the connectorremoved. Now the pilot balloon grasp with an artery forceps andpulled out gently through the passage in the floor of the mouth.
  • 20. The tip of the artery forceps was quickly reinserted through the submentalincision and the proximal end of the tracheal tube should be brought outthrough the tunnel using gentle rotational movement in the oral to skindirection while stabilizing the tracheal tube in the oral cavity with Magillsforceps. The connector and breathing system are reattached and the cuffreinflate. The tracheal tube now lies in the floor of the mouth between thetongue and the mandible. The endotracheal tube fixed by the muscles ofthe oral floor and may be additionally secured to the underside of the chinwith 2-0 black silk suture with cutting needle and elastoplast to preventaccidental displacement, after ensuring bilaterally equal air entry
  • 21. Medial approach for submental intubation Endotracheal tube through submental region
  • 22. RETROMOLAR INTUBATIONOn arrival in O.T, after starting I.V infusion line, basic parameter likepulse rate, blood pressure and ECG should be recorded as basevalue. Patients should be premedicated with I.V glycopyrolate andmidozalam in a dose of 0.004mg/kg and 0.05mg/kg. Induction wasdone with Inj. Thiopentone 3-5mg/kg body weight and oralintubation should be done after giving succinylcholine with PVCtube.After oral intubation and after checking bilateral air entry, hold thetube and move it laterally along the buccal sulcus beyond the lastmolar with fingers so that it rest in the retromolar space. In simplewords it is “repositioning” of the oral tube in the retromolar spaceso that it doesn’t interfere in dental occlusion. Tube is fixed at theangle of the mouth.
  • 23. CRICOTHYROTOMY• Wire-guided cricothyrotomy involves the passage of a malleable wire through a needle (Seldinger technique)• Blind passage of a trach tube through the cricothyroid membrane in to the trachea• Performed when all other means of supporting the airway and ventilations have been exhausted• • Proper placement is not guaranteed• Indicated in the “can’t intubate, can oxygenate” scenario
  • 24. CRICOTHYROTOMY• Incising the skin along the midline at the cricothyroid membrane• Introduction of a needle at a 45 degree angle• caudadly through the cricothyroid membrane in to the trachea
  • 25. CRICOTHYROTOMY• Passage of wire through needle (Seldinger technique) in to the trachea and removal of needle• Introduction of the wire in to the channel within the dilator• Advancement of the dilator in to the incision site
  • 26. CRICOTHYROTOMY• Advancement of the tube and dilator through the incision site resting the hub of the tube on the neck• Ensuring placement through auscultation and CO2 detection• Secure endotracheal tube
  • 27. TRACHEOSTOMYTYPE OF TRACHEOSTOMY Percutaneous tracheostomy and surgical tracheostomy . Inpercutaneous trachestomy a puncture is made on trachea by a needleand subsequently the puncture is sequentially dilated over a flexibleguiding catheter, whereas in surgical trachestomy tracheal cartrilage isdissected.INDICATION OF PCT Upper airway obstruction; long term airway protection afterhead injury, stroke; prolonged intubation, prolong pulmonaryventilationCONTRAINDICATION Absolute contraindication: refused consent; presence ofinfection of anterior neck; age <15 years; anatomical abnormalitiesincluding an enlarged thyroid gland or vascular abnormalities, need ofPEEP or >15 cm of H2O Relative Contraindication: Coagulopathy; previous neck surgeryor neck trauma.
