blind intubation methods

1. Blind Oral And Nasal Intubation
Dr ZIKRULLAH

2. Introduction
• Airway difficulties are a major concern for
anesthesiologists.
• Fiber-optic intubation →generally accepted method
for management of difficult airways, has
disadvantages—requires patient cooperation,
• Cannot perform on soiled airway or upper airways
with pre-existing narrowing pathology.
• Fiberoptic bronchoscopy is not available at every
medical institution.

3. NECESSITY OF BLIND
ORAL/NASAL INTUBATION
• Highly innovative and versatile airway equipments
may not be available at all locations and also their
cost of purchase and maintenance is often difficult.
• Thus for medical personnel who are responsible for
airway management , proper training in blind
oral/nasal intubation should still be high on priority
to reduce the time to perform blind intubations,
increase success rate and decrease the incidence of
complications.

4. Endotracheal Intubation -----------
indications
• Routine
• To provide General anaesthesia
• Emergency
• Airway obstruction
• Oxygenation failure
(hypoxia)
• Mental status alteration
(GCS<8/15)
Emergency
•Cardio pulmonary resuscitation
•Respiratory distress
•Ventilation failure (hypercarbia)
•Flail chest/Pulmonary contusion

5. Blind intubation
• Blind procedure → intubation →without a
laryngoscope or a view of the larynx → with or
without a Bougie.

6. USE/ INDICATIONS
• Cramped environment (e.g.
Patient trapped in vehicle)
• Copious oral fluids
• Large amount of blood or
vomitus in oral cavity,
obscuring visualization with
laryngoscope.

7. • Inability to visualize vocal
cords with laryngoscope
• Decreased mouth opening,
TMJ ankylosis, trismus.
• Severe head/ neck trauma
requiring immobilization of
cervical spine
USE/ INDICATIONS

8. Awake blind orotracheal intubation
• Instrumentation of airway is uncomfortable and
distressing to conscious patient. An informed and
reassured patient adds to the success of awake
intubation.
• A struggling patient markedly reduces the
chances of successful intubation, increases
morbidity from cervical or cranial fractures, and
accentuates the degree of oral, dental, or
laryngeal trauma.

9. • Irritation of the larynx or tracheal mucosa during
attempted intubation causes significant increase
in airway resistance, especially in patients with
reactive airway disease or those recovering from
upper respiratory tract infection.
• Hypertension, tachycardia, or dysrhythmias
secondary to CNS responses may precipitate
myocardial ischaemia, as well as unacceptable
increases in intraocular and intracranial
pressure.

10. • The impact of awake intubation can be
minimized with judicious use of topical
anaesthesia and conscious sedation
• Opioid analgesics are used to facilitate awake
intubation as they provide mild sedation,
analgesia and reduction of cough and
bronchospasm.
• Of the narcotics, fentanyl is most suitable
and the greatest advantage is the ease of
reversibility by naloxone.

11. • Benzodiazepine group of drugs is useful
adjuvant to narcotics, midazolam being most
popular.
• When awake intubation is planned, a dose of
anticholinergic, such as glycopyrrolate 0.2 mg
IV is recommended.
• The commonly used local anaesthetic agents
are lignocaine, benzocaine and tetracaine.
• Lignocaine is available as 2%, 4% solutions,
2% viscous solution, 10% aerosol preparation
and 5% ointment.

12. Pre-requisites of awake intubation
• A co-operative spontaneously breathing
patient.
• Psychological Counselling of the patient.
• Informed Consent
• Optimal Premedication
• Adequate Local Anaesthesia of the airway
with or without sedation.

13. Elements of Awake Intubation(AI)
Element Underlying Concept or Action
Explanation Patients understand Safety
Desiccation Dry the Airway
Dilatation Prepare the Nose
Tropicalization Obtund Reflexes
Sedation Maintain the patient’s airway
control
Procrastination AI Cannot and Should not be
RUSHED

14. Premedication…….why and what
• Desiccate, → “dry”, prior to the manipulation
of the airway, it should be free of secretions
because
• Saliva is a protective barrier – it will protect the
mucosa from topical agents.
• Manipulation of the airway produces more
secretions these secretions are an airway
stimulant, causing more cough, laryngospasm,
etc.

15. • Saliva dilutes topical local anesthetic, and
decreases it’s effectiveness.
• Glycopyrrolate is the most favoured drug
used for antisialogogue action.
• 0.2mg of Glycopyrrolate should be given
intravenously, at least 20 min before
intubation.

