Airway Skills 9:
Nasotracheal Intubation
- While talking to the patient, anesthetize the nasal passages and posterior pharynx as described in Vol II—Air Skills 10 Topical Anesthesia. Select a 7.0 Endotrol (Mallinckrodt, Inc.) ET tube and lubricate it well after testing its balloon cuff.
The Endotrol tubes come in sizes 6, 7, and 8. They have a plastic ring at the proximal end that, when pulled up, causes the tip of the tube to bend as shown.
- Select the nares that seems to have the largest pathway to the pharynx. Look for septal deviation. Insert the ET tube directly backward over the superior surface of the hard palate. Be sure the cuff is fully deflated. When the tube is in the posterior nasopharynx, pull the trigger of the Endotrol tube so that it does not scrape the adenoid tissue in the rear of the pharynx. Advance it further until the patient's breath can be heard coming through the ET tube.
- When the patient inhales, advance the ET tube and it may go right into the larynx and trachea. If it does, the patient will try to cough. The patient will not be able to speak. If it does not go into the trachea, pull it back until the breath sounds are heard again. This time, turn the ET tube 1/4 turn counterclockwise and try again. Turning the ET tube in this way changes the orientation of the bevel so that it spreads the arytenoids rather than being deflected to the side. If this fails, pull back the ET tube as before and insert a tracheal suction catheter through the ET tube. When the patient coughs, the catheter has entered the trachea. Now use the tracheal catheter as a guidewire and advance the ET tube over it into the trachea.
- Once the trachea is intubated, positive pressure ventilation greatly improves the patient's oxygenation. Now the patient will be able to lie down, permitting sedation, aggressive management of fluid volume overload, and systemic blood pressure control.
Nasotracheal intubation causes a rise in intracranial pressure (ICP), so it has lost favor in trauma situations and other cases when ICP is a concern.
Reference
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Roppolo LP, Vilke GM, Chan TC, Krishel S, et al. Nasotracheal intubation in the emergency department, revisited. J Emerg Med. 1999;17:791-799.