II. Indications: Nasolaryngoscopy mediated Nasotracheal Intubation - Anticipated Difficult Airway
- Epiglottitis
- Mandible Fracture
- Angioedema
- Airway Burns
- Ludwig's Angina
III. Contraindications
- Apnea
- Hearing breath sounds is critical to blind nasotracheal technique
- Apnea does not affect fiberoptic technique
- However in apnea, standard Endotracheal Intubation would be preferred
- Age under 10 years old
- Large vascular adenoids can bleed heavily from tube related Trauma
- Third trimester pregnancy
- Nasal mucosa is engorged and friable and more likely to bleed from tube related Trauma
- Combative patients
- Distorted airway (e.g. neck Hematoma)
- Basilar Skull Fracture (or suspected based on facial Trauma)
- Mid-face Fractures
- Increased Intracranial Pressure
- Upper airway abscess or other infection or obstruction
- Coagulopathy (e.g. Warfarin)
- Encephalocele
- Rapid intubation is critical
- Employ Apneic Oxygenation
- Other techniques are faster with lower failure rates
IV. Management: Equipment
- Flexible fiberoptic scope >60 cm
- Nasopharyngeal Airway
-
Endotracheal Tube (6.0 to 7.0)
- Warm the Endotracheal Tube in a pocket or warmer to soften
- Flexible tip ET Tubes are available (Parker Flex-tip)
-
Anesthetic
- Lidocaine 4% aqueous solution
- Lidocaine 4-5% ointment (e.g. LMX)
-
Anesthesia Applicators
- Tongue blades
- Cotton-tipped applicators
- Atomizers (e.g. MADD)
- Sedation
V. Management: General
- Position patient in comfortable, semirecumbent position (typically 30-45 degrees)
- Consider patient arm restraints
- Avoid Emesis!
- Administer prophylactic Antiemetic (e.g. Ondansetron or Zofran 4-8 mg IV)
- Dry the airway
- A wet airway is difficult to topicalize with Anesthetic
- Suction the airway
- Consider drying agents (e.g. Glycopyrrolate 0.4 mg IV) if no significant delay
- Oxymetazoline (Afrin) 4 sprays in nare to reduce risk of Nasal bleeding
- Pre-oxgenate patient (e.g. Nasal Cannula AND Bipap)
- Select a nasotracheal tube
- Choose an adequate tube size (e.g. 6-0) or larger if likely to clear nares (e.g. 6-5 or 7-0)
- Tube may need to be rotated on insertion
- Sedation
VI. Preparations: Nasopharynx and Oropharynx Anesthesia
- Adequate topical Anesthesia is critical to success of awake intubation
- Atomize Anesthetic into both nares
- Option 1: Atomize Lidocaine 4% 5 cc or more (and optionally Phenylephrine 2%)
- Wolf Tory Mucosal Atomization Device (MAD)
- MADgic Atomizer
- EASY-Spray (reservoir connected to oxygen or air)
- Option 2: Insert a urojet Lidocaine tube full cartridge into largest nare
- Ask patient if either nare typically obstructs
- Option 1: Atomize Lidocaine 4% 5 cc or more (and optionally Phenylephrine 2%)
- Anesthetize the Tongue
- Reduce the Gag Reflex with a Glossopharyngeal Nerve block
- Dip 2 small cotton-tipped applicators in aqueous Lidocaine
- Apply 1 applicator to each base of the Tonsillar Pillars
- Leave cotton-tipped applicators in place for 2 minutes
- Atomize Lidocaine into the posterior pharynx and airway
- Insert the atomizer (e.g. MADD) and spray while the patient takes deep breaths
- Additional Lidocaine is applied to Vocal Cords via scope
- See below
- Insert well lubricated Nasal Trumpet into nare with least obstruction
- Use Lidocaine Jelly for lubricant
- Stop inserting if meets obstruction and try opposite nare (risk of inferior turbinate Trauma)
- Atomize Anesthetic again - now via the Nasal Trumpet
- Remove Nasal Trumpet and insert the nasal Laryngoscope (see above)
- Consider using gloved finger to widen nares
- Avoid Nebulized Lidocaine
- Most of Nebulized Lidocaine is delivered to alveoli
- Alveolar Lidocaine absorption may be very high
- Increased risk of LAST Reaction when combined with other Anesthetic exposures
VII. Technique: Fiberoptic Nasotracheal tube insertion
- Fiberoptic techniques have largely supplanted Blind Nasotracheal Intubation
- Practice Nasal laryngoscopy outside of emergencies (e.g. evaluation for suspected laryngeal Retained Foreign Body)
- Requires adequate topical airway Anesthesia (see above)
- Liberal use of topical Anesthesia prevents Vomiting (see above)
- Any gagging by patient during the procedure should be met with repeat Anesthesia application
- Endotracheal Tube is inserted into nose and passed into posterior pharynx, but still well above cords
- Long nasal Laryngoscope (designed for nasal intubation) or bronchoscope is threaded through Endotracheal Tube
- Pass the endoscope into the ET Tube (as it passes through the Nasopharyngeal Airway)
- Nasal Laryngoscope maneuvers airway and down toward glottis (cords)
- Use the scope port to spray 4% Lidocaine aqueous solution over the cords before advancing tube
- Once endoscope is sufficiently through the Vocal Cords, slide the Endotracheal Tube into position
- If unable to advance Endotracheal Tube, consider rotating the tube 90 degrees
- Lens fogging
- Clean lens with warm soapy water prior to procedure
- Flush oxygen through endoscope suction port
- Gently tap lens against the mucosa
- Once ET Tube is placed within the airway, start induction/sedation agent (e.g. Ketamine, Propofol, Fentanyl)
VIII. Technique: Blind Nasotracheal tube insertion (not recommended)
- Blind Nasotracheal Intubation has significant disadvantages when compared with newer techniques
- Longer to perform with a higher failure rate
- Limited to smaller tube sizes
- Reliant on excellent operator Hearing in a noisy environment
- Consider attaching Beck Airflow Airway Monitor (BAAM)
- BAAM is an ET whistle to top of tube
- Precaution: Apply loosely to tube to allow for easy removal
- Risk of shearing off inferior nasal turbinate
- Test nasal passage first with Nasal Trumpet
- Use the larger nare to insert the nasotracheal tube
- Endotracheal Tube bevel should open toward lateral nare with leading edge riding the septum
- Consider NG tube to facilitate nasotracheal tube passage inferiorly (where there is less chance of Epistaxis)
- NG tube is threaded through the nasotracheal tube, then inserted into the nare until it enters mouth
- Feed the nasotracheal tube over the NG tube and into the airway and remove the NG tube
- Lim (2014) Anaesthesia 69(6): 591-7 [PubMed]
IX. Complications
- Nasopharyngeal Hemorrhage
- Retropharyngeal Perforation (may occur with Blind Nasotracheal Intubation)
- Post-Intubation Otitis Media
- Occurs in more than a third of patients who are nasotracheally intubated
- Ear effusions are common, but treat if infected to cover Pseudomonas, Klebsiella, Enterobacter
- Treat infection with Ceftazidime, Imipenem, Piperacillin-Tazobactam or Ciprofloxacin
- References
X. Resources
- Awake nasal intubation (HQMedEd, Hubbard, Reardon, Jubert)
XI. References
- Goodwin in Walls (2012) Emergency Airway Management, 3rd Ed, Lippincott, Philadelphia, p. 105-11
- Levitan (2013) Practical Airway Management Course, Baltimore
- Laurin and Schandera (2024) Difficult Airway Course, attended 9/7/2024
- Mason, Herbert, Weingart and Merriman in Herbert (2016) EM:Rap 16(7):10-11