16. Nasal Preparation
• It is to be done in all cases, regardless of intent of
nasal or oral intubation.
• During preparation of the nose much of the effect
occurs in areas of the oropharynx by both cross
innervation, and passive leak of local anesthetic.
• A vasoconstrictor is used to decongest the nasal
mucosa. This widens the space and reduces the risk
of bleeding during manipulation.
• Oxymetazoline, is the most effective and long acting
agent.

17. Sedation
Judicious titration – do not give significant
boluses of the drugs to prevent over-sedation
and hypoventilation.
2) Avoid polypharmacy – stay with one or two
agents.
3) Have reversal agents available.
• Drugs like – Midazolam (0.02-0.03mg/kg iv)
or Opioids, Droperidol or Dexmedetomideine
can be used.

18. Local anaesthetic regimes:
• Nebulization
• Direct mucosal Application
• Nerve Blocks
• Infiltration
• Directly through the bronchoscope (Spray –
as – you- go – technique)

19. Three basic approaches of blind oro-
tracheal intubation
1. Bougie guided blind oral intubation
tracking the epiglottis by two fingers.
2. Thumb guided blind oral intubation.
3. Mouth prop guided blind oral intubation.

20. Blind digital intubation with a bougie-
---technique.
• 1.After adequate preparation, the operator
stands to the left of the patient, facing him,
the patient is asked to protrude out his
tongue.

21. • 2. The operator now
passes two fingers of his
left hand over the dorsum
of the tongue and tries to
hook the epiglottis
upwards.
• Epiglottis feels like a wet
earlobe,

22. 3. After the epiglottis is
identified by palpating it with
the long finger of the left hand,
the Bougie is threaded through
the glottis and advanced into
the trachea.
Tracheal clicking elicits tactile
vibrations, which confirm
tracheal placement of the
Bougie.

23.  The bougie is
withdrawn slightly so
that the 25-cm mark is
at the corner of the lip.
 The endotracheal tube
is threaded over the
bougie while the bougie
is stabilized in place.

24.  With the bougie held in place, the
endotracheal tube is turned a quarter turn
to the left and then advanced to an
appropriate depth.
 The tube is held in place while the bougie is
withdrawn. Tracheal intubation is then
confirmed using capnography or an
esophageal detector device.

25. • This technique is more suitable for a deeply
anaesthesized patient.
• In this method, the operator stands at the
head end of the table and inserts his left
thumb into the patients mouth while
keeping rest of the fingers over the patient
chin.
• The tip of the thumb makes contact with the
base of the tongue as deep as possible..
Thumb guided blind oral intubation.

26. • This gives good control of the lower jaw,
with which the tongue can be moved
forward and backward as needed.
• The ETT is now guided into the glottis with
right hand.

27. Mouth prop assisted technique
• In this technique, one uses a LONDON
HOSPITAL MOUTH PROP.
• Here the curved ETT is passed blindly
through the Prop, which is placed in
the mouth. It is important to keep the
head of the patient fully extended as
intubation is being attempted.
• Like above, this technique is also
suitable more for a anaesthesized
patient.

28. Advantages
• Fast (in experienced hands)
• No requirement for optimal positioning
• Minimal c-spine movement for trauma patients
• Ideal for those predicted to be difficult airway
(eg. underbite, short neck, obese)
• Can be used if copious secretions/blood in
airway and cannot visualize landmarks

29. Disadvantages
• Requires training (cadaver or simulation lab)
• Risks operator trauma from patient’s teeth
• Airway trauma
• Patient must be paralyzed or comatose/dead
• Benefits operators with long, slender fingers

30. The Blind Nasotracheal Intubation
• Valuable for intubating spontaneously
breathing patients with or without sedation, or
under general anesthesia.
• It may be used in elective as well as selected
emergent situations by the experienced
operator, who may expect that more than 75%
of patients will be intubated in less than 1 or 2
minutes.

31. Nasal intubation- indications!!
• Nasal intubation is performed when the surgery is
1.in the oral cavity Or
2.on the mandible and
3.when the oral route is difficult or impossible
e.g. temporo-mandibular joint ankylosis,
trismus.
4.Visualization of larynx by direct laryngoscopy
is poor

32. • Potentially difficult Oro-tracheal intubation
include
1.patients with dental fractures,
2.arthritis or dislocations of the temporo-
mandibular joints,
3. a small mouth, a short neck or a large tongue,
4. a history of previous head and neck surgery,
5. cervical spine immobility

33. Points to consider:
• The patient should not suffer from a
bleeding diathesis from, for example,
thrombocytopenia or oral anticoagulants.
• Moderately severe epistaxis may result.
• The nasal mucosa should be gently
prepared with phenylephrine,
oxymetazolone (Afrin), or cocaine.

