Nasotracheal intubation was first described by Magill in the 1920s and the basic technique has changed little

over the years. Modifications have been described that increase the success rate and limit complications. The tube may be placed blindly or with the aid of a laryngoscope or bronchoscope. lind nasotracheal intubation can be one of the more technically demanding airway approaches! with the outcome being heavily dependent on the s"ill and e#perience of the operator. The primary advantage of blind nasotracheal intubation is that it minimi$es nec" movement and does not require opening the mouth. General Indications and Contraindications

Nasotracheal intubation is technically more difficult than oral intubation! but it has definite advantages. %t is especially suitable for the patient with a short! thic" nec" or other anatomic characteristics that would ma"e orotracheal intubation difficult. &atients with clenched teeth or suspected cervical spine in'ury can be intubated with minimal preparation. (ervical spine films! 'aw spreading! or paraly$ing agents as preliminaries to airway control are unnecessary. lind nasotracheal intubation is possible with the patient in the sitting position! a distinct advantage when intubating the patient with congestive heart failure who cannot tolerate lying flat. %n fact! patients in respiratory distress are the easiest to intubate blindly because their air hunger results in increased abduction of the vocal cords! which facilitates tube entry into the trachea. The drug overdose patient with a decreased level of consciousness is a candidate for nasotracheal intubation. These patients are often intubated before gastric lavage and may be sufficiently awa"e to ma"e orotracheal intubation difficult without paraly$ing agents. ) nasotracheal tube has advantages that e#tend beyond the immediate difficulties of airway control. The patient cannot bite the tube or manipulate it with the tongue. *ral in'uries may be cared for without interference by the tube. ) nasotracheal tube is more easily stabili$ed and generally easier to care for than an orotracheal tube. %t is better tolerated by the patient! permitting easier movement in bed! and produces less refle# salivation than do oral tubes. Nasal intubation should be avoided in patients with severe nasal or midface trauma. %n the presence of a basilar s"ull fracture! a nasotracheal tube may inadvertently enter the brain through a basilar s"ull fracture. +,1- The technique should be avoided in patients in whom thrombolytic therapy is being considered. Nasal intubation is relatively contraindicated if the patient is ta"ing anticoagulants or is "nown to Blind have a coagulopathy. Placement

lind nasotracheal intubation is the most common form of nasotracheal intubation in the emergency setting. .an$l and Thomas reported a success rate of 92/ in a large series of emergency department patients. Indications and Contraindications

)ny patient requiring airway control who has spontaneous respirations is a candidate for blind nasotracheal intubation. 0pecific indications that favor this approach over others are 112 short! thic" nec"!

122 inability to open the mouth! 132 inability to move the nec"! 1,2 gagging or resisting the use of the laryngoscope! and 142 oral in'uries. )pnea is the ma'or contraindication to blind nasotracheal intubation. )ttempts to place the tube without respirations as a guide are futile. 5elative contraindications include basilar s"ull fracture and nasal in'ury. 6urthermore! significant bleeding may occur if the patient is receiving anticoagulants or has a coagulopathy. lind nasotracheal intubation should be avoided in patients with e#panding nec" hematomas. &atient combativeness! if not controlled with sedation! is also a contraindication. 0ome would argue that the inability to open the mouth is a relative contraindication! because emesis may be induced that could not be cleared. The operator must e#ercise 'udgment in the individual case and be prepared to use neuromuscular bloc"ing agents or to bypass the upper airway with a surgical technique if such Procedure The patient is placed in the 7sniffing7 position with the pro#imal nec" slightly fle#ed and the head e#tended on the nec". %n preparation for intubation! the operator constricts the nasal mucosa of both nares! using either 0.24 to 1.0/ phenylephrine drops! o#ymeta$oline 1)frin2 spray! or ,/ cocaine spray. Topical anesthesia of the nares! oropharyn#! and hypopharyn# with lidocaine spray 110/2 is also indicated if time permits. %f available! cocaine is ideal because it is both a vasoconstrictor and an anesthetic8 caution is necessary in hypertensive patients. The most patent nostril is chosen. %n the cooperative patient! this can be determined simply by occluding each nostril and as"ing the patient which one is easier to breathe through. The most patent nostril can also be identified by direct vision! or by gently inserting a gloved finger lubricated with viscous lidocaine! full length into the nostrils. %f time is not an issue! an effective method to dilate the nasal cavity and administer the anesthetic is to pass a lidocaine gel9lubricated nasopharyngeal airway 1nasal trumpet2 into the selected nostril. This airway is left in place for several minutes! and progressively larger trumpets are introduced. )fter preparation of the nostril! a well9lubricated endotracheal tube with a :.0 or :.4 mm %. is inserted along the floor of the nasal cavity. The tube is not directed cephalad! as one might e#pect from the e#ternal nasal anatomy! but rather is directed straight bac" toward the occiput! corresponding with the nasal floor. Twisting the tube may help bypass soft tissue obstruction in the nasal cavity. %t is sometimes recommended that the bevel of the tube be oriented toward the septum to avoid in'ury to the inferior turbinate. ;owever! such an event is rare. )t < to : cm! one usually feels a 7give7 as the tube passes the nasal choana and negotiates the abrupt 90= curve required to enter the nasopharyn#. This is the most painful and traumatic part of the procedure and must be done gently. %f resistance is encountered that persists despite continued gentle pressure and twisting of the tube! the passage of a suction catheter down the tube and into the oropharyn# may allow for successful passage of the tube over the catheter. +,,- %f this fails! the other nostril should be tried. %n an attempt to avoid this difficulty from the outset! a controllable9tip tracheal tube 1>ndotrol! Mallinc"rodt Medical %nc! 0t ?ouis2 may be used that allows the operator to increase the fle#ion of the tube and facilitates passage past this tight curve. *ne study found the >ndotrol tube to enhance first attempt success with blind nasotracheal intubation. a complication develops.

