Nasal intubation

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

1. Sniffing position (like oral ET)
2. Pretreat with glycopyrrolate 0.2mg or 0.04 mcg/kg and 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 intranasal phenylephrine
4. Provide sedation with small doses of ketamine (10-20mg aliquots as needed) or midazolam
5. Tube size = 1.0 mm smaller
6. Listen with stethoscope at end of tube (breath sounds become louder as tube approaches cords)
7. 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

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
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

• Intubation