1. Non-Visual Intubation Techniques Orlando Hung Departments of Anesthesia, Surgery and Pharmacology, Dalhousie University Halifax, Nova Scotia

2. Objectives Non-visual techniques Non-visual techniques Light-guided intubation Light-guided intubation Blind nasal intubation Blind nasal intubation Retrograde Intubation Retrograde Intubation Digital Intubation Digital Intubation

3. Why Do We Need Non-visual Intubation Techniques?

4. Why Do We Need non-visual Intubation Techniques? Difficult laryngosopic intubation 1 – 3% patients Difficult laryngosopic intubation 1 – 3% patients Alternative techniques have been developed to overcome this difficulties Alternative techniques have been developed to overcome this difficulties Many of these techniques require expensive equipment, and special skill and training. Additionally, a lot of these techniques may be difficult to employ in emergency situations, and in patients with copious secretions, vomitus, or blood in the oropharynx. Many of these techniques require expensive equipment, and special skill and training. Additionally, a lot of these techniques may be difficult to employ in emergency situations, and in patients with copious secretions, vomitus, or blood in the oropharynx.

5. Would it not be safer to place a tracheal tube using a technique that is under direct vision? In principle, the placement of an endotracheal tube into the trachea under direct vision ought to be safer. In principle, the placement of an endotracheal tube into the trachea under direct vision ought to be safer. Intubation is not always possible under vision. Intubation is not always possible under vision. Most procedures performed in medicine are in fact blind techniques. Most procedures performed in medicine are in fact blind techniques.

13. Tips to Enhance Oral Trachlight Intubation Positioning: Positioning: head and neck neutral or extended head and neck neutral or extended Adjusting ambient light and retracting chest tissues for obese patients Adjusting ambient light and retracting chest tissues for obese patients

15. Look for the cone of light

18. Limitations of Light-guided intubation

19. Blind Nasal Intubation

20. Nasal Intubation Occasionally, to lift the tip of the ETT anteriorly, it is necessary to inflate the cuff with 20 mL of air

21. Retrograde Intubation In 1960, Drs. Butler and Cirillo reported the first retrograde intubation in surgical patients through an existing tracheostomy opening. In 1960, Drs. Butler and Cirillo reported the first retrograde intubation in surgical patients through an existing tracheostomy opening. The technique was subsequently modified by Waters who performed a cricothyroid membrane puncture using a Touhy needle The technique was subsequently modified by Waters who performed a cricothyroid membrane puncture using a Touhy needle

25. Limitations of retrograde Intubation The major difficulty of the technique relates to the inability in determining the location of the tip of endotracheal tube during intubation. In some situations, the epidural catheter or guide-wire is removed even though the tip of the tube is mistakenly placed in the vallecula. The major difficulty of the technique relates to the inability in determining the location of the tip of endotracheal tube during intubation. In some situations, the epidural catheter or guide-wire is removed even though the tip of the tube is mistakenly placed in the vallecula.

26. Modifications of the Techniques Subcricoid puncture Subcricoid puncture

28. Modifications of the Techniques Subcricoid puncture Subcricoid puncture Through the Murphy eye of ETT Through the Murphy eye of ETT

29. Modifications of the Techniques Subcricoid puncture Subcricoid puncture Through the Murphy eye of ETT Through the Murphy eye of ETT Pull through using a silk suture Pull through using a silk suture

30. Modifications of the Techniques Subcricoid puncture Subcricoid puncture Through the Murphy eye of ETT Through the Murphy eye of ETT Pull through using a silk suture Pull through using a silk suture Flexible bronchoscope Flexible bronchoscope

32. Modifications of the Techniques Subcricoid puncture Subcricoid puncture Through the Murphy eye of ETT Through the Murphy eye of ETT Pull through using a silk suture Pull through using a silk suture Flexible bronchoscope Flexible bronchoscope Light-guided using transillumination Light-guided using transillumination

35. Limitations of Retrograde Intubation Any situation that makes it difficult to perform a cricothyrotomy will also be difficult to perform a retrograde intubation. Any situation that makes it difficult to perform a cricothyrotomy will also be difficult to perform a retrograde intubation.

36. Digital intubation Tactile digital intubation was probably first described by Herholdt and Rafn in 1796. Tactile digital intubation was probably first described by Herholdt and Rafn in 1796. Although digital intubation is seldom the intubation technique of choice in modern airway management, this technique can be life-saving in some situations. Although digital intubation is seldom the intubation technique of choice in modern airway management, this technique can be life-saving in some situations.

42. Summary Laryngoscopic intubation remains a challenge in a small percentage of the population. Laryngoscopic intubation remains a challenge in a small percentage of the population. While many alternative techniques are available, they are expensive and not particularly useful for emergency situations with limited resources. While many alternative techniques are available, they are expensive and not particularly useful for emergency situations with limited resources. Non-visual intubating techniques can play an important role in airway management. Non-visual intubating techniques can play an important role in airway management. Over the last several decades, these non-visual techniques have been shown to be effective and safe in securing an airway. Over the last several decades, these non-visual techniques have been shown to be effective and safe in securing an airway.

44. Non-Visual Intubation Techniques Orlando Hung Departments of Anesthesia, Surgery and Pharmacology, Dalhousie University Halifax, Nova Scotia