1. Alternative Technique Of
Intubation Retromolar, Retrograde,
Submental And Other Technique
Under the Guidance
Assistant Prof (Dr.) Adokshak Joshi
Presented by
Dr. Munesh Kumar Meena

2. Fundamental of Airway
A. 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 ventilation
C. 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 Larynx
It extend from the laryngeal inlet (C3-C4 in adults) to lower
border of cricoid cartilage (c6 in adults). It moves vertically and
anteroposterorly during swallowing and phonation. Larynx
include cartilages, paired cartilage include arytenoids
corniculates and the cuneiforms and unpaired cartilage
includes thyroid, cricoid and epiglottis
According to Sappey the average measurements of the adult
larynx 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 between
the larynx and parts around these have been described in the section
on Myology; and intrinsic, confined entirely to the larynx. The
intrinsic muscles are:
Cricothyreoideus. Cricoarytænoideus lateralis.
Cricoarytænoideus posterior. Arytænoideus.
Thyroarytænoideus.

5. Vessels and Nerves : The chief arteries of the larynx are the
laryngeal branches derived from the superior and inferior thyroid.
The veins accompany the arteries; those accompanying the
superior laryngeal artery join the superior thyroid vein which
opens into the internal jugular vein; while those accompanying the
inferior laryngeal artery join the inferior thyroid vein which opens
into the innominate vein. The lymphatic vessels consist of two
sets, superior and inferior. The former accompany the superior
laryngeal artery and pierce the hyothyroid membrane, to end in
the glands situated near the bifurcation of the common carotid
artery. Of the latter, some pass through the middle cricothyroid
ligament and open into a gland lying in front of that ligament or in
front of the upper part of the trachea, while others pass to the
deep cervical glands and to the glands accompanying the inferior
thyroid artery.

6. The nerves are derived from the internal and external branches of
the superior laryngeal nerve, from the recurrent nerve, and from
the sympathetic. The internal laryngeal branch is almost entirely
sensory, but some motor filaments are said to be carried by it to
the Arytænoideus. It enters the larynx by piercing the posterior
part of the hyothyroid membrane above the superior laryngeal
vessels, and divides into a branch which is distributed to both
surfaces of the epiglottis, a second to the aryepiglottic fold, and a
third, the largest, which supplies the mucous membrane over the
back of the larynx and communicates with the recurrent nerve.
The external laryngeal branch supplies the Cricothyreoideus.

7. The recurrent nerve passes upward beneath the lower
border of the Constrictor pharyngis inferior immediately
behind the cricothyroid joint. It supplies all the muscles
of the larynx except the Cricothyreoideus, and perhaps a
part of the Arytænoideus. The sensory branches of the
laryngeal nerves form subepithelial plexuses, from which
fibers pass to end between the cells covering the mucous
membrane.

8. Evaluation of the difficult laryngoscopy &
Tracheal intubation
Assessment of cervical atlanto occipital joint – Larygoscopy
view becomes easier when the neck is flexed on the chest by
25-35° and a-o joint is well extened (85°). Assess the first
movement by asking the patient to touch his manubrium
sternil with his chin. This assure neck flexion of 25-30°.
Following this ask the patient to look at the ceiling without
raising eyebrows to test a-o joint function.
Reduction of a-o extension
i.No reduction
ii.1/3rd reduction
iii.2/3rd reduction
iv.Complete reduction

9. 2/3rd or complete reduction of extesion at a-o joint is a clear pointer
to 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 left
hand of the clinician is placed under the tip of the jaw while the
index finger of the right hand is placed on the patient’s occipital
tuberosity. Patient is now asked to look at the ceiling. If the left
index finger becomes higher than right, extension which considered
normal. If the left index finger is remains at the same level of the
right or lower, extension is abnormal.
In Diabetic Patient: Long term juvenile diabetes patients present
with laryngoscopic difficulty due to “stiff joint syndrome”. In this
patient have difficulty approximating their palms and can not bend
their finger backwards. If present, it should alert the laryngoscopy
to the possibility of cervical spine involvement and limited a-o
movement leading to difficult laryngoscopy and intubation.

10. Assessment of termpromandibular joint (TMJ) function: Rotation of
the condyle in the synovial cavity and forward displacement of
condyle. The former is responsible for 2-3 cm mouth opening and
the latter for a further responsible for 2-3 cm mouth opening.
Assessment of the mandibular space:
Thyromental distance: >6.5cm no problem with laryngoscopy and
intubation. 6-6.5cm difficulty in laryngoscopy and intubation but
possible. <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 impossible
to laryngoscopy and intubation

11. Assessment of Oropharynx for Laryngoscopy and Intubation:
Mallampati Grading :
Grade I - Faucial pillars, uvula, soft and hard
palate 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 intubation
Absolute : inability to open mouth and easily performed orotracheal
intubation.
Relative contraindication: Systemic coagulopathy, infection in the
skin 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.

