Nasotracheal Intubation Periprocedural Care

Updated: Feb 28, 2019
  • Author: Marina Shindell, DO; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Periprocedural Care

Equipment

Equipment required for nasotracheal intubation includes the following:

  • Endotracheal tube (Nasal Rae [see the first image below] or a regular endotracheal tube)
  • Lidocaine jelly or any other water-soluble lubricant
  • Magill forceps (see the second image below)
  • Afrin spray (oxymetazoline 0.05%)
  • Nasal trumpets
  • Syringe to inflate the cuff
  • Suction
  • Intubation equipment (eg, laryngoscope, Glide-scope, fiberoptic scope)
Nasal Rae endotracheal tube. Nasal Rae endotracheal tube.
Magill forceps. Magill forceps.

Commercial airway device adjuncts are available. The GlideScope Video Laryngoscope (GVL, Verathon Medical Inc., Bothell, WA) intubation system has an established role in routine and difficult orotracheal intubation not only by experienced handlers but also by novices. [5, 6]

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Patient Preparation

Anesthesia

If, on the basis of the physical examination or prior history of intubation, no difficulties are suspected in securing the airway, general anesthesia and neuromuscular blockade can be induced. General anesthesia is routinely induced using rapid-acting hypnotic or induction agents (eg, propofol, etomidate, thiopental, ketamine).

After anesthesia induction, assess the ability to carry out mask ventilation before giving neuromuscular blockers (except in the case of rapid sequence induction, when mask ventilation is not attempted, and succinylcholine or rocuronium is administered simultaneous to the hypnotic agent). After the neuromuscular blocker drug is administered and given time to achieve maximal effect, perform direct laryngoscopy or blind intubation.

Lubricants and vasoconstrictors are commonly applied to the nasal passages before the introduction of an endotracheal tube. Various vasoconstrictors are available (eg, cocaine 4% solution [not to exceed 1.5 mg/kg], oxymetazoline 0.05% nasal spray, or phenylephrine nose drops 0.25-1%). The choice of vasoconstrictor usually depends on the anesthetist's preference. Applying lidocaine jelly or water-soluble lubricant allows for smoother advance, as well as better transfer of rotation along the endotracheal tube's length during directional manipulation.

If awake fiberoptic intubation is necessary, prepare the nasal passages as described above. Additionally, in awake or sedated patients, topical anesthesia to the larynx and pharynx is also required. This can be accomplished with a number of techniques, such as transoral application of a local anesthetic agent or use of superior laryngeal nerve block with 4% lidocaine (up to 3 mg/kg) administered transtracheally or sprayed down the fiberscope's lumen intermittently in advance of the scope's passage. Incomplete topical anesthesia not only causes patient discomfort but also makes the procedure much more difficult and may lead to morbidity.

An antisialagogue drug (eg, glycopyrrolate 0.2-0.3 mg IV) is administered to improve the visualization of the field. Small amounts of sedation are advocated as well, with the caveat that sedation is not a substitute for a well-anesthetized airway. [7]

Positioning

For the induction of general anesthesia, the patient should be in the supine position.

If awake fiberoptic intubation (or any other awake intubation) is pursued, often the most practical position may be sitting (on the operating room table), in that this will prevent the larynx from falling posteriorly as it does in the supine position.

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