34. • Local anaesthetics should be considered,
especially in the awake, sedated patient.
• Sedation (or even general anesthesia) may be
helpful. Intravenous agents, infused
continuously, allow for controlled sedation
that is independent of airway and breathing.
• Place patient's head and neck in the "sniffing
position" if not contraindicated.

35. • It is a bit easier for right handed operators
to use the right nares, though either may be
used.
• If both nares are equally patent, the right
nostril may be preferable because the bevel
of endotracheal tube will face the flat nasal
septum when introduced through the right
nostril, reducing damage to the turbinates.

36. • This minimizes chances of injury to the septum,
turbinates and epistaxis.
• The inferior turbinates limit the size of the
endotracheal tube
• A 6.0 to 6.5 mm ID endotracheal tube for
women and 7.0 to 7.5 mm ID endotracheal tube
for men are suitable for nasotracheal route.

37. Technique of awake blind nasal
 Explain the procedure to the patient.
 Preparation and premedication for awake
intubation.
 Selection of proper ETT size.
 Lubricate the ETT and nostril with KY-
jelly or @% xylocaine jelly.
 Right sided nares to be preferred.

38. Operator stands on left/head end.
Pre-oxygenation with 100% O2 for 3-5min.
Gently introduce ETT into nostril, concavity
facing patient’s feet.
Thrust the ETT backwards ,not upwards.
Resistance encountered when ETT approaches
posterior pharyngeal wall→ retract ETT,
extend the patient’s neck → gradually advance
→keep on hearing breath sounds.

39. • To enhance quality of breath sounds, close
opposite nostril, ask patient to breath with
mouth closed.
• Ask the patient to lift the lower jaw, to lift up
the epiglottis.
• Continue to advance the tube during
inspirations until one of the five response
positions are reached.
• Decide which position has been reached, then
make the appropriate response:

40. ADVANCE, DECIDE, RESPOND:
Position T (Trachea):
This is the goal position! Signs are: breath
sound continue through tube, tube continues to
advance, patient coughs through tube.
Response T: Secure tube.
• Auscultate breath sounds bilaterally.
• Confirm ETCO2.

41. • Position A (Anterior):
Position A can be diagnosed by the following
signs: breath sounds continue through the tube,
the tube stops (unable to advance further), and
the patient coughs (mostly through the tube).
• Response A: Position A can almost always be
converted directly to Position T by slight
withdrawal and re-advance of tube while the
patient's head and neck are gradually flexed
toward the chin-on-chest positon.

42. • Position L or R (Left or Right pyriform
sinus): Signs are: breath sounds through tube
STOP, tube stops (unable to advance), there
is NO coughing. Occasionally the tube may
be palpable on one side of the neck.
• Response L or R: Position L or R can
invariably be converted into one of the other
three (T, A or E) by slight withdrawal (to the
point where breath sounds through tube
resume) and slow rotation (back toward
midline) and re-advance.

43. • Position E (Esophagus): Signs: breath sounds
through tube STOP, tube continues to
advance, there is NO coughing.
• Response E: Position E can most often be
converted to position T by withdrawing the
tube until breath sounds through tube
resume and then employing one or more of
the following (separately or together):

44. How to convert to position T
• 1. Extend patient's head and re-advance.
2. Largely inflate cuff, advance tube until
resistance is felt, maintain some advancing
pressure on tube while cuff is slowly deflated.
3. Apply posterior pressure on the larynx and
re-advance tube.
Most often, position T can be achieved. It only
takes a minute or two to find out!

45. Complications of nasal intubation.
• Increased airway resistance and work of
breathing- use of smaller diameter ETT for naso-
tracheal intubation.
• The tube tends to soften and kink in the
nasopharynx, →increase airway resistance and
make passage of suction catheters more difficult→
airway secretions!!

46. • There is increased risk of sinusitis and
because of these concerns nasotracheal
intubation is rarely used for long-term
intubation.
• Nasal intubation may produce a
bacteremia and appropriate endocarditic
prophylaxis should therefore precede it.

47. Complications are rarely serious, but can
include
• nasopharyngeal haemorrhage,
• laryngeal trauma,
• retropharyngeal perforation, and
• paranasal sinusitis.

48. Contraindications
• Acute epiglottitis,
• Apnoea,
• Basilar skull fractures with or without
cerebrospinal fluid rhinorrhoea,
• Bleeding diathesis,

49. • Upper airway foreign body,
• Large bilateral nasal polyps,
• Abscesses and severe
• Laryngeal trauma.
Contraindications