The technique of submental endotracheal intubation has been established as a safe alternative to tracheostomy and can be utilized when oro tracheal and naso tracheal routes of intubation are not. Endotracheal intubation is the approved way of providing breathing support to covid19 coronavirus disease patients as of this articles update in early april, 2020 noninvasive mechanical ventilation like cpap continuous positive airway pressure machines used for sleep apnea are not good for covid19 patients, according to clinical guidelines from the american society of anesthesiologists. From may 2008 to august 2010, 23 patients with different conditions were intubated by submental route of tracheal intubation and patients were evaluated on different parameters during and after surgery to find its efficacy, indications and utilization in maxillofacial surgeries. Introduction management of airway is a significant issue in. Sep 22, 2012 from may 2008 to august 2010, 23 patients with different conditions were intubated by submental route of tracheal intubation and patients were evaluated on different parameters during and after surgery to find its efficacy, indications and utilization in maxillofacial surgeries. Tracheostomy complications include haemorrhage, surgical emphysema, wound site infection, recurrent laryngeal nerve injury, tracheal stenosis, poor scar aesthetics, tracheoarterial fistula and death 30, 46, 55. This conditioning of inhaled gas filtration, heating and humidification is important to the. This method was recently implemented in the case of a patient with altered nasal anatomy who sustained a mandibular fracture necessitating. A comparison of different techniques of airway access in complex maxillofacial injury is. Submental intubation technique for airway during surgery.
The present study was planned to assess the efficacy, utility and complications of transmylohoid intubation in facial polytrauma patients, by setting and design. Fiberoptic assisted submental endo tracheal intubation a good and safe alternative to tracheostomy introduction s urgical repair of maxillofacial trauma requires modification of the standard anaesthesia technique. Endotracheal tube insertion or endotracheal intubation ei is an emergency procedure most often performed in patients who are unconscious or who cannot breathe on their own. Adam law, md,frcpca,e f in 1878, william macewen1 was the first to use endotracheal intubation for a patient who had cancer of the base of the tongue rather than tracheostomy, as was routine. In contrast, the submental route for endotracheal intubation represents a fast and lowmorbidity alternative to tracheostomy. A 2 cm long incision was made 2 cm from the midline, 2 cm medial to and parallel with the mandible in the submental region 222 rule. Nasal tracheal intubation after severe craniomaxillo. Transmylohoidsubmental endotracheal intubation in panfacial. In comparing submental intubation and tracheostomy, submental intubation has no significant reported major complications. After standard orotracheal intubation, a passage was created by blunt dissection with a hemostat clamp through the floor of the mouth in the submental area. An alternative to the classic methods is the submental route for tracheal. Perforation or laceration of upper esophagus, vocal cords, larynx 4.
After intravenous induction of anaesthesia, traditional orotracheal intubation and insertion of a throat pack was performed. At the end of the procedure, extubation is done through. Jun 01, 20 submental endotracheal intubation, as compared to the use of tracheotomy, is an alternative for the surgical management of maxillofacial trauma, as described by altemir fh the submental route for endotracheal intubation. Submental endotracheal intubation is a simple, useful and safe technique in maxillofacial trauma when oral and nasal endotracheal intubation cannot be performed. Using the bougie for endotracheal intubation duration. For millennia, tracheotomy was considered the most reliable and most risky method of tracheal intubation. Entire intubation sequence using the macintosh blade duration. Submental intubation technique for airway during surgery of. In order to avoid tracheostomy, submental endotracheal intubation was. Tracheal intubation eliminates the participation of the upper airways, and the air inhaled enters the lower respiratory tract directly without going through the normal process of conditioning. Medical records of 25 patients who had surgical reduction of midfacial or panfacial fractures while securing their airway with. It is frequently performed in critically injured, ill, or anesthetized patients to facilitate ventilation of the lungs, including mechanical ventilation, and to. Submental endotracheal intubation, as compared to the use of tracheotomy, is an alternative for the surgical management of maxillofacial trauma, as described by altemir fh the submental route for endotracheal intubation.
It is frequently performed in critically injured, ill, or anesthetized patients to facilitate ventilation of the. Submental intubation in oral maxillofacial surgery. Submental intubation steps of the procedure explained. Submental intubation in oral maxillofacial surgery submental intubation in oral maxillofacial surgery. Although the submental endotracheal intubation is a useful technique, a wide range of complications have been reported in. This procedure consists of exteriorizing an oral endotracheal tube through the floor of the mouth and submental triangle. Pdf acquisition of a secure airway is an essential element of the operative management of. In addition, the anesthesiologist has probably included the intubation in the anesthesia fee, of which it is typically considered a part. Despite the widespread use of submental intubation for other purposes, it was bogi and incze in 1996 who recommended the use of submental intubation in elective osteotomies.
St georgesutherland hospitals and health services workplace. Sep 25, 2015 submental intubation steps of the procedure explained 1. Definitiondefinition endotracheal intubation is the placement of a flexible plastic tube into the trachea to maintain an open airway or to serve as a conduit through which to administer certain drugs. We utilized submental endotracheal intubation in such situations and the experience has. Icu nursing practice committee, j cosgrove february 2014 page 1 of 20 st georgesutherland hospitals and health services intensive care unit intubation and tracheal tube management cross references. Submental tracheal intubation avoids the complications associated with tracheostomy and the difficulty of nasal intubation during intubation and surgery. Therefore, absolute assurance of the patients ability to protect his airway was necessary prior to submental extubation. Submentaltransmylohyoid route for endotracheal intubation. Transmylohoidsubmental endotracheal intubation in pan.
Icu nursing practice committee, j cosgrove february 2014 page 1 of 20. Therefore, submental tracheal intubation is useful in the intraoperative management of patients with complex maxillofacial trauma. When an intubation is performed in the emergency department, however, it may sometimes be coded separately using 31500 intubation, endotracheal, emergency procedure. After routine oro tracheal intubation with a sterile, disposable, armoured ett, under the aseptic precautions, a 1. Complications from submental endotracheal intubation. Ei helps to prevent suffocation or obstruction of the passage of air. Aziz darwish b, ismail faraj b, hesham elzenati c, yasir altrai. It prevents need for tracheostomy and its consequent morbidity. This study was conducted between may 2008 and may 2011 and 35 patients of facial polytrauma were included irrespective of sex, caste and religion. Page 1 of 6 standardized procedure manual sp 303 endotracheal intubation i. Any complications occurring after submental extubation, such as emesis with aspiration or laryngospasm, would have. Intubation may be contraindicated for patients that are known diabetics or narcotics overdoses, prior to the administration of dextrose or narcan.
Rapporterede komplikationer i forbindelse med submental intubation. By the late 19th century, advances in the sciences of anatomy and physiology. By the late 19th century, advances in the sciences of anatomy and physiology, as well as the beginnings of an appreciation of. Pdf submental endotracheal intubation, as compared to the use of tracheotomy, is an alternative for the surgical management of maxillofacial. The proximal end of the orotracheal tube was pulled through the submental incision.
Submental intubation versus unhindered access to the operative field. The purpose of this retrospective study was to evaluate the efficacy and complications of this technique. Hernandez first described the submental route for endotracheal intubation in 1986 as an alternative airway maneuver for maxillofacial procedures. Tracheal intubation under direct laryngoscopy duration. A flexible and kinkresistant reinforced endotracheal tube. This video demonstrates how to perform orotracheal intubation. After routine orotracheal intubation with a sterile, disposable, armoured ett, under the aseptic precautions, a 1. Pdf submental endotracheal intubation cassiano pereira. Emergency orotracheal intubation is indicated in any situation that requires definitive control of the airway. Up to 40% of cases are associated with marked hypoxemia or hypotension. The average total duration from oral endotracheal intubation to submental tracheal intubation was 36. Although the submental endotracheal intubation is a useful technique, a wide range of complications have been.
Icu nursing practice committee, j cosgrove february 2014 page. Submental endotracheal intubation as an alternative to. An intraoperative radiograph shows the course of the endotracheal tube through the sub mental route figure 3 results the technique of submental intubation was used in a. Tracheal intubation may also be used to control ventilation paco2 and to administer medications such as surfactant and those indicated for cardiorespiratory arrest. Submental tracheal intubation is a technique for use in patients with maxillofacial trauma. Pdf complications from submental endotracheal intubation. In the submental tracheal intubation group, the patients did not require ventilation support in the icu. Submandibular intubation is a modification of submental intubation, first described by hernandez altemir 8 in 1986 as an alternative method for shortterm tracheostomy, when both oro tracheal and naso tracheal intubation are contraindicated, impossible, or may interrupt the surgical access or techniques. Even in the hospital, despite advances in monitoring and management, the need for urgent or emergent endotracheal intubation occurs with regular frequency. Submental approach for oral endotracheal intubation in. Figure 2 demonstrates excellent exposure allowed because of unobtrusive location of the endotracheal tube. All the selected 35 patients were male and the age of patients. This method was recently implemented in the case of a patient with altered nasal anatomy who sustained a mandibular fracture.
