The concept of finger guide intubation was first described in 1543 when Vesalius mentioned how to place a tube into the trachea for control of ventilation. In 1941 Ross and Strong reported using this concept for neonatal resuscitation. Sensing it was not gaining traction among clinicians, in 1968 Woody and Woody advocating this technique again arguing in experienced hands it only took 3–5 s [3]. In 1992 Hancock reported their experiences with finger intubation in newborns and stated it was their preferred method of intubation among physician or nurse once learned [4]. In 2011 Xue pointed out that finger guided intubation in newborns and infants with difficult airways is a possible ignored technique [5].
Nanjing Children’s hospital is one of the largest PRS treatment centers in China. In 2017 alone, we treated 225 patients with PRS including 8 neonates, 24 infants aged 1~3 months, 54 infants aged 3~6 months, as well as 98 infants aged 6~12 months. We are well versed in direct laryngoscopy as well as all advanced airway equipment such as GlideScope, fiberoptic scope, lighted wand, LMA or combination of those instruments. This patient was born by G4P3 mother with 2 normal siblings. We didn’t anticipate too much of difficulty when it was time to secure his airway thinking he was just another patient with PRS. The combination of PRS, cleft palate and the presence of vallecular cyst made this into a cascade reaction of difficult airway. The cyst pushed patient’s epiglottis downward which almost completely obscured the view of patient’s vocal cord. Direct laryngoscopy, glidescope, size 1 LMA, fiberoptic scope as well as lighted wand all failed to establish his airway. Ultimately it was the finger guide intubation, this old technique without any equipment, that eventually rescued this patient from lose of airway. Tracheostomy would have been plan B had digital intubation failed, however, tracheostomy has its own complication such as sudden airway obstruction from accidental decannulation, or mucous plugging; airway infections, tracheal obstruction and inhibition of proper speech and swallowing development.
After this, we made a point to teach this technique to our trainees and junior attending physicians. The contents of the course include guided learning in neonates with normal anatomy/abnormal anatomy and guided learning using manikin models. Familiarity with the technique makes it possible to quickly confirm intubation where unexpected anatomic abnormalities emerges with no immediate availability of hightech airway equipment. Sometimes neonates born with meconium aspiration are hard to be intubated due to poor visualization because of meconium soiling of larynx. Likewise, in ruptured airway vascular abnormality, digital intubation might be the only means to secure patient’s airway when blood gushing out of patient’s mouth. For newborns, the fingers are more flexible than the laryngoscope therefore easier to touch the position of the epiglottis. Plus, there is no need to stoop or bend to adjust eye level, no need for equipment not even lighting source. Having said that, an obvious limitation factor for newborns is the size (airway versus clinician’s finger), it might be very difficult to do digital intubation by a beefy hand trying to negotiate inside a neonate’s very small upper airway.
At a tertiary Children’s Hospital specialized in treating pediatric Pierre Robin Sequence, we had to resort to old fashioned digital intubation to finally secure the airway of this PRS neonate due to unique anatomy. Therefore, perhaps there should be a role of this technique so future anesthesia providers will have one more weapon in their armamentarium of airway management. The anesthesiologist’s newborn rescue intubation training should include the finger guide intubation.
