II. Indications: Nasolaryngoscopy mediated Nasotracheal Intubation - Anticipated Difficult Airway

III. Preparation: General

  1. Position patient in comfortable, semirecumbent position (typically 30-45 degrees)
  2. Consider patient arm restraints
  3. Avoid Emesis!
    1. Administer prophylactic Antiemetic (e.g. Ondansetron or Zofran 4-8 mg IV)
  4. Dry the airway
    1. Suction the airway
    2. Drying agents (e.g. Glycopyrrolate) are not typically recommended due to delays
  5. Pre-oxgenate patient (e.g. Nasal Cannula AND Bipap)
    1. See Endotracheal Intubation Preoxygenation
  6. Select a nasotracheal tube
    1. Choose an adequate tube size (e.g. 6-0) or larger if likely to clear nares (e.g. 6-5 or 7-0)
    2. Tube may need to be rotated on insertion
  7. Sedation
    1. Avoid if possible
    2. Consider Midazolam 1-2 mg IV
    3. Consider Ketamine 0.3 to 0.5 mg IV (risk of emergence reaction or Agitation at too low of a dose)

IV. Preparations: Nasopharynx and Oropharynx Anesthesia

  1. Atomize Anesthetic into both nares
    1. Option 1: Atomize Lidocaine 4% 5 cc or more (and optionally Phenylephrine 2%)
      1. Wolf Tory Mucosal Atomization Device (MAD)
      2. MADgic Atomizer
      3. EASY-Spray (reservoir connected to oxygen or air)
    2. Option 2: Insert a urojet Lidocaine tube full cartridge into largest nare
      1. Ask patient if either nare typically obstructs
  2. Anesthetize the remaining airway
    1. Nebulized Lidocaine
    2. Place a Tongue blade with LMX 4% Lidocaine paste on the back of the patient's Tongue
  3. Insert well lubricated Nasal Trumpet into nare with least obstruction
    1. Use Lidocaine Jelly for lubricant
    2. Stop inserting if meets obstruction and try opposite nare (risk of inferior turbinate Trauma)
    3. Atomize Anesthetic again - now via the Nasal Trumpet
    4. Remove Nasal Trumpet and insert the nasal Laryngoscope (see above)
    5. Consider using gloved finger to widen nares

V. Technique: Fiberoptic Nasotracheal tube insertion (preferred)

  1. Fiberoptic techniques have largely supplanted Blind Nasotracheal Intubation
  2. Practice Nasal laryngoscopy outside of emergencies (e.g. evaluation for suspected laryngeal Retained Foreign Body)
  3. Long nasal Laryngoscope (designed for nasal intubation) or bronchoscope is threaded through Endotracheal Tube
  4. Nasal Laryngoscope (or bronchoscope) is inserted via nare (with ET Tube out of nare)
    1. Nasal Laryngoscope maneuvers airway and down through glottis (cords)
  5. ET Tube is pushed into nare over the nasal Laryngoscope and down into glottis (observed to pass tip of scope)
    1. Endotracheal Tube may require rotation to pass the nares
  6. Nasal Laryngoscope is removed

VI. Technique: Fiberoptic Oropharyngeal Insertion

  1. Endoscope is inserted into oropharynx
    1. Variation of fiberoptic nasotracheal placement described above
  2. Preparation
    1. Liberal use of topical orotracheal Anesthesia to prevent Vomiting (see above)
    2. Endoscope size is typically 4-5 mm diameter, and Endotracheal Tube should be at least 1 mm larger
      1. Thread Endotracheal Tube over endoscope before starting procedure
    3. Patient placed in upright or semi-upright position
    4. Assistant performs cervical extension or Jaw Thrust during intubation
  3. Lens fogging
    1. Clean lens with warm soapy water prior to procedure
    2. Flush oxygen through endoscope suction port
    3. Gently tap lens against the mucosa
  4. Endotracheal Tube insertion
    1. Once endoscope is through the Vocal Cords, slide the Endotracheal Tube into position
    2. If unable to advance Endotracheal Tube, consider rotating the tube 90 degrees
  5. References
    1. Warrington (2019) Crit Dec Emerg Med 33(12): 14

VII. Technique: Blind Nasotracheal tube insertion (not recommended)

  1. Blind Nasotracheal Intubation has significant disadvantages when compared with newer techniques
    1. Longer to perform with a higher failure rate
    2. Limited to smaller tube sizes
    3. Reliant on excellent operator Hearing in a noisy environment
      1. Consider attaching Beck Airflow Airway Monitor (BAAM)
      2. BAAM is an ET whistle to top of tube
      3. Precaution: Apply loosely to tube to allow for easy removal
    4. Risk of shearing off inferior nasal turbinate
      1. Test nasal passage first with Nasal Trumpet
  2. Use the larger nare to insert the nasotracheal tube
  3. Endotracheal Tube bevel should open toward lateral nare with leading edge riding the septum
  4. Consider NG tube to facilitate nasotracheal tube passage inferiorly (where there is less chance of Epistaxis)
    1. NG tube is threaded through the nasotracheal tube, then inserted into the nare until it enters mouth
    2. Feed the nasotracheal tube over the NG tube and into the airway and remove the NG tube
    3. Lim (2014) Anaesthesia 69(6): 591-7 [PubMed]

VIII. Contraindications

  1. Apnea
    1. Hearing breath sounds is critical to blind nasotracheal technique
    2. Apnea does not affect fiberoptic technique
      1. However in apnea, standard Endotracheal Intubation would be preferred
  2. Age under 10 years old
    1. Large vascular adenoids can bleed heavily from tube related Trauma
  3. Third trimester pregnancy
    1. Nasal mucosa is engorged and friable and more likely to bleed from tube related Trauma
  4. Combative patients
  5. Distorted airway (e.g. neck Hematoma)
  6. Basilar Skull Fracture (or suspected based on facial Trauma)
  7. Mid-face Fractures
  8. Increased Intracranial Pressure
  9. Upper airway abscess or other infection or obstruction
  10. Coagulopathy (e.g. Warfarin)
  11. Encephalocele
  12. Rapid intubation is critical
    1. Employ Apneic Oxygenation
    2. Other techniques are faster with lower failure rates

IX. Complications

  1. Nasopharyngeal Hemorrhage
  2. Retropharyngeal Perforation (may occur with Blind Nasotracheal Intubation)
  3. Post-Intubation Otitis Media
    1. Occurs in more than a third of patients who are nasotracheally intubated
    2. Ear effusions are common, but treat if infected to cover Pseudomonas, Klebsiella, Enterobacter
      1. Treat infection with Ceftazidime, Imipenem, Piperacillin-Tazobactam or Ciprofloxacin
  4. References
    1. Claffey (1981) Ann Emerg Med 10(3):142-4 [PubMed]

X. Resources

  1. Awake nasal intubation (HQMedEd, Hubbard, Reardon, Jubert)
    1. https://vimeo.com/101452570

XI. References

  1. Goodwin in Walls (2012) Emergency Airway Management, 3rd Ed, Lippincott, Philadelphia, p. 105-11
  2. Levitan (2013) Practical Airway Management Course, Baltimore
  3. Mason, Herbert, Weingart and Merriman in Herbert (2016) EM:Rap 16(7):10-11

Images: Related links to external sites (from Bing)

Related Studies