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Techniques for Nasal Intubation

Blind Technique

Fiberoptic Nasal Intubation

 

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Techniques for Nasal Intubation

Blind Nasal Intubation Techniques

The approaches for blind and fiberoptic nasotracheal intubation are identical until the tube is actually delivered to the level of the larynx. The patient must have effective topical anesthesia (and vasoconstrictants applied to prevent bleeding), and the tube should be advanced to the level of the hypopharynx. Some patients will benefit from sedation, analgesia, or amnestic agents. With blind nasal intubation tube delivery is done using breath sounds (through the tube) as a guide of proper placement. With fiberoptic nasal intubation placement of the tube into the trachea is done via visualization through the fiberscope.

 

Although nasal intubation can be done using standard tracheal tubes, there are softer tracheal tubes and those with a trigger that allow directional control of the distal tip. Some practitioners thermosoften standard tracheal tubes by placing them in warmed water or saline prior to insertion. Commercially available articulating tubes (trigger pulls distal tip of tube forward) that also have a softer durometer plastic are the Endotrol tube (a Mallinckrodt/Nellcor product) and the Parker Easycurve Articulating tracheal tube (Parker Medical). These tubes make nasal intubation much easier and probably cause less bleeding. A second advantage of the Parker tube design is a symmetric skit-tip shape to the distal tip. This eliminates mechanical interaction problems between a left-facing bevel and the nasal turbinates, and may also lessen the mechanical problems of tube insertion when sliding a tube off of a smaller diameter fiberoptic instrument.

 

Blind Intubation Technique:

1) The soft nasal trumpet proves the patency of the nasal passage and serves as a conduit for topical anesthesia into the hypopharynx and larynx. Note that nasal trumpets have a left-facing bevel. The bevel should always face lateral upon insertion, with the leading edge of the trumpet riding the septum of the nose. For insertion on the left, the trumpet is inserted into the nare at 90 degrees. For insertion on the right, the trumpet is initially inserted with the trumpet curve upside down---the bevel faces laterally and the trumpet inserted at 90 degrees; after clearing the inferior nasal turbinate (about 1/3 to 1/2 of the trumpet length), turn over the trumpet so the curve again face inferiorly (and curve follows exit of nasopharynx into orophraynx).

2) The Endotrol tube and Parker Easycurve tube have a trigger on their proximal ends that can flex the distal tip of the tube. A slight pull of the trigger directs tube downward at the end of the nasopharynx and anterior into the larynx from the hypopharynx. Only a very slight pull is needed. These tubes are also made of softer plastic than standard tubes. The articulation becomes useful leaving the nasopharynx as well as moving the tip anterior (into the trachea) when the tube tip at the level of the larynx.

3) The BAAM (Beck Airflow Airway Monitor, a.k.a., the BAAM whistle) placed on the tube end creates noise as air moves through the tube when the tip is advanced near the larynx. Attach lightly for easy removal.

 

Overview of Nasal Intubation Technique (S-T-S-T-S-T)

Spray, Trumpet, Spray, Tube, Spray, Tube.

Good topical anesthesia from the nares to the larynx is kind to the patient and blunts protective reflexes, permitting tube passage into the trachea. Some patients may also need IV medications, such as opiates, benzodiazepines, and small aliquots (10 mg) of ketamine.

1 S

Anesthetic sprays into nare (combination of oxymetazoline and 4% topical lidocaine – do not exceed 5 cc of 4% lidocaine, i.e., ~200 mg).

2 T

Insert 32 French soft nasal trumpet, lubricated with 2% lidocaine jelly, straight back (90º to face plane), directed midline.

3 S

Spray anesthetic through trumpet twice. Patient will cough as anesthesia hits larynx. Remove trumpet.

4 T

Insert Endotrol tracheal tube to approximately 14–16 cm, keeping the proximal end of the tube directed toward the patient’s contralateral nipple (this directs the tip of the tube toward the midline – see above). Loud breath sounds should be audible through the tube.

5 S

Spray anesthetic once more through tracheal tube.

6 T

Pass tracheal tube through cords on inspiration.

7

Confirm placement (loss of phonation, breath sounds, end-tidal CO2) and secure tube (26 cm at nare for women and 28 cm for men).

 

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