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Nasal Intubation

With or without fiberoptic assistance, nasal intubation remains a valuable technique in some emergency airway situations, despite its overall decline in use. It is best in patients who are not critically hypoxic and in whom there is obvious oral pathology making intubation and ventilation through the mouth problematic. In these situations, when the mouth is off limits, awake intubation must occur through the nose or through the neck. Examples include severe angioedema of the tongue, and mechanical obstructions to mouth opening from mandibular fixation or other oral pathology. I have also used the technique in patients with fixed neck contracture and limited mouth opening. In situations of…

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  Nasotracheal Intubations with the BAAM Device

Nasotracheal intubation is an essential skill that allows a flexible approach to airway management. These are generally performed with the patient awake and spontaneously breathing and protecting their airway. They can either be performed with a endoscope or blindly. In order for blind nasotracheal intubation to be successful it requires patient respiratory effort and air exchange so that you can listen for air movement from the end f the endotracheal tube. The Beck Airway Airflow Monitor (BAAM) is a device which when attached to a 15 mm endotracheal tube adapter, magnifies airway-airflow sounds, producing a whistling sound which greatly aids in correct endotracheal tube placement.

 Learning and Mastering Nasotracheal Intubations

Nasotracheal intubation is an invaluable tool for securing a definitive in patients where laryngoscopy (either direct or video) would be difficult or has failed. This technique is especially helpful when intubating the patient awake. Endoscope intubations can also be performed orally or even blindly, which we have covered before. Nasotracheal route is generally preferred over the oral route in awake patients because it is better tolerated and the path to supraglottic space is more direct from the nasopharynx.

Articles of Interest

Emergency Medicine Guidewire

Fill 10cc syringe with 5cc 4% lidocaine, 5cc oxymetazoline, Alternatively use 5% liquid cocaine. Inject with atomizer into the nares.

Nasotracheal intubation in the emergency department, revisited

Nasotracheal intubation is a useful alternative to oral intubation, particularly when oral access is compromised. While not the optimal approach, we conclude that NTI is still a valuable method for establishing an airway and should remain among the emergency physician's arsenal of intubation techniques.

Nasotracheal Intubation: An Overview

There are two pathways along which a tube can be introduced through the nasal cavity namely the lower and upper pathway. Lower pathway lies along the floor of the nose and is safer. The upper pathway lies between the inferior turbinate and middle turbinate. The lower pathway is a preferred pathway. We are well versed with the nasal anatomy but not with the anomalies.

The Do's and Don'ts of Nasotracheal Intubation

Insert the nasotracheal tube into the nostril with the flanged end of the tube facing the nasal septum. Gently guide the tube in the anterior-to-posterior direction (the angle should be parallel to the roof of the mouth). As the tube is felt to drop into the posterior pharynx (at approximately 10 cm to 15 cm), listen closely to the patient’s breath sounds. Using the trigger found on the nasotracheal tube and gentle rotation, manipulate the tube until it’s positioned such that breath sounds are loudest.

Resources

Life in the Fastlane

when passing a nasal trumpet or ETT ensure the bevel faces the turbinates (laterally) and that the tube is advanced along the septum (medially) and the floor of the nasal cavity (which is perpendicular to the plane of the face)

The Airway Jedi

Maximize the size of the nasal passage and minimize the risk for bleeding by using a nasal vasoconstrictor such as oxymetazolone or phenylephrine. If using cocaine, monitor hemodynamic effects. By gently passing progressively larger, well-lubricated nasal airways you will both lubricate and test the passage for size and obstructions.