)s the tube is advanced through the oropharyn# and hypopharyn# and approaches the vocal cords! breath sounds from the tube become louder! and fogging of the tube may occur. )t the point of ma#imal breath sounds! the tube is lying immediately in front of the laryngeal inlet. The tube is most easily advanced into the trachea during inspiration because that is when the vocal cords are ma#imally open. )s the patient begins to breathe in! the tube is advanced in one smooth motion. %f a gag refle# is present! the patient usually coughs and becomes stridulous during this maneuver! suggesting successful tracheal intubation. The absence of such a response should alert the operator to probable esophageal passage. %f there is a delay in advancing the tube! o#ygen can be added to the end of the tube to increase inspired o#ygen. *nce the tube is in the trachea! moaning and groaning should cease. %f they continue! esophageal intubation is li"ely. reath sounds coming from the tube and tube fogging are other signs of endotracheal placement. 5efle# swallowing during blind nasotracheal intubation may direct the tube posteriorly toward the esophagus. %f this occurs! the conscious patient should be directed to stic" out the tongue to inhibit swallowing and prevent consequent movement of the laryn#. )pplication of laryngeal pressure may also help avoid esophageal passage. 6ollowing intubation! both lungs are auscultated while positive9pressure ventilation is applied. %f only one lung is being ventilated! the tube is withdrawn until breath sounds are heard bilaterally. The optimum distance from the e#ternal nares to the tube tip is about 2@ cm in males and 2< cm in females. )fter verification Technical of tracheal placement! the cuff is inflated and the tube is secured. Difficulties

The nasotracheal tube may slide smoothly through the hypopharyn# and into the trachea on the first pass. Anfortunately! this is not always the case8 in the operating room! the first attempt was successful in B40/ of cases. Chen the initial pass is unsuccessful! there are , potential locations of the tip of the tubeD 112 anterior to the epiglottis in the vallecula! 122 on the arytenoid or vocal cord! 132 in the piriform sinuses! or 1,2 in the esophagus. *bservation and palpation of the soft tissues of the nec" during attempted passage of the nasotracheal tube are helpful in determining the location of the misplaced tube. This is ideally done by the operator but may also be performed by an e#perienced attendant. efore reattempting placement! the tube is withdrawn slightly8 it is not removed from the nose! because this will create additional trauma to the nasal soft tissues. The possibility of cervical spine in'ury must be "ept in mind when considering corrective maneuvers. )ny maneuver that moves the nec" significantly should not be used if alternatives are available. Methods for achieving success when difficulties with tube placement are encountered include the Anterior to the followingD epiglottis.

.ifficulty advancing the tube beyond 14 cm or palpation of the tube tip anteriorly at the level of the hyoid bone suggests an impasse anterior to the epiglottis in the vallecula. Cithdrawing the tube 2 cm! decreasing the degree of nec" e#tension! and readvancing the tube will frequently remedy this problem.

Arytenoid

cartilage

and

vocal

cord.

