Is digital intubation an option for emergency physicians in definitive airway management?

Abstract

Objectives

This study was designed to determine whether digital intubation is a valid option for definitive airway control by emergency physicians.

Methods

Digital intubation was performed by 18 emergency medicine residents and 4 staff emergency medicine physicians on 6 different cadavers. Placement was confirmed by direct laryngoscopy. The total time for all attempts used, as well as the number of attempts, was recorded. Each participant attempted intubation on all 6 cadavers.

Results

For 5 of the 6 cadavers, successful intubation occurred 90.9% of the time (confidence interval [CI], 85.5%-96.3%) for all participants. The average number of attempts for these 5 cadavers was 1.5 (CI, 1.4-1.7), and the average time required for success or failure was 20.8 seconds (CI, 16.9-24.8). The sixth cadaver developed soft tissue damage and a false passage near the vocal cords resulting in multiple failed attempts.

Conclusions

Although the gold standard for routine endotracheal intubation remains to be direct laryngoscopy, its effectiveness in certain situations may be limited. We believe that digital intubation provides emergency physicians with another option in securing the unprotected airway.

Introduction

The ability to provide definitive management of the unstable airway is one of the most important facets of the emergency physician's skill set. The gold standard in airway management remains to be endotracheal intubation facilitated by direct laryngoscopy (DL). Although this is clearly the most ideal way to establish airway control, the wide array of rescue devices available on the market demonstrates how this method may not always be the most successful [1]. Many of these products, including the gum elastic bougie, laryngeal mask airway, Combitube, and others can be helpful, successful implementation relies on both the provider's skill and the availability of the product [2], [3]. On occasion, the use of a laryngoscope may not be feasible, such as in the setting of massive facial trauma, during tactical operations when the need for light discipline is paramount, or in multiple prehospital scenarios where a patient is entrapped in such a position to prevent traditional methods of managing the unstable airway. Digital intubation (DI) is a potentially valuable tool for definitive airway control, requiring less equipment and patient positioning than any of the other major methods of airway management [4].

In DI, the practitioner uses the index and middle fingers in the same fashion as a Miller laryngoscope blade, lifting the epiglottis and guiding the endotracheal tube (ETT) between the fingers and into the trachea. Ideally, the practitioner stands on the side of the patient, caudal to the head, facing the patient's head. One prior study looked at the success rate of paramedics performing this technique in the field, demonstrating that DI is a reasonable failed airway technique when used by experienced paramedics [5].

A cadaveric pilot study was conducted to determine whether DI is a valid option for definitive airway control by emergency medicine staff and resident physicians. The primary outcome measures evaluated were success rate, number of attempts, and time needed for endotracheal intubation in cadavers after a brief instructional session.