Nasotracheal Intubation

Nasotracheal Intubation

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Nasotracheal intubation may be performed in patients undergoing maxillofacial surgery or dental procedures or when orotracheal intubation is not feasible (eg, in patients with limited mouth opening). [1]  Nasotracheal intubation used to be the preferred route for prolonged intubation in critical care units, but nasal damage, sinusitis, [2]  and local abscesses have limited its use.

Because of the necessity of longer and narrower tubes for the nasal route, pulmonary toilet is more difficult and airway resistance is greater. The nasal route in the spontaneously ventilating patient was once considered a technique of choice for emergency operations, but orotracheal intubation under direct vision following the rapid sequence induction of anesthesia is now the technique of choice.

Most commonly, this technique is employed in the operating room for dental procedures and intraoral (eg, mandibular reconstructive procedures or mandibular osteotomies) and oropharyngeal operations. Some authors advocate using nasotracheal intubation for minor otolaryngologic and maxillofacial surgical procedures, maintaining that the technique is underused in current practice. [3]

Other indications include securing the airway in patients with questionable cervical spine stability or severe degenerative cervical spine disease (using the awake fiberoptic intubation technique), patients with intraoral mass lesions or structural abnormalities, and patients with limited mouth opening (eg, trismus).

Absolute contraindications for nasotracheal intubation include the following:

Relative contraindications for nasotracheal intubation include the following:

Kwak HJ, Lee SY, Lee SY, Cho SH, Kim HS, Kim JY. McGrath Video Laryngoscopy Facilitates Routine Nasotracheal Intubation in Patients Undergoing Oral and Maxillofacial Surgery: A Comparison With Macintosh Laryngoscopy. J Oral Maxillofac Surg. 2016 Feb. 74 (2):256-61. [Medline].

O’Reilly MJ, Reddick EJ, Black W, Carter PL, Erhardt J, Fill W, et al. Sepsis from sinusitis in nasotracheally intubated patients. A diagnostic dilemma. Am J Surg. 1984 May. 147 (5):601-4. [Medline].

Hall CE, Shutt LE. Nasotracheal intubation for head and neck surgery. Anaesthesia. 2003 Mar. 58 (3):249-56. [Medline].

Sun DA, Warriner CB, Parsons DG, Klein R, Umedaly HS, Moult M. The GlideScope Video Laryngoscope: randomized clinical trial in 200 patients. Br J Anaesth. 2005 Mar. 94 (3):381-4. [Medline].

Jones PM, Armstrong KP, Armstrong PM, Cherry RA, Harle CC, Hoogstra J, et al. A comparison of glidescope videolaryngoscopy to direct laryngoscopy for nasotracheal intubation. Anesth Analg. 2008 Jul. 107 (1):144-8. [Medline].

Lee MC, Tseng KY, Shen YC, Lin CH, Hsu CW, Hsu HJ, et al. Nasotracheal intubation in patients with limited mouth opening: a comparison between fibreoptic intubation and the Trachway®. Anaesthesia. 2016 Jan. 71 (1):31-8. [Medline].

Yeom JH, Oh MK, Shin WJ, Ahn DW, Jeon WJ, Cho SY. Randomized comparison of the effectiveness of nasal intubation using a GlideScope video laryngoscope with Magill forceps versus vascular forceps in patients with a normal airway. Can J Anