Chapter 23: Digital (Tactile) Orotracheal Intubation

INTRODUCTION

Digital orotracheal intubation is an alternative advanced airway technique that has been demonstrated to be effective when performed by trained prehospital, aeromedical, combat, and hospital providers.^1-18 The index and middle fingers are used to direct the endotracheal tube into the patient’s larynx. This technique is “blind” in that the airway is not visualized at any point during the procedure. Use this technique in the Emergency Department as a secondary or tertiary method. It may be particularly useful when oral secretions or blood inhibit direct visualization of the upper airway.¹ There is evidence in hospitalized neonatal patients that digital intubation may be more effective than direct laryngoscopy as a primary method of orotracheal intubation.^2-4,14

ANATOMY AND PATHOPHYSIOLOGY

The significant anatomic structures that the Emergency Physician will encounter are the patient’s tongue and epiglottis. The epiglottis is the cartilaginous structure that is located at the root of the tongue and serves as a valve over the superior aperture of the larynx during the act of swallowing.⁶ Refer to Chapters 9 and 18 for a more complete discussion of the airway anatomy.

INDICATIONS

Digital orotracheal intubation is an alternative technique for intubating the comatose or chemically paralyzed patient. There are three major indications for digital intubation. The equipment required to perform direct or video laryngoscopy is either not available or not functioning. The physical positioning of the patient does not permit the provider to intubate using direct or video laryngoscopy.⁷ Visualization cannot be achieved using conventional techniques due to trauma, excessive secretions, or blood in the airway.¹

This technique involves minimal movement of the head and neck. It may be a suitable method for intubating patients with known or suspected cervical spine injuries. Digital intubation may be a useful procedure for paramedics and aeromedical personnel in the out-of-hospital setting, when trapped patients require intubation but are not in a position for more conventional methods.⁷ It is an alternative technique for out-of-hospital intubation where other techniques and equipment are unavailable or limited.

This procedure may be considered a primary method of intubation in neonatal patients.^2,4,5 One small study demonstrated that digital intubation of the neonate was more successful and faster than direct laryngoscopy when performed by a very experienced neonatal intubator.³ The first-pass success rate was 90.5% for the digital intubation versus 50% for the direct laryngoscopy, with a mean time to intubation of 8.2 seconds and 13.1 seconds, respectively.

Digital intubation may be a life-saving technique for difficult airways.^16,17 Adequate skill training and maintenance of competency are critical to achieve successful outcomes. Medical flight crewmembers and Emergency Medicine residents in a simulated tactical setting were found to require more attempts and take longer to provide advanced airway management with digital intubation ...