Emergency endotracheal intubation in failed mask ventilation, using a cross-finger technique

11 Aug

Abstract: Reported is a case of successful endotracheal intubation in an emergency situation with failed mask ventilation, wherein after the malleable plastic stylet broke into two pieces, a cross-finger technique to hold the endotracheal tube allowed us to successfully secure the airway.

Key-words: Difficult mask ventilation, Difficult laryngoscopy and intubation

Key Messages: Unexpected/emergency difficult airway management can be a night-mare even for the experienced anaesthesiologist because not only is there a shortage of resources in terms of limited options but the time available is also too short to think of alternative techniques.


The difficult airway is a challenge to all critical care physicians or anesthetists. In the anesthesia literature, frequency ranges from 0.4 to 8.5 % (1, 2, 3) of all elective intubations. In emergency medicine literature, it is more common, ranging from 2 to 14.8 % (4). The American Society of Anesthesiologists (ASA) Task Force on management of difficult airway defines it as ‘the clinical situation in which a conventionally trained anesthesiologist experiences difficulty with face mask ventilation of upper airway, difficulty with tracheal intubation or both’(5). Stylet guided intubation particularly lighted stylet guided is a useful technique in patients with difficult airway.

An anterior larynx is one of the most common anatomic features associated with difficult laryngoscopy (6). Currently, there are several options available for management of anticipated difficult airway. These include, but are not limited to, Flexible Fiberoptic Intubation (FFI), Intubating Laryngeal Mask Airway (ILMA) assisted ETI, Lightwand aided ETI, Indirect fiberoptic laryngoscope aided ETI [Bullard TM, Upsher-Scope TM], Gum-elastic bougie aided ETI and Retrograde intubation. Rapid airway assessment is the only means of identifying a difficult airway in emergency. In an unexpected/emergency difficult airway situation, the options available for an anesthesiologist are pretty scarce. Rapidly and correctly securing the airway is of prime importance.

Case History: A 65-year male, having Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation presented to the Emergency Room (ER) with gasping respiration. Radial pulse was regular with a rate of 110/min, bounding in character, blood pressure was 150/94 mmHg and SpO2 was 70%. Auscultation of the chest revealed markedly reduced air entry with prominent rhonchi. Arterial Blood Gas Analysis revealed severe hypoxemia, hypercarbia and uncompensated respiratory acidosis (PaO2 = 50 mmHg, PaCO2 = 82 mmHg, pH = 7.12, Bicarbonate =25 mEq/L). As the patient had features of respiratory failure, emergency ventilatory support was dictated. Airway of the patient was examined using the Rapid assessment (One finger for insinuation test – Temporomandibular joint mobility, Two fingers for mouth opening and Three fingers for thyromental distance). Patient was edentulous with sinking cheeks and an anterior larynx – prominent Adam’s apple. As difficult mask ventilation was anticipated, gauze pieces were fluffed and compressed inside the mouth along the buccal pouches to restore cheek fullness.

Despite this, it was not possible to ventilate the patient with bag and face-mask and hence decision for immediate ETI using rapid sequence technique was taken. Direct laryngoscopy with Macintosh blade size 4 revealed difficulty in lifting the epiglottis (Cormack-Lehane grade IIIa). Immediately the laryngoscope was changed to McCoy flexi-tip blade size 4 with short (stubby) handle, with which the epiglottis was lifted yet only a partial view of the glottis was visible (Percentage Of Glottic Opening POGO = 33%). Endotracheal tube (ETT) 8.0 mm internal diameter rail-roaded over pre-lubricated malleable plastic stylet was advanced under the epiglottis and the assistant anesthesiologist was asked to pull out the stylet while the first person tried to push it in. Just as the stylet was being manipulated, it broke into two pieces at the bend. To avoid the distal part of the broken stylet from entering the trachea, the ETT was withdrawn as such.

Laryngeal mask airway was available but as the patient was to be put on ventilator, it was not tried. Fiberoptic bronchoscope was not available in the emergency room. So, another ETT was taken and held in between crossed fingers such that the index finger was above and the middle finger was below the tube. Using opposing forces at these two fingers, the curvature of the tube was increased and the tube passed beneath the epiglottis into the trachea. Successful ETI was confirmed by bilaterally equal chest rise, bilaterally equal air-entry on auscultation and an increasing SpO2. This was a desperate situation as other means of ETI including FFI were either not available or not feasible.


The management of difficult airway has gained increasing interest because it is associated with high morbidity and mortality due to hypoxia (7). In our case, two risk-factors viz. Elderly (65 yrs) and edentulous were present. Patient had sinking cheeks and anterior larynx. These factors were enough to anticipate difficult mask ventilation. To improve the situation, gauze-pieces were fluffed inside the mouth along the buccal pouches to restore cheek fullness but it did not help in mask ventilation hence decision for immediate ETI using Rapid Sequence Intubation was taken.

While putting the stylet as indicated in patients with difficult airway stylet broke into two pieces. To prevent the entry of broken stylet into the trachea, ETT was removed. Another ETT held in between crossed index and middle fingers with pressure applied to give curvature to ETT was then passed beneath the epiglottis into the trachea. Patient was intubated using this manoeuvre.

No such technique or procedure, as per our knowledge, is present in the literature of anesthetic technique. It is an innovation which can be used in patients with difficult airway as we have applied in a patient with anterior larynx. We later tried to reproduce this technique in other patients with similar predictive factors, and all attempts were successful.


Our innovation, what we call as Cross-finger pressure technique, is a simple procedure and of great advantage in cases with difficult intubation.


  1. Burkle CM, Walsh MT, Harrison BA, Curry TB, Rose SH. Airway management after failure to intubate by direct laryngoscopy: outcomes in a large teaching hospital. Can J Anaesth 2005; 52: 634-40.
  2.  Samsoon GLT, Young JRB. Difficult tracheal intubation: a retrospective study. Anaesthesia 1987; 42: 487–90.
  3. Crosby ET, Cooper RM, Douglas MJ, Doyle DJ, Hung OR, Labrecque P et al. The unanticipated difficult airway with recommendations for management. Can J Anaesth1998; 45(8): 757–76.
  4. Sagarin MJ, Barton ED, Chng YM, Walls RM. Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. Ann Emerg Med 2005; 46(4): 328–36.
  5. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003; 98(5): 1269–77.
  6. Connelly NR, Ghandour K, Robbins L, Dunn S, Gibson C. Management of unexpected difficult airway at a teaching institution over a 7-year period. J Clin Anesth 2006;18(3): 198-204.
  7.  Krafft P, Frass M. The difficult airway. Wien Klin Wochenschr 2000; 112(6): 260-70.

Dr. Sunny Malik, Dr. Pratik Tantia, Dr. Shahin N Jamil, Dr. Rohit Varshney

Corresponding Author:

Dr. Sunny Malik
Post-graduate student,
Department of Anaesthesiology, J.N. Medical College Hospital,
Aligarh Muslim University, Aligarh, India
E mail: dr.malik_sunny@yahoo.co.in
Contact No. : +91-9873915911, +91-9410644701.

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