14. TECHNIQUE OF RETROGRADE INTUBATION

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 INTUBATION
Secure endotracheal tube and monitor end tidal carbon dioxide
Maxillo facial surgery
Dental Surgery
Plastic Surgery including rhinoplasty and Rhytidectomy

18. TECHNIQUE OF SUBMENTAL INTUBATION
Under sterile painting and draping of chin and mouth, 2 ml of 2%
xylocaine with adrenaline infiltration and a small 1.5 cm transverse
skin crease incision should be made in the medial region of
submental area, 2 cm behind the mental symphysis and adjacent to
lower border of mandible. Blunt dissection through the
subcutaneous fat, platysma, cervical fascia, and anterior bellies of
diagastric, geniohyoid, and genioglossus muscles is made to create a
tunnel. 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 skin
incision and formed tunnel, until the tip of the artery forceps tented
the mucosa of the floor of the mouth staying close to the lingual
surface of mandible in order to avoid injury to the submandibular
duct and the lingual nerve. The tented oral mucosa incised to make
a small opening and the blades of the artery forceps separate to a
distance equal to the diameter of the tube. The endotracheal tube
then disconnected from the breathing circuit and the connector
removed. Now the pilot balloon grasp with an artery forceps and
pulled out gently through the passage in the floor of the mouth.

20. The tip of the artery forceps was quickly reinserted through the submental
incision and the proximal end of the tracheal tube should be brought out
through the tunnel using gentle rotational movement in the oral to skin
direction while stabilizing the tracheal tube in the oral cavity with Magill's
forceps. The connector and breathing system are reattached and the cuff
reinflate. The tracheal tube now lies in the floor of the mouth between the
tongue and the mandible. The endotracheal tube fixed by the muscles of
the oral floor and may be additionally secured to the underside of the chin
with 2-0 black silk suture with cutting needle and elastoplast to prevent
accidental displacement, after ensuring bilaterally equal air entry

21. Medial approach for submental intubation
Endotracheal tube through submental region

22. RETROMOLAR INTUBATION
On arrival in O.T, after starting I.V infusion line, basic parameter like
pulse rate, blood pressure and ECG should be recorded as base
value. Patients should be premedicated with I.V glycopyrolate and
midozalam in a dose of 0.004mg/kg and 0.05mg/kg. Induction was
done with Inj. Thiopentone 3-5mg/kg body weight and oral
intubation should be done after giving succinylcholine with PVC
tube.
After oral intubation and after checking bilateral air entry, hold the
tube and move it laterally along the buccal sulcus beyond the last
molar with fingers so that it rest in the retromolar space. In simple
words it is “repositioning” of the oral tube in the retromolar space
so that it doesn’t interfere in dental occlusion. Tube is fixed at the
angle 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. TRACHEOSTOMY
TYPE OF TRACHEOSTOMY
Percutaneous tracheostomy and surgical tracheostomy . In
percutaneous trachestomy a puncture is made on trachea by a needle
and subsequently the puncture is sequentially dilated over a flexible
guiding catheter, whereas in surgical trachestomy tracheal cartrilage is
dissected.
INDICATION OF PCT
Upper airway obstruction; long term airway protection after
head injury, stroke; prolonged intubation, prolong pulmonary
ventilation
CONTRAINDICATION
Absolute contraindication: refused consent; presence of
infection of anterior neck; age <15 years; anatomical abnormalities
including an enlarged thyroid gland or vascular abnormalities, need of
PEEP or >15 cm of H2O
Relative Contraindication: Coagulopathy; previous neck surgery
or neck trauma.

28. GUIDELINE TO DECIDE WHETHER
SURGICAL OR PERCUTANEOUS
TRACHEOSTOMY
Surgical 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

35. DIFFERENT TECHNIQUES OF PCT
• 1.CIAGILLA’S TECHNIQUE
• 2.GRIGG’S TECHNIQUE
• 3.WHITE TUSK TECHNIQUE
• 4.PERCUTWIST TECHNIQUE
• 5.Trans laryngeal tracheostomy

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 1
2. PEEP is reduced to minimum level
3. 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 excursions
2.Incipient upper airway obstruction prior to
definitive surgical access
3.Alternative to cricothyroidectomy for semi-
urgent surgical access

49. Minitracheostomy
• Contraindications –
1.Inadequate glottic reflexes like GCS<7 and
laryngeal dysfunction
2.Coagulopathy
3.Difficult local anatomy like previous neck
surgery, inability to palpate cricothyroid
membrane, burns, cellulitis
4.Repiratory failure requiring ventilation

50. Thanks