Blind Digital Intubation
OVERVIEW
- digital intubation allows intubation to be performed without a laryngoscope or a view of the larynx
- may be performed with or without a bougie
USE/ INDICATIONS
- Cramped environment (e.g. patient trapped in vehicle)
- Copious oral fluids (e.g. large amount of blood or vomitus in oral cavity, obscuring visualization with a laryngoscope)
- Inability to visualize vocal cords with laryngoscope
- Severe head/ neck trauma requiring immobilization of cervical spine
DESCRIPTION OF PROCEDURE
Rich JM. Successful blind digital intubation with a bougie introducer in a patient with an unexpected difficult airway. Proc (Bayl Univ Med Cent). 2008 Oct;21(4):397-9. PMC2566913
- 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.
- The bougie is withdrawn slightly so that the 25-cm mark is at the corner of the lip.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.
- 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- The tube is held in place while the bougie is withdrawn.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.
OTHER INFORMATION
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
Disadvantages
- Requires training (cadaver or sim lab)
- Risks operator trauma from patient’s teeth
- Airway trauma
- Patient must be paralyzed or comatose/dead
- Benefits operators with long, slender fingers
References and Links
CCC Airway Series
Emergencies: Can’t Intubate, Can’t Intubate, Can’t Oxygenate (CICO), Laryngospasm, Surgical Cricothyroidotomy
Conditions: Airway Obstruction, Airway in C-Spine Injury, Airway mgmt in major trauma, Airway in Maxillofacial Trauma, Airway in Neck Trauma, Angioedema, Coroner’s Clot, Intubation of the GI Bleeder, Intubation in GIH, Intubation, hypotension and shock, Peri-intubation life threats, Stridor, Post-Extubation Stridor, Tracheo-esophageal fistula, Trismus and Restricted Mouth Opening
Pre-Intubation: Airway Assessment, Apnoeic Oxygenation, Pre-oxygenation
Paediatric: Paediatric Airway, Paeds Anaesthetic Equipment, Upper airway obstruction in a child
Airway adjuncts: Intubating LMA, Laryngeal Mask Airway (LMA)
Intubation Aids: Bougie, Stylet, Airway Exchange Catheter
Intubation Pharmacology: Paralytics for intubation of the critically ill, Pre-treatment for RSI
Laryngoscopy: Bimanual laryngoscopy, Direct Laryngoscopy, Suction Assisted Laryngoscopy Airway Decontamination (SALAD), Three Axis Alignment vs Two Curve Theory, Video Laryngoscopy, Video Laryngoscopy vs. Direct
Intubation: Adverse effects of endotracheal intubation, Awake Intubation, Blind Digital Intubation, Cricoid Pressure, Delayed sequence intubation (DSI), Nasal intubation, Pre-hospital RSI, Rapid Sequence Intubation (RSI), RSI and PALM
Post-intubation: ETT Cuff Leak, Hypoxia, Post-intubation Care, Unplanned Extubation
Tracheostomy: Anatomy, Assessment of swallow, Bleeding trache, Complications, Insertion, Insertion timing, Literature summary, Perc. Trache, Perc. vs surgical trache, Respiratory distress in a trache patient, Trache Adv. and Disadv., Trache summary
Misc: Airway literature summaries, Bronchoscopic Anatomy, Cuff Leak Test, Difficult airway algorithms, Phases of Swallowing
Journal articles
- Hardwick WC, Bluhm D. Digital intubation. J Emerg Med. 1984;1(4):317-20. PubMed PMID: 6501845.
- Rich JM. Successful blind digital intubation with a bougie introducer in a patient with an unexpected difficult airway. Proc (Bayl Univ Med Cent). 2008 Oct;21(4):397-9. PMC2566913
- Stewart RD. Tactile orotracheal intubation. Ann Emerg Med. 1984 Mar;13(3):175-8. PubMed PMID: 6696305.
- Vacanti CA, Roberts JT. Blind oral intubation: the development and efficacy of a new approach. J Clin Anesth. 1992 Sep-Oct;4(5):399-401. PMID: 1389195.
- Young SE, Miller MA, Crystal CS, Skinner C, Coon TP. Is digital intubation an option for emergency physicians in definitive airway management? Am J Emerg Med. 2006 Oct;24(6):729-32. PMID: 16984845.
FOAM and web resources
- AirwayCam — Digital Intubation
- SOCMOB — Digital Intubation, and I Don’t Mean Video (2013)
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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