Nasal intubation

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Indications

  • Severe cervical spine disease/instability
  • Intra-oral masses or other limiting pathology such as mandibular fixation
  • Trismus
  • Severe angioedema

Contraindications

Absolute

  • Epiglottitis
  • Significant midface fractures
  • Basilar skull fractures

Relative

Awake Technique

  1. Sniffing position (like oral ET)
  2. Pretreat with lido, hurricaine, or 4cc nebulized lidocaine for 5 minutes
  3. Also consider topical cocaine to the nares, typically 4% solution, for 2-3 minutes or nasal phenylephrine
  4. Tube size = 1.0 mm smaller
  5. Listen with stethoscope at end of tube (breath sounds become louder as tube approaches cords)
  6. 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.

Sedated Technique

  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 right nostril to dilate nasal airway (R nostril = less bleeding, faster[1]
  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

See Also

References

  1. Boku et al. Which nostril should be used for nasotracheal intubation: the right or left? A randomized clinical trial. J Clin Anesth. 2014 Aug;26(5):390-4.