Digital Intubation without Stylet: Myth or Reality? Case Report

Digital intubation was discovered as one of the first methods to face a difficult airway without direct laryngoscopy. From the very beginning, this technique has been surrounded by much controversy, mainly because it required to be performed by an expert. Nowadays, it remains a useful technique when treating patients with difficult airways, so it is of utmost importance all personnel involved with airway management must know and perfect this technique when scenarios where conventional laryngoscopy or rescue devices for difficult airway are not available or contraindicated. The present work’s main ob-jective is to suggest digital intubation as a safe and effective technique for the management of patients with difficult airways when there are no other devices available. The authors present a successful case of digital intubation on a patient with a difficult airway, demonstrating this technique is useful when performed by expert practitioners and when there is no other equipment available.

different scenarios in which a tracheal tube is placed either through the mouth or nose, going through the glottis, up to the trachea to provide the patient medicinal gases such as oxygen and inhaled anesthetics [1]. Nowadays, we have at our disposal multiple options for the management of difficult airways, beginning with a more rigid endotracheal cannula or using a cannula for intubation, up to the use of more complex devices, such as supraglottic devices and video laryngoscopes, to mention some which have been developed to increase the success rate for intubation [2].
The digital intubation technique is one of the multiple existing techniques with the variant of being a blind procedure based on anatomical references. It was first performed in 1543 when Andrea Vesalio accomplished intratracheal access of a metallic tube in animals guided by touch. In 1878, Mac Ewen was the first to place an endotracheal cannula in humans using only his touch to administer inhaled anesthetics [3].
Difficulty to secure airway is frequently seen not only in the polytraumatized patient, but also in elective surgical patients. On some occasions, difficult airway predictive scales may not provide an accurate approach to which patients do possess difficult airways. On this note, the anesthesiologist, expert on airway management, and other medical specialties related to airway management, should know, and perform digital intubation when all the other techniques and devices have failed or in environments with limited resources, where healthcare providers do not possess the infrastructure or material necessary to manage airways adequately [3] [4] [5]. Statistics in different studies have shown approximately 30% of all deaths related to anesthetic events are related to difficult airway management, which in turn determines failed intubation and difficult airway management with low incidence problems but serious consequences. Thus, these aspects are considered of utmost importance when airway management in anesthetic events is present [6] [7] [8].

Case Report
We present a 58-year-old female patient with indications for a surgical nasal polyp resection and septumplasty for nasal septum deviation and 100% occlusion of right nasal lumen. Previous medical history consists of chronic rhinosinusitis, diabetes mellitus type 2, and systemic hypertension. She referred allergy to aminophylline. Previous surgeries consist of hysterectomy and previous caesarean section managed with regional anesthesia without complications. During preanesthetic evaluation, ASA II was given. Patient entered operating room, and the only preanesthetic medication given was conventional preoxygenation. Anesthetic induction with fentanyl, etomidate and vecuronium (without documenting exact dosage) was performed without incidents.
Direct atraumatic diagnostic laryngoscopy revealed Cromack-Lehane IV, so five intubation attempts were performed by different anesthesiologists without being able to secure airway. Thus, anesthesia reversal was decided, and patient Anthropometric data and vital signs in Table 1.
On airway physical examination, nasal deviation to the left was observed, buccal aperture of 5.5 cm noticed, interdental distance of 4.6 cm registered, Mallampati grade III, thyromental distance grade III, sternomental distance grade III, micrognatia, short neck without noticeable adenomegaly (Figure 1).
During the new surgical event, preoxygenation with face mask was perfomed at 4 flow volumes. Anesthetic intravenous induction was then started as follows: fentanyl 225 mcg, cisatracurium 5.5 mg, propofol 120 mg. After pharmacological latency, digital intubation was realized after a single attempt, confirmed by capnography curve. Hemodynamic stability is confirmed pre-and post-intubation, and surgical event began without incidents. At the end of the surgical event, patient is extubated without accidents or complications, is sent to the PACU, and later discharged and sent to hospitalization floor.
Digital Intubation Technique: 1) Orotracheal cannula must be covered in topical local anesthetic, mainly at the distal portion.
2) Operator must be located on patient's right side (in case of being righthanded, or vice-versa if left-handed) and in front of the patient. Topical local anesthetic must be applied on index and medium finger of introducing hand once the patient has been induced and preoxygenated.
3) The previously mentioned fingers should slide over the superior surface of

5)
Once the cannula has crossed the vocal cords, the cuff must be inflated so the airway is sealed, and the operator must verify adequate capnography curve and pulmonary auscultation correct tube placement and intubation (Figure 4.)

Discussion
Adequate airway management remains a challenge for the anesthesiologist, either trained or untrained. There are several fewer known alternatives that are   not included in the difficult airway management algorithm, such as the digital intubation without stylet [5] [9]. In several situations, preanesthetic evaluation poses challenges that show an airway might be a difficult airway, which in turn forces the specialist to use different methods to securely ventilate the patient [7].

Conclusion
Digital intubation without stylet is a poorly described technique, with high success rates when performed in expert hands, with a relative risk of airway damage and orotracheal structures. Some health institutes do not possess the resources Open Journal of Anesthesiology to acquire advanced devices for airway rescue. It is because of this that digital intubation without stylet becomes a useful and rational alternative to overcome a difficult airway or a failed intubation in an environment where resources are limited.