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  • The bougie is withdrawn slightly so that the 25-cm mark is at the corner of the lip.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  • The tube is held in place while the bougie is withdrawn.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

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


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and 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 two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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