Nasal intubation

Indications

• Severe cervical spine disease/instability, intraoral masses, trismus

Contraindications

• Absolute - epiglottitis, significant midface fractures, basilar skull fractures
• Relative - large nasal masses, nasal foreign bodies, recent nasal instrumentation, nasal or upper airway hematoma/infection, epistaxis

*Example of a technique

1. sniffing position (like oral ET)
2. pretreat with lido, hurricaine, or 4cc nebulized lidocaine for 5 minutes
3. Tube size = 1.0 mm smaller
4. listen with stethoscope at end of tube (breath sounds become louder as tube approaches cords)
5. when tube hits cords patient will cough, back up 1 or 2 cm. wait for beginning of inspiration, as patient begins inspiration advance 3-4 cm (tube should be 22-26cm in women, 23-28cm in men)

tips: occlude other nostril to hear better, cricoid pressure when advancing, use a small suciton catheter as a seldinger guide, precurve tube before insertion.

Alternative technique (sedated pt)

1. Prepare Afrin in 10 cc syringe, nasal trumpet, nasal tube (or smaller ETT) without stylet, DL blade, McGills/long curved Kellys
2. Afrin in both nostrils
3. Nasal trumpet into R nostril to dilate nasal airway (R nostril = less bleeding, faster
4. Insert tube in a postero-inferior direction (may feel some crunching along ethmoid, so be careful along that surface)
5. DL to visualize tube insertion past vocal cords
6. McGills or Kellys to grasp tube tip and facilitate passing tube