(ontrary to the classic teaching! recent studies have demonstrated a propensity for a nasotracheal tube! when placed through the right nares! to lie posteriorly and to the right as it approaches the laryn#. %t is not surprising! then! that the most common obstacles to advancement of the nasotracheal tube are the right arytenoid and vocal cord. No data are available on the common obstacles encountered if the tube is placed in the left nares. %f the tube appears to be hanging up on firm! cartilaginous tissue! withdraw the tube 2 cm! rotate it 90= countercloc"wise! and readvance the tube. This maneuver orients the bevel of the tube posteriorly and frequently results in successful passage . )nother technique is to pass a suction catheter down the tube8 it often will pass through the laryn# without difficulty and the tube can then be advanced Piriform over the catheter. sinus.

ulging of the nec" lateral and superior to the laryn# indicates tube location in a piriform sinus. The tube should be withdrawn 2 cm! rotated slightly away from the bulge! and readvanced. )n alternate method is to tilt the patientEs head toward the side of the misplacement and reattempt placement. Esophageal placement.

>sophageal placement is indicated by a smooth passage of the tube with the loss of breath sounds. The laryn# may be seen or felt to elevate as the tube passes under it. )ssisted ventilation will usually produce gurgling sounds when the epigastrium is auscultated. The tube should be withdrawn until breath sounds are clearly heard! and passage should be reattempted while pressure is applied to the cricoid. %ncreased e#tension of the head on the nec" during placement may help. %f attempts continue to result in esophageal misplacement! the following maneuver may result in successful tracheal intubationD from the precise point at which breath sounds are lost! the endotracheal tube is withdrawn 1 cm. The cuff is inflated with 14 mm of air! resulting in an elevation of the tube off the posterior pharyngeal wall and angling it toward the laryn#. The tube is then advanced 2 cm8 continued breath sounds indicate probable intralaryngeal location. )t this point! the cuff is deflated and the endotracheal tube is advanced into the trachea . This technique may be particularly useful in the patient with cervical spine in'ury! because it requires no manipulation of the head or nec". This maneuver! when used on the first pass in 20 patients in the operating room! was successful in :4/ of cases. *ne should bear in mind! however! that these patients were paraly$ed and thus did not e#perience the laryngospasm that may be encountered in a breathing patient. The use of topical anesthesia is recommended. )lternatively! if a controllable9tip endotracheal tube 1>ndotrol2 is used! the tip can be fle#ed anteriorly to help avoid esophageal placement. 5emember that the tip is very responsive to pulling on the ring. ) common mista"e is to e#ert too much force on the ring! resulting in the tube curling up short of the laryn#! thus preventing tube advancement. Laryngospasm. ?aryngospasm is common when attempting nasotracheal intubation. %t is usually transient. The tube is withdrawn slightly and the operator should wait for the patientEs first gasp8 advancement of the tube at this

precise moment is frequently successful! as the vocal cords are widely abducted during forced inhalation. ?aryngeal anesthesia should also be assessed! and if %F and nebuli$ed lidocaine have already been administered without success! transcricothyroid anesthesia 1e.g.! 2 m? of ,/ lidocaine2 should be considered. *ccasionally! a 'aw lift is necessary to brea" prolonged spasm. )nother option is to use a smaller Placement Under Direct tube. Vision

This technique combines elements of oral and nasotracheal intubation. The indications and precautions are similar! and the importance of considering cervical spine in'ury is identical. ?i"ewise! the need for 'aw opening by physical or pharmacologic means is unchanged. This method is preferred to orotracheal intubation if the presence of an orotracheal tube might interfere with the repair of an oral in'ury. %t is also useful when blind nasotracheal intubation has failed. &reparation of the nose and nasopharyn# and passage of the tube into the oropharyn# are the same as described for blind nasotracheal intubation. %t is with the introduction of the laryngoscope that the technique changes. ?aryngoscopy! as described with orotracheal intubation! is used to visuali$e the vocal cords and the tip of the endotracheal tube. Cith the Magill forceps in the right hand! the endotracheal tube is grasped pro#imal to the cuff 1to avoid damage to the balloon2 and directed toward the laryn# . )n assistant advances the tube gently while the operator directs the tip into the laryn# and trachea. (ricoid pressure may facilitate the passage. *ften the laryn# can be manipulated sufficiently with the laryngoscope so that the physician can advance the tube with the right hand and guide it between the cords without using the Magill forceps. *ccasionally! the natural curve of the tracheal tube guides it through the cords without any manipulation. The cuff is inflated! and both lungs are auscultated to ensure ventilation. Chen placement is satisfactory! the Complications >pista#is is the most common complication of nasotracheal intubation. ;owever severe epista#is was encountered in only 4 of 300 cases reported by .an$l and Thomas. +,2- Tintinalli and (laffey reported severe bleeding in 1 of :1 cases and less serious bleeding in 12 others. +4,leeding is usually not a problem unless it provo"es vomiting or aspiration! a serious potential problem in obtunded patients with a clenched 'aw or a decreased gag refle#. *ther immediate complications include turbinate fracture! intracranial placement through basilar s"ull fracture! retropharyngeal laceration or dissection! and delayed or unsuccessful placement. Ansuccessful placement may be minimi$ed by selection of a smaller tube and by gentle technique. 0inusitis in patients with nasotracheal tubes is common and can be an unrecogni$ed cause of sepsis. 5are but potentially fatal delayed complications include mediastinitis following retropharyngeal abscess and massive pneumocephalus. ecause most of the complications occur during tube advancement through the nasal passage and pro#imal nasopharyn#! the complications of blind nasotracheal intubation and placement under direct tube is secured.

