John K. Stene

Appropriate techniques for airway management of emergency patients with suspected spinal cord injury.

While we would like to respectfully express skepticism about the proposal recently made by Gorback (1) regarding manipulations of the endotracheal tube (ETT) cuff to achieve blind nasal intubation, we would, more importantly, like to protest the fact that he, along with so many other anesthesiologists, continues to automatically assume that nasotracheal intubation is either necessary or desirable in patients with suspected or actual spinal cord injuries. As clinicians at the Shock Trauma Center of the Maryland Institute for Emergency Medical Services Systems (MIEMSS), we appreciate the difficulty of intubating the trauma patient with suspected cervical spine instability. Each year since 1983, more than 600 patients with suspected or actual spinal cord injury (SCI) requiring emergency intubation have been admitted to our facility, the statewide referral center for neurotrauma. Predominately using an oral intubation technique as an alternative to nasal intubation, we have afforded safe and efficient airway management to this large patient population. Difficulties encountered when using blind nasal intubation techniques have prompted the development of various modifications using the tactile, visual, and auditory senses. Additionally, combinations of techniques can be used to improve the efficacy of blind nasal intubation if one feels compelled to use this approach. Although some anesthesiologists consider nasal intubation to be the ideal approach for securing the airway in a patient with cervical SCI, we believe this technique may be contraindicated in the majority of traumatically injured patients. Nasal intubation (blind or fiberoptically guided) is associated with complications and limitations. Nasal intubation should not be used if the patient is apneic, nor should it be used if the patient has a basilar skull fracture because bacteria and foreign materials (including the ETT) could enter the cerebral subarachnoid space through the skull defect. Nasal intubation may induce nosebleeds, which may be aggravated by dilutional coagulopathy. Nasally intubated patients are at risk for postoperative sepsis due to sinusitis. Nasal intubation should not be performed in frightened, inebriated, obtunded, and combative patients, who may thrash about during intubation and cause further damage to a cervical SCI. Concerning Gorback’s technique of blind nasal intubation, we have several comments:

The BAAM and Endotrol endotracheal tube for blind oral intubation

Blind oral intubation in a spontaneously breathing patient can be facilitated with a combination of two devices used mainly for nasotracheal intubation, the BAAM (Beck Airway Air Flow Monitor, Great Plains Ballistics, Lubbock, TX) and the Endotrol endotracheal tube (Mallinckrodt Critical Care, Inc., St. Louis, MO). We describe a case in which intubation of a spontaneously breathing intensive care unit patient was unsuccessful by traditional methods. In the successful approach we describe, the tube was passed through the oral cavity and pharynx in a blind fashion, using the BAAMs whistling sound for guidance and the plastic ring of the Endotrol tube to help positioning. This equipment combination may be useful in certain difficult intubation situations.

Use of a beck airway airflow monitor and controllable-tip endotracheal tube in two cases of nonlaryngoscopic oral intubation

Alternative techniques and equipment for intubation may be particularly useful in settings such as air-medical transport, prehospital on-scene care, mass casualty incidents, or incidents in which there may be a lack of medications or equipment. Once traditional techniques of endotracheal intubation and tube verification have been mastered, emergency medicine residents and other intubators should be encouraged to learn alternative techniques, such as these, that may be of use in some special situations, even within the ED. Neither of these two techniques of BAAM-assisted blind oral intubation can be considered essential, nor should it be contended that these techniques supplant learning of more conventional methods of endotracheal intubation and tube placement verification. However, particularly in the setting of residency training, multiple methods of endotracheal intubation should be taught in order to allow the clinician alternative methods if unable to intubate by traditional means in a particular setting. Use of a BAAM to assist in blind oral intubation of a spontaneously breathing patient may allow for oral intubation of awake patients without the additional use of paralytic medications. Use of the BAAM with a digital technique during external cardiac massage may facilitate intubation by the digital technique and help to verify endotracheal tube position. These two additional uses for the BAAM should be noted and these two additional methods of airway control be recognized as backup methodologies in the armamentarium for situations in which they may be needed.