Submental intubation international journal of oral and. This procedure avoids the use of tracheostomy and bypasses its associated morbidities. For aeromedical settings, the percentage of patients undergoing tracheal intubation is 18. Endotracheal tube rerouted through submental space and fixed to. Submental tracheal intubation in oromaxillofacial surgery original. Nov 10, 2007 entire intubation sequence using the macintosh blade duration.
Submental intubation was first reported by francisco hernandez altemir in 1986 as a procedure that could avoid tracheostomy and allow for the concomitant restoration of occlusion and reduction of facial fractures in patients ineligible for nasotracheal intubation 8. Since that time, several case studies have been performed demonstrating the efficacy of the submental approach. We present a case of multiple facial fractures leefortii were later on converted to submental intubation which avoided the need for tracheostomy. Submental intubation as an alternative to tracheostomy in patients with midfacial trauma submental intubation is a safe procedure which can be used tabel 1. Thus, submental intubation is a simple, safe, with low morbidity technique for operative. Tracheal intubation technique as previously discussed, because of differences in anatomy, there are differences in techniques for intubating the trachea of infants and children compared with adults. Tracheal intubation usually simply referred to as intubation, an invasive medical procedure, is the placement of a flexible plastic catheter into the trachea. Submental endotracheal intubation in concurrent orthognathic. Endotracheal intubation ei is an emergency procedure thats often performed on people who are unconscious or who cant breathe on their own. Efficacy and complications of submental tracheal intubation. In these cases, submental route of endotracheal intubation is simple and safe alternative to tracheostomy and its consequent morbidity. Endotracheal intubation in the icu critical care full text.
The icu patient is physiologically very different from the usual patient who undergoes intubation in the operating room, and different intubation techniques should be considered. Thus,submental intubation is a simple, safe, with low morbidity technique for operative. Appropriate broad spectrum antibiotic, preferably amoxicillin and clavulanic acid, is given intravenously 1 h prior to the. The submental route for endotracheal intubation has been proposed as an alternative to tracheotomy in the surgical management of patients with maxillofacial trauma. This standardized procedure is designed to establish guidelines that will enable the advanced life support als registered nurse rn and advanced life support als respiratory therapist rt to perform endotracheal intubation while on transport.
Facilitating submental endotracheal intubation with an. Anaesthesia was maintained with a mixture of oxygen, nitrous oxide and sevoflurane in all cases. Indications for submental intubation are maxillofacial injuries with. In patients who require intubation for maxillofacial. Fiberoptic assisted submental endotracheal intubation a. We can consider that any patient requiring ventilatory support by means of pulmonary ventilation mechanical has an indication for tracheal intubation. Submental intubation in patients with complex maxillofacial injuries.
Macinnis and baig published a single elective case of simultaneous le fort iii midface advancement and sagittal ramus osteotomy for mandibular setback. Hernandez altemir f first described the use of submental intubation as an alternative route to secure the airway through oral or nasal intubation. Panfacial fractures or concomitant nasoethmoidal injuries. The conventional submental intubation technique essentially involves creation of an orocutaneous tunnel and diverting the proximal end of the armoured ett through anterior floor of the mouth. Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic tube into the trachea windpipe to maintain an open airway or to serve as a conduit through which to administer certain drugs. Nov, 2012 hernandez first described the submental route for endotracheal intubation in 1986 as an alternative airway maneuver for maxillofacial procedures. Submental intubation in oral maxillofacial surgery med oral patol oral cir bucal.
Securing a childs nasal endo tracheal tube ett duration. Workplace instruction manual st george intensive care unit approved by. It avoids retromolar intubation tracheostomy and its disadvantages. Endotracheal intubation in the icu is a highrisk procedure, resulting in significant morbidity and mortality.
An alternative for tracheostomy was first described by hernandez altemir in 1986. Submental intubation permitted reduction and fixation of all the fractures without the interference of the tube during surgical procedure in all of the patients. The contraindications of submental intubation are patients refusal, bleeding diathesis, laryngotracheal disruption, infection at the proposed site, gunshot injuries in the maxillofacial region, longterm airway maintenance, tumor ablation in maxillofacial region, and history of keloid formation. Twentytwo 88% of the 25 cases had minor or moderate head injury gcs.