vision are largely the same. ;owever! retropharyngeal laceration and esophageal intubation are more of a threat in blind placement techniques because they are more li"ely to go unrecogni$ed. *ne unique problem associated with nasotracheal intubation is damage of the tube cuff with the Magill forceps. .elayed nasotracheal placement under direct vision deserves special discussion. Manipulation of the endotracheal tube through the nose and with the Magill forceps during the direct vision technique involves additional steps that require time. patient! Summary Nasotracheal intubation is being used less frequently than in the past! because practitioners are increasingly comfortable using oral intubation in the patient with potential cervical spine in'ury. %n addition! emergency physicians frequently use paralytics to facilitate orotracheal intubation. Nevertheless! nasotracheal intubation remains an effective and potentially life saving approach to the difficult airway and should be a dependable part of the armamentarium of all providers who are active in emergency airway management. orotracheal ecause time is of the essence in the resuscitation of the critically ill intubation may be preferable.

Nasotracheal intubation may be performed in patients undergoing ma#illofacial surgery or dental procedures or when orotracheal intubation is not feasible 1eg! patients with limited mouth opening2. Nasotracheal intubation 1see the video below2 used to be the preferred route for prolonged intubation in critical care units! but nasal damage! sinusitis!+1- and local abscesses have limited its use. ecause of the necessity of longer and narrower tubes for the nasal route! pulmonary toilet is more difficult and airway resistance is greater. The nasal route in the spontaneously ventilating patient was once considered a technique of choice for emergency operations! but orotracheal intubation under direct vision following the rapid sequence induction of anesthesia is now the technique of choice.

Indications
Most commonly! this technique is employed in the operating room for dental procedures and intraoral 1eg! mandibular reconstructive procedures or mandibular osteotomies2 and oropharyngeal surgeries. 0ome authors advocate using nasotracheal intubation for minor otolaryngologic and ma#illofacial surgeries! as they believe the technique is underused in the current practice. +2*ther indications include securing the airway in patients with questionable cervical spine stability or severe degenerative cervical spine disease 1using awa"e fiberoptic intubation technique2! patients with intraoral mass lesions or structural abnormalities! and patients with limited mouth opening 1eg! trismus2.

Contraindications
Absolute contraindications
0uspected epiglottitis Midface instability (oagulopathy 0uspected basilar s"ull fractures )pnea or impending respiratory arrest 1)ny patient with advanced upper airway obstruction! who is apneic or having difficulties maintaining his or her airway! should not be sub'ected to any form of awa"e intubation.2

Relati e contraindications
?arge nasal polyps 0uspected nasal foreign bodies 5ecent nasal surgery Apper nec" hematoma or infection ;istory of frequent episodes of epista#is &rosthetic heart valves 1increased ris" of bacteremia during the insertion2

Anesthesia
General anesthesiaD %f no difficulties are suspected in securing the airway! based on the physical e#amination or prior history of intubation! general anesthesia and neuromuscular bloc"ade can be induced. General anesthesia is routinely induced using rapid9acting hypnotic or induction agents 1eg! propofol! etomidate! thiopental! "etamine2. )ssess mas" ventilation before neuromuscular bloc"adeD )fter anesthesia induction! assess the ability to mas"9ventilate the patient prior to giving neuromuscular bloc"ers 1e#cept in the case of rapid sequence induction! when mas" ventilation is not attempted! and succinylcholine or rocuronium is administered simultaneous to the hypnotic agent2. )fter the neuromuscular bloc"er drug is administered and given time to achieve ma#imal effect! perform direct laryngoscopy or blind intubation. &repping nasal passagesD ?ubricants and vasoconstrictors are commonly applied to the nasal passages prior to introduction of an endotracheal tube. Farious vasoconstrictors are available! such as cocaine ,/ solution 1not to e#ceed 1.4 mgH"g2! o#ymeta$oline 0.04/ nasal spray 1)frin2! or phenylephrine nose drops 0.2491/ 1Neo90ynephrine2. The choice of vasoconstrictor is usually at the anesthetistEs preference. )pplying lidocaine 'elly or water9soluble lubricant allows for smoother advance as well as better transfer of rotation along the endotracheal tubeEs length during directional manipulation. 6iberoptic intubationD %f awa"e! fiberoptic intubation is necessary8 prepare the patientEs nasal passages as described above. )dditionally! in awa"e or sedated patients! topical anesthesia to the

