Nasotracheal Intubation

Aka: Nasotracheal Intubation, Fiberoptic Nasal Intubation, Fiberoptic Oral Intubation, Endoscopic Intubation, Blind Nasotracheal Intubation, Blind Nasal Intubation, Awake Nasotracheal Intubation

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

  1. Epiglottitis
  2. Mandible Fracture
  3. Angioedema
  4. Airway Burns
  5. Ludwig's Angina

III. 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

IV. Management: Equipment

  1. Flexible fiberoptic scope >60 cm
  2. Nasopharyngeal Airway
  3. Endotracheal Tube (6.0 to 7.0)
    1. Warm the Endotracheal Tube in a pocket or warmer to soften
    2. Flexible tip ET Tubes are available (Parker Flex-tip)
  4. Anesthetic
    1. Lidocaine 4% aqueous solution
    2. Lidocaine 4-5% ointment (e.g. LMX)
    3. Anesthesia Applicators
      1. Tongue blades
      2. Cotton-tipped applicators
      3. Atomizers (e.g. MADD)
  5. Sedation
    1. Avoid significant sedation if possible
      1. Sedation may result in apnea or loss of muscular tone
    2. Consider Midazolam 1-2 mg IV in adults
    3. Consider Ketamine 0.1 to 0.15 mg/kg IV doses in adults
      1. Consider administering in small, 10 mg IV doses
      2. Risk of emergence reaction or Agitation (esp. doses >0.3 mg/kg)

V. Management: 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. A wet airway is difficult to topicalize with Anesthetic
    2. Suction the airway
    3. Consider drying agents (e.g. Glycopyrrolate 0.4 mg IV) if no significant delay
    4. Oxymetazoline (Afrin) 4 sprays in nare to reduce risk of Nasal bleeding
  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)

VI. Preparations: Nasopharynx and Oropharynx Anesthesia

  1. Adequate topical Anesthesia is critical to success of awake intubation
  2. 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
  3. Anesthetize the Tongue
    1. Cover a Tongue blade with 4 to 5% Lidocaine paste
    2. Place the paste side down over the Tongue and leave in place for 2 minutes
    3. Allow the Lidocaine to drip down the posterior Tongue and posterior pharynx
  4. Reduce the Gag Reflex with a Glossopharyngeal Nerve block
    1. Dip 2 small cotton-tipped applicators in aqueous Lidocaine
    2. Apply 1 applicator to each base of the Tonsillar Pillars
    3. Leave cotton-tipped applicators in place for 2 minutes
  5. Atomize Lidocaine into the posterior pharynx and airway
    1. Insert the atomizer (e.g. MADD) and spray while the patient takes deep breaths
  6. Additional Lidocaine is applied to Vocal Cords via scope
    1. See below
  7. 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
  8. Avoid Nebulized Lidocaine
    1. Most of Nebulized Lidocaine is delivered to alveoli
    2. Alveolar Lidocaine absorption may be very high
      1. Increased risk of LAST Reaction when combined with other Anesthetic exposures

VII. Technique: Fiberoptic Nasotracheal tube insertion

  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. Requires adequate topical airway Anesthesia (see above)
    1. Liberal use of topical Anesthesia prevents Vomiting (see above)
    2. Any gagging by patient during the procedure should be met with repeat Anesthesia application
  4. Endotracheal Tube is inserted into nose and passed into posterior pharynx, but still well above cords
  5. Long nasal Laryngoscope (designed for nasal intubation) or bronchoscope is threaded through Endotracheal Tube
    1. Pass the endoscope into the ET Tube (as it passes through the Nasopharyngeal Airway)
    2. Nasal Laryngoscope maneuvers airway and down toward glottis (cords)
    3. Use the scope port to spray 4% Lidocaine aqueous solution over the cords before advancing tube
  6. Once endoscope is sufficiently through the Vocal Cords, slide the Endotracheal Tube into position
    1. If unable to advance Endotracheal Tube, consider rotating the tube 90 degrees
  7. 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
  8. Once ET Tube is placed within the airway, start induction/sedation agent (e.g. Ketamine, Propofol, Fentanyl)
    1. Confirm placement with immediate EtCO2
    2. Avoid giving full induction dose before ET Tube secured (postural tone may be lost along with airway)
    3. Until tube is placed, use lower Sedative doses for anxiolysis, analgesia (e.g. Ketamine 0.1 mg/kg up to 10-15 mg doses)

VIII. 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]

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. Laurin and Schandera (2024) Difficult Airway Course, attended 9/7/2024
  4. Mason, Herbert, Weingart and Merriman in Herbert (2016) EM:Rap 16(7):10-11

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