  • 28. GUIDELINE TO DECIDE WHETHER SURGICAL OR PERCUTANEOUS TRACHEOSTOMYSurgical tracheostomy-• 1.presence of coagulation abnormality• 2.high level of ventilatory support{Fio2> 0.7% and PEEP >10 cm H2O}• 3.fragile cervical spine• 4.neck injury• 5.previus surgery and tumour• 6.obesity
  • 29. ADVANTAGE OF PCT OVER SURGICAL TRACHEOSTOMY• 1.PCT is a relatively simple technique• 2.no requirement of O.T.,can be done under local anaesthesia• 3.time requirement is one fourth of surgical.• 4.less blood loss.• 5.infection rate is 0 to 3.3%{surgical 36%}• 6.stenosis up to 9%• 7.cost is lower
  • 30. DISADVANTAGE OF PCT OVER ST• 1.incresed risk of delayed airway loss• 2.tracheal tube displacement can lead to death
  • 31. EARLY TRACHEOSTOMY• -.if TS is performed within 10 days of endotracheal intubation• GUIDELINE FOR EARLY TRACHEOSTOMY- when ventilatory support requirement is <10 days
  • 32. PATIENT BENEFIT FROM EARLY TRACHEOSTOMY• In Neurological patient GCS <8• injury severity score >25• Presence of pneumonia• Age <30
  • 33. ADVANTAGE OF EARLY TRACHEOSTOMY• -decreased ventilatory associated pneumonia• -decresed hospital mortality• -help in early weaning• -less ICU and hospital stay
  • 34. DISADVANTAGE OF EARLY TRACHEOSTOMY• -Dilation of trachea is more difficult in early tracheostomy• -it increases the incidence of PCT
  • 36. PCT TECHNIQUE IN THE ICU• Ciagila’s technique – safer, effective, simple and can be done by non-surgeons in ICU• Ventilator settings before performing PCT –1. FiO2 is increased to 12. PEEP is reduced to minimum level3. High pressure limit on the ventilator is increased These are done to accommodate the increased peak airway pressure caused by the presence of bronchoscope in the endotracheal lumen and to maintain the original tidal volume
  • 37. SITE OF TRACHEOSTOMY• Performed in the intercartilagenous area between first and second tracheal ring or second and third tracheal ring• Above the first ring, it increases the incidence of subglottic stenosis• Below third ring, it causes injury to thyroid isthmus and accidental erosion into the innominate artery
  • 38. PCT in pediatric patient• Translaryngeal tracheostomy should be performed because its approach is retrograde requiring minimum pressure on the trachea and pretracheal tissue.
  • 39. Complications of PCT• Perioperative – bleeding, tracheal laceration. Subcutaneous emphysema, pneumomediastinum, pneumothorax, tracheal ring fracture, paratracheal insertion, oesophageal perforation• Postoperative – bleeding, accidental extubation, tracheal stenosis, tracheomalacia, tracheoeosophageal fistula
  • 40. Common steps of tracheostomy technique• Sedation and relaxation with non-depolarising muscle relaxants• Ventilator adjusted to maintain expiratory volumes near normal• Patient placed in supine position and rolled towels placed behind shoulders to hyperextend the neck.• Identify thyroid notch, cricoid cartilage, tracheal rings and sternal notch
  • 41. Common steps of tracheostomy technique• Clean and drape the area• Infiltration of line of incision with lignocaine and adrenaline• 3mm flexible fibreoptic bronchoscope inserted into ET tube• Tip of bronchoscope placed distal to the tube and angled anteriorly for transillumination• Cuff of ET tube deflated and tube slowly withdrawn until transillumination of ant trachea is just above selected site
  • 42. Common steps of tracheostomy technique• Cuff of ET tube reinflated enough to achieve original tidal volume• Tip of bronchocope withdrawn inside the ET tube• 1.5-2cm horizontal skin incision at midline directly over selected site, followed by blunt dissection using a curved artery forceps until pretracheal fascia is felt
  • 43. Common steps of tracheostomy technique• Left middle finger and thumb used to secure lateral edges of trachea, while index finger used to locate intercartilagenous area previous selected• Gentle dissection by rotating the finger in the hole created• Introducer needle connected to a syringe half- filled with saline held by right hand is guided in and advanced into tracheal lumen under continuous suction
  • 44. Common steps of tracheostomy technique• Midline, intracheal placement of needle is guided by direct bronchoscopic visualisation and confirmed by free aspiration of air bubbles in the syringe• Catheter sheath over introducer needle passed over trachea while the needle is withdrawn.
  • 45. Common steps of tracheostomy technique• Guide wire is placed by seldinger technique inside the trachea• Free movement and bronchoscopic visualisation of guide wire must be confirmed before proceeding further
  • 46. Modification needed while performing PCT in obese patients• Because pretracheal tissue and fat plane is too thick, an extra long tracheostomy tube should be inserted
  • 47. Investigations mandatory after PCT• Xray neck with chest is mandatory to confirm the placement of the tracheostomy tube and rule out pneumothorax and subcutaneous emphysema
  • 48. Minitracheostomy• Permanent access to the trachea for suction while avoiding conventional methods• Indications –1.Short term upper airway access as an adjunct for secretion clearance in patients with reduced expiratory excursions2.Incipient upper airway obstruction prior to definitive surgical access3.Alternative to cricothyroidectomy for semi- urgent surgical access
  • 49. Minitracheostomy• Contraindications –1.Inadequate glottic reflexes like GCS<7 and laryngeal dysfunction2.Coagulopathy3.Difficult local anatomy like previous neck surgery, inability to palpate cricothyroid membrane, burns, cellulitis4.Repiratory failure requiring ventilation
  • 50. Thanks