Alternative Technique Of Intubation Retromolar, Retrograde,

Submental And Other Technique

Under the Guidance Assistant Prof (Dr.) Adokshak Joshi

Presented byDr. Munesh Kumar Meena

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 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.

Anatomy of LarynxIt 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 epiglottisAccording 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

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.

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.

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.

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.

Evaluation of the difficult laryngoscopy & Tracheal intubationAssessment 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 extensioni.No reductionii.1/3rd reductioniii.2/3rd reductioniv.Complete reduction

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.

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 - > 6cmGrade II - 4.0 – 6.0 cmGrade III - <4 cm.

Grade III hyomental distance is usually associated with impossible to laryngoscopy and intubation

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

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 swellingc. 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 atresiab. Hypertrophic tubinates and deviated nasal septum

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.

TECHNIQUE OF RETROGRADE INTUBATION

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

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

TECHNIQUE OF RETROGRADE INTUBATIONSecure endotracheal tube and monitor end tidal carbon dioxide

Maxillo facial surgeryDental SurgeryPlastic Surgery including rhinoplasty and Rhytidectomy

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.

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.

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

Medial approach for submental intubation

Endotracheal tube through submental region

RETROMOLAR INTUBATIONOn 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.

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

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

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

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

TRACHEOSTOMYTYPE 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 ventilationCONTRAINDICATION

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.

GUIDELINE TO DECIDE WHETHERSURGICAL 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

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

DISADVANTAGE OF PCT OVER ST

• 1.incresed risk of delayed airway loss

• 2.tracheal tube displacement can lead to death

EARLY TRACHEOSTOMY

• -.if TS is performed within 10 days of endotracheal intubation

• GUIDELINE FOR EARLY TRACHEOSTOMY- when ventilatory support requirement is <10

days

PATIENT BENEFIT FROM EARLY TRACHEOSTOMY

• In Neurological patient GCS <8

• injury severity score >25

• Presence of pneumonia

• Age <30

ADVANTAGE OF EARLY TRACHEOSTOMY

• -decreased ventilatory associated pneumonia• -decresed hospital mortality• -help in early weaning• -less ICU and hospital stay

DISADVANTAGE OF EARLY TRACHEOSTOMY

• -Dilation of trachea is more difficult in early tracheostomy

• -it increases the incidence of PCT

DIFFERENT TECHNIQUES OF PCT

• 1.CIAGILLA’S TECHNIQUE

• 2.GRIGG’S TECHNIQUE

• 3.WHITE TUSK TECHNIQUE

• 4.PERCUTWIST TECHNIQUE

• 5.Trans laryngeal tracheostomy

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

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

PCT in pediatric patient

• Translaryngeal tracheostomy should be performed because its approach is retrograde requiring minimum pressure on the trachea and pretracheal tissue.

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

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

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

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

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

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.

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

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

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

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

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, cellulitis

4.Repiratory failure requiring ventilation

Thanks