A Novel Rescue Technique for Difficult Intubation and Difficult Ventilation

Summary

We describe a technique to maintain oxygenation and ventilation using an endotracheal tube inserted nasally to the level of the naso-pharynx while sealing the mouth and nares for successful positive pressure ventilation.

Abstract

We describe a novel non surgical technique to maintain oxygenation and ventilation in a case of difficult intubation and difficult ventilation, which works especially well with poor mask fit.

Can not intubate, can not ventilate" (CICV) is a potentially life threatening situation. In this video we present a simulation of the technique we used in a case of CICV where oxygenation and ventilation were maintained by inserting an endotracheal tube (ETT) nasally down to the level of the naso-pharynx while sealing the mouth and nares for successful positive pressure ventilation.

A 13 year old patient was taken to the operating room for incision and drainage of a neck abcess and direct laryngobronchoscopy. After preoxygenation, anesthesia was induced intravenously. Mask ventilation was found to be extremely difficult because of the swelling of the soft tissue. The face mask could not fit properly on the face due to significant facial swelling as well. A direct laryngoscopy was attempted with no visualization of the larynx. Oxygen saturation was difficult to maintain, with saturations falling to 80%. In order to oxygenate and ventilate the patient, an endotracheal tube was then inserted nasally after nasal spray with nasal decongestant and lubricant. The tube was pushed gently and blindly into the hypopharynx. The mouth and nose of the patient were sealed by hand and positive pressure ventilation was possible with 100% O₂ with good oxygen saturation during that period of time. Once the patient was stable and well sedated, a rigid bronchoscope was introduced by the otolaryngologist showing extensive subglottic and epiglottic edema, and a mass effect from the abscess, contributing to the airway compromise. The airway was secured with an ETT tube by the otolaryngologist.This video will show a simulation of the technique on a patient undergoing general anesthesia for dental restorations.

Protocol

1. An endotracheal tube size appropriate for the patient's age for endotracheal intubation should be chosen. We use the formula: ETT size = age(yr)/4 +4.
2. We chose a one size smaller uncuffed endotracheal tube to be inserted nasally, in case the endotracheal intubation fails after the patient is put to sleep.
3. Before nasal insertion of the tube, we measure the approximate distance from the nose to the level of the vocal cords, which is usually at the level of mid thyroid cartilage.
4. After the patient is anesthetized, and after a failed endotracheal intubation attempt and failed ventilation, the well lubricated one size smaller endotracheal tube will be i....

Discussion

This technique is comparable to a supraglottic airway device, such as a laryngeal mask airway¹ or a Combitube², both of which have been successfully described as rescue techniques in CICV situation to ensure ventilation and oxygenation as nonsurgical technique. This ETT technique however has the ease of availability and readiness, not necessitating any special training or equipment. In cases of CICV, and especially in neonates and small infants, oxygen desaturation can happen very quickly and can be.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
ETT size appropriate for patient’s age: ETT=age/4 +4
tape to protect the eyes
decongestant and lubricant to use in the nostril
ASA standard anesthesia monitors
red rubber suction catheter
Anesthesia circuit and mask