patientEs laryn# and pharyn# is also required. This can be accomplished by a number of techniques! such as transoral application of a local anesthetic agent or use of superior laryngeal nerve bloc" with ,/ lidocaine 1up to 3 mgH"g2 administered transtracheally or sprayed down the fiberscopeEs lumen intermittently in advance of the scopeEs passage. %ncomplete topical anesthesia not only causes patient discomfort! it ma"es the procedure much more difficult and may lead to patient morbidity. )n antisialagogue drug is administered 1eg! glycopyrrolate 0.290.3 mg %F2 to improve the visuali$ation of the field. 0mall amounts of sedation are advocated as well! "eeping in mind that sedation is not a substitute for a well anestheti$ed airway.

!"uipment
>ndotracheal tube 1Nasal 5ae +see image below- or the regular endotracheal tube2

Nasal 5ae endotracheal tube.

?idocaine 'elly or any other water9soluble lubricant

Magill forceps 1see image below2 Magill forceps. )frin spray 1o#ymeta$oline 0.04/2 Nasal trumpets 0yringe to inflate the cuff 0uction %ntubation equipment 1eg! laryngoscope! Glide9scope! fiberoptic scope2 (ommercial airway device ad'uncts are available. ) novel intubation system! Glide0cope Fideo ?aryngoscope 1GF?! Ferathon Medical %nc.! othell! Ca2 has an established role in routine and difficult orotracheal intubation not only by e#perienced handlers but also by novices. +3! ,- %n a recent study! authors showed GF? superiority compared to direct laryngoscopy in improvement of time to successful intubation and in regard to lower incidence of moderate to severe sore throat postoperatively. +4-

Positionin#
6or the induction of general anesthesia! the patient should be in the supine position. %f awa"e fiberoptic intubation 1or any other awa"e intubation2 is pursued! often the most practical position may be sitting 1on the operating room table2! as it prevents the laryn# from falling posteriorly as it does in the supine position.

Techni"ue

>stablish patency of the nares with a well9lubricated nasal trumpet 1see images below2.

%nserting nasal trumpet. Notice that insertion angle is almost perpendicular to the

face.

Nasal trumpet insertion 1continued2.

%nsert a well9lubricated tube with fully deflated cuff via a patent! lubricated naris! at a right angle to

the face 1see image below2.

.irect laryngoscopy with Miller blade. %nsert Nasal 5ae endotracheal tube and advance it a little prior to putting the laryngoscope in the mouth.

0ome resistance is commonly encountered! most li"ely due to the right arytenoid. This is usually overcome with slight countercloc"wise rotation of the tube. *nce the tube is beyond the nasopharyn#! introduce the laryngoscope into the oral cavity and

advance the tube under direct vision 1see images below2.

cords are seen! the endotracheal tube is advanced by the laryngoscopist or an assistant.

*nce the vocal

Magill forceps directing the endotracheal tube 1above the cuff2 for its advance through the vocal cords.

0ometimes! to avoid tearing the cuff with the forceps! Magill forceps are needed to guide the tube through the vocal cords8 if this is the case! an assistant advances the tube 1see image below2.

The endotracheal tube is advanced using Magill forceps by the laryngoscopist. )n assistant helps advance the tube by slowly pushing it in.

Complications
>pista#isD This is the most common complication! resulting from abrasion of the nasal mucosa when the tube is passed posteriorly. %f bleeding is noticed but intubation could still be achieved! then it should be completed. )n endotracheal tube in proper position allows tamponade of the bleeding and protects the airway. %f repeated attempts are needed! then the tube should be withdrawn until the cuff is positioned to be inflated in order to tamponade the bleeding 1usually in the postnasal space2. )nother option is to withdraw the tube completely and pinch the nostrils together. .amage to nasal cavity 1avulsion of nasal polyps! fracture of the turbinates! septal abscesses2 )spiration Fagal stimulation ?aryngospasm Focal cord damage+<acteremia from introduction of nasal flora to the trachea &neumothora#

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