Modified Submental Orotracheal Intubation Using the Blue Cap on the End of the Thoracic Catheter

Abstract

The technique of submental intubation in patients with multiple facial fractures and skull base fracture was originally described by Altemir. This technique provides a secure airway and allows intermaxillary fixation while avoiding the complications of nasotracheal intubation or tracheostomy. However, when the endotracheal pilot balloon and endotracheal tube are pulled through the submental incision site using this technique, soft tissues or blood may enter the endotracheal tube and trauma may result in the surrounding tissues. To overcome these problems, we carried out a modification of submental orotracheal intubation using the blue cap on the end of the thoracic catheter in a patient with mandibular fractures and injury to the skull base and found that this modification resulted in a safer and less traumatic intubation.

Submental intubation: a literature review

“…The most common indication for submental intubation was trauma (N = 721) in 86% of the reported cases followed by elective facial osteotomy (N = 100) in 12% of patients 1,2,4,6,[9][10][11]13,15,17,[19][20][21][22][25][26][27][28][31][32][33][34][35][36][37][39][40][41][42][43][44][45][49][50][51][52]54 . Transmaxillary cranial base tumour access (N = 18) comprised 2% of patients 13 .…”

“…Devices utilized in performing the submental intubation consisted of reinforced spiral embedded endotracheal tubes (N = 775), non-reinforced endotracheal tubes (N = 22), reinforced laryngeal mask airway (LMA) (N = 6), Combitube (N = 1) and not reported (N = 38). Fibre or metal reinforced tubing is preferred due to the ability to maintain lumen patency at the acute tube angles common in submental intubation 1,9,[13][14][15]19,21,22,[25][26][27][31][32][33]35,36,38,[40][41][42][43][49][50][51]54 . No correlations were found between the type of tube utilized and damage to the tube during the procedure.…”

“…10 Articles have been published outlining modifications to the original technique primarily aimed at reducing complications 4,6,12,14,28,[35][36][37]42,43 . Modifications were classified according to intended benefit.…”

“…Modifications were classified according to intended benefit. Four modifications were instituted to reduce the potential for intraoperative bleeding whilst three modifications aimed at reducing tube damage despite the relatively low reported frequency of these minor complications: 0.24% and 1.19%, respectively 4,14,[35][36][37]42,43 . Table 4 details the reported modifications and intended benefit of each modification.…”

Transmylohoid/Submental Endotracheal Intubation in Pan-facial Trauma: A Paradigm Shift in Airway Management with Prospective Study of 35 Cases

“…It also allows better visualization of the intraoral position of the tube with direct laryngoscopy [1]. Lim et al modified this technique by covering blue cap of thoracic catheter on the end of ETT and pilot balloon while passing the ETT through submental area to reduce injury to the surrounding tissues and passing the ETT smoothly through submental tunnel without influx of soft tissues or blood into the ETT [6]. Nyarady et al introduced'2-2-2 rule' incision (2 cm long, 2 cm away, 2 cm medial to the mandible) in submental region to create a tunnel [7].…”