Nasotracheal Intubation Steve Lan Overview

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Nasotracheal Intubation

• Steve Lan

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Overview

• Indications/Contraindications
• Basic technique
• Adjusting placement

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Nasotracheal Intubation

• Indications
• Need for definitive airway and oral access not an
  option (trismus, trauma, etc)
• Imminent resp failure (concerned about RSI)
• Unable to align for oral intubation
• Contraindications
• Apnea
• Nasal/maxillofacial trauma (?basal skull )
• Coagulopathy

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Complications

• Epistaxis
• Vomit/aspiration

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Set Up

• Awake intubation, usually sitting
• sniffing position
• Tube 0.5-1.0mm smaller than for oral
• Topical anesthesia, vasoconstrictor, lube
• Usual monitors

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Technique

• Advance tube with bevel towards septum
• Straight back
• Slight twisting action
• Dont force it!
• Give at 6-7cm as tube goes past 90 degree turn

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Technique

• Auscultate proximal end listening for breath
  sounds
• May also see fogging
• Loudest point should be just in front of
  laryngeal inlet
• Advance during inspiration
• Males 28cm at nares, women 26cm

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Where did it go?

• Operating Room study found lt50 trachea placement
  on first try
• Possible placements
• Anterior to epiglottis (vallecula)
• Piriform fossa
• Esophagus

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Where did it go?
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Tube Placement In Trachea

• Breath sounds persist
• Able to advance tube
• Coughing
• No voice

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Tube Placement Anterior to Epiglottis

• Signs
• Tube gets stuck 15cm
• Breath sounds may continue
• Cough through tube
• Adjustment
• Pull back 2 cm
• Slightly flex neck

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Tube Placement Piriform sinus

• Signs
• Tube gets stuck
• Breath sounds stop, no cough reflex
• Pt able to phonate
• Bulge to lateral neck above larynx
• Adjustment
• Pull back tube
• Slight twist away from bulge and advance

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Tube Placement Esophagus

• Signs
• No breath sounds
• Tube can still be advanced
• No cough
• Pt able to vocalize
• Adjustment
• Pull back tube, slightly extend neck
• Slight pressure to larynx
• Stick tongue out

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Another Trick(if c-spine is a concern)

• Pull back 1cm from point where breath sounds are
  lost
• Inflate cuff with 15cc

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Another possible problem

• Tube caught on aretynoid cartilage
• Pull back
• Rotate tube 90 degrees (bevel posterior) and
  advance