Nasotracheal Intubation

Overview:

Nasotracheal intubation is a procedure that is used as an alternative to endotracheal intubation. It is mainly used for the induction of inhalational anesthesia such as Sevoflurane, Desflurane, and Nitrous oxide. It also shows significant advantages in oral procedures such as sleep apnea surgeries and maxillofacial reconstructive surgeries.

What Is the Difference Between a Nasotracheal and Orotracheal Intubation?

The only difference between a nasotracheal and orotracheal method of intubation is the external opening through which the tube is intubated. Orotracheal intubation is the most common method of intubation used. In orotracheal intubation, the endotracheal tube is intubated through the mouth and then to the vocal cord, followed by the trachea with the assistance of a lighted laryngoscope. The tube has an increased width when compared to the nasotracheal tube. In nasotracheal intubation, the tube is inserted through the patient's nostril and then to the vocal cords, followed by the trachea without any use of a laryngoscope.

What Are the Pathways of Nasotracheal Intubation?

There are two different pathways through which the nasotracheal tube can be introduced through the nasal space. They are the lower and upper pathways.

• Lower Pathway - The lower pathway is the most commonly preferred one. The lower pathway is located along the floor of the nasal cavity. This pathway is quite safer when compared to the upper pathway. The nasal turbinates are curtain-like structures that are located on the lateral side of the nasal cavities.

• Upper pathway - The upper pathway is located between the nasal cavity's inferior turbinate and middle turbinates.

What Are the Indications?

• Intraoral surgeries and procedures that involve the oropharynx.

• In the situation where the oral route of intubation is not possible due to limited jaw mobility of the patient (trismus).

• In the intensive care unit (ICU) as an alternative method to tracheostomy when the patient requires a longer ventilation period.

• Surgeries that involve maxillofacial reconstruction and also that need better surgical access to the mouth region.

• Removal of tonsils when there is chronic and recurring tonsillitis.

• Rigid laryngoscopy.

• Micro laryngeal surgery.

What Are the Contraindications?

Nasotracheal intubation is contraindicated in the following conditions:

• Midface instability.

• Coagulation disorders.

• When the patient has basilar skull fractures.

• When the patient has an advanced upper respiratory tract obstruction and is unable to breathe.

• When the patient has nasal polyps.

• When the patient is noted to have any nasal obstruction by foreign bodies.

• When the patient has had recent nasal surgery.

• Upper-neck blood clots.

• Any septic condition in the nasal and neck regions.

• When the patient has a past medical history of frequent epistaxis (nose bleeding).

• When the patient has a past medical history of prosthetic heart valves, these patients have a higher risk of spreading nasal infections to those valves.

What Is the Equipment That Is Used?

• Lidocaine jelly.

• Magill forceps.

• Oxymetazoline 0.05% (inhalational anesthetic).

• Nasal trumpets.

• Syringe.

• Suction.

How Is the Patient Positioned?

If general anesthesia is going to be used for the planned surgery, the patient has to be placed in the prone position. If the patient is awake, fiberoptic intubation is being used. The most practical position for an awake patient is sitting in the operating room or table. This is a precautionary measure taken to prevent the larynx from falling posteriorly, which is common in the prone position.

What Is the Method of Insertion?

The following are the steps that are involved in the insertion of a nasotracheal tube.

1. Anesthetic spray such as Lidocaine or Oxymetazoline is administered into the nasal opening with the help of a disposable single patient bottle or by a disposable spray pump.

2. The nasal trumpet is then being lubricated with 2% Lidocaine jelly at least one minute prior to insertion.

3. The required anesthetic is then sprayed through the trumpet.

4. Once the anesthetic has been completely administered, the trumpet is removed.

5. Once the anesthetic has started to numb, the tube can now be inserted.

6. Then the tube which suits the size of the patient's nasal space is selected. The most common width is at least 7.0 mm and has a length of approximately 14–16 cm.

7. The tube is being inserted by keeping the contiguous end of the tube directed towards the patient's opposite nipple.

8. This will help the physician to direct the tip of the tube toward the midline of the airway.

9. Once the tube's length is inserted at least 16 cm, the tube's location has to be checked.

10. This can be checked by hearing the sounds produced in the external tip of the tube. There should be a loud breathing type of sound audible through the tube. This proves the location of the tube.

11. After ensuring the location, the anesthetic is sprayed again through the tube.

12. The patient will cough.

13. The nasotracheal tube is then being passed through the cords when the patient inspires air.

14. Again the placement of the nasotracheal tube is confirmed and sedated adequately for the patient to tolerate the procedure that is planned.

15. Muscle relaxants can be administered as needed.

What Are the Complications?

The following includes all the possible complications that could be seen in nasotracheal intubation.

1. Epistaxis is the most commonly seen complication in this procedure. Epistaxis is nothing but nose bleeding when the tissue in the nasal space is torn. This happens when the nasotracheal tube is pulled back.

2. Potential damage to the nasal cavity can also occur, such as tearing of the nasal polyps fracture to the nasal turbinates. The most common nasal turbinate that is injured is the inferior nasal turbinate.

3. Damage to the nasal abscesses is also possible. This can lead to the potential spread of infection to the upper or lower respiratory tract pathway and the patient's heart valves.

4. Aspiration of fluid into the respiratory tracts.

5. Vagal nerve stimulation.

6. Spasm of the laryngeal muscles, such as the posterior cricoarytenoid muscles.

7. If the tube is introduced quickly without proper care, it might damage the vocal cords.

8. If the tube punctures the lung tissues during intubation, it might lead to a pneumothorax (presence of air external to the lungs)

9. Bacteria spread from the nasal surfaces to the respiratory tract.

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