Nasal intubation: Difference between revisions
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==Indications== | ==Indications== | ||
*Severe cervical spine disease/instability | [[File:F2.png|thumb|Normal anatomy of the nasal sinuses.]] | ||
[[File:F6.png|thumb|Sagittal section through the head and neck showing the subdivisions of the pharynx.]] | |||
*Severe cervical spine disease/instability | |||
*Intra-oral masses or other limiting pathology such as mandibular fixation | |||
*Trismus | |||
*Severe angioedema | |||
==Contraindications== | ==Contraindications== | ||
* | ===Absolute=== | ||
* | *[[Epiglottitis]] | ||
*Significant [[facial trauma|midface fractures]] | |||
*[[Basilar skull fracture]]s | |||
==* | ===Relative=== | ||
# | *Large nasal masses | ||
# | *[[Nasal foreign body]] | ||
*Recent nasal instrumentation | |||
*Nasal or upper airway hematoma/infection | |||
*[[Epistaxis]] | |||
==Awake Technique== | |||
#Sniffing position (like oral ET) | |||
#Pretreat with [[glycopyrrolate]] 0.2mg or 0.04 mcg/kg and [[lidocaine|lido]], [[benzocaine|hurricaine]], or 4cc nebulized [[lidocaine]] for 5 minutes | |||
#Also consider topical cocaine to the nares, typically 4% solution, for 2-3 minutes or intranasal [[phenylephrine]] | |||
#Provide sedation with small doses of ketamine (10-20mg aliquots as needed) or midazolam | |||
#Tube size = 1.0 mm smaller | #Tube size = 1.0 mm smaller | ||
# | #Listen with stethoscope at end of tube (breath sounds become louder as tube approaches cords) | ||
# | #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 suction catheter as a seldinger guide | |||
**Precurve tube before insertion. | |||
== | ==[[sedation|Sedated]] Technique== | ||
#Prepare Afrin in 10 cc syringe, nasal trumpet, nasal tube (or smaller ETT) without stylet, DL blade, McGills/long curved Kellys | #Prepare [[Afrin]] in 10 cc syringe, nasal trumpet, nasal tube (or smaller ETT) without stylet, DL blade, McGills/long curved Kellys | ||
#Afrin in both nostrils | #Afrin in both nostrils | ||
#Nasal trumpet into | #Nasal trumpet into right nostril to dilate nasal airway (R nostril = less bleeding, faster<ref>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.</ref> | ||
#Insert tube in a postero-inferior direction (may feel some crunching along ethmoid, so be careful along that surface) | #Insert tube in a postero-inferior direction (may feel some crunching along ethmoid, so be careful along that surface) | ||
#DL to visualize tube insertion past vocal cords | #DL to visualize tube insertion past vocal cords | ||
#McGills or Kellys to grasp tube tip and facilitate passing tube | #McGills or Kellys to grasp tube tip and facilitate passing tube | ||
==See Also== | |||
{{Related Difficult Airway Pages}} | |||
{{Mechanical ventilation pages}} | |||
==External Links== | |||
*[https://www.merckmanuals.com/professional/critical-care-medicine/respiratory-arrest/tracheal-intubation?query=nasotracheal%20intubation Merk Manual - Nasotracheal Intubation] | |||
==References== | |||
<references/> | |||
[[Category:Critical Care]] | |||
[[Category:Procedures]] | |||
Latest revision as of 21:03, 10 April 2024
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
- Large nasal masses
- Nasal foreign body
- Recent nasal instrumentation
- Nasal or upper airway hematoma/infection
- Epistaxis
Awake Technique
- Sniffing position (like oral ET)
- Pretreat with glycopyrrolate 0.2mg or 0.04 mcg/kg and lido, hurricaine, or 4cc nebulized lidocaine for 5 minutes
- Also consider topical cocaine to the nares, typically 4% solution, for 2-3 minutes or intranasal phenylephrine
- Provide sedation with small doses of ketamine (10-20mg aliquots as needed) or midazolam
- Tube size = 1.0 mm smaller
- Listen with stethoscope at end of tube (breath sounds become louder as tube approaches cords)
- 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 suction catheter as a seldinger guide
- Precurve tube before insertion.
Sedated Technique
- Prepare Afrin in 10 cc syringe, nasal trumpet, nasal tube (or smaller ETT) without stylet, DL blade, McGills/long curved Kellys
- Afrin in both nostrils
- Nasal trumpet into right nostril to dilate nasal airway (R nostril = less bleeding, faster[1]
- Insert tube in a postero-inferior direction (may feel some crunching along ethmoid, so be careful along that surface)
- DL to visualize tube insertion past vocal cords
- McGills or Kellys to grasp tube tip and facilitate passing tube
See Also
Airway Pages
- Pre-intubation
- Induction
- Intubation
- Surgical airways
- Post-intubation
Mechanical Ventilation Pages
- Noninvasive ventilation
- Intubation
- Mechanical ventilation (main)
- Miscellaneous
External Links
References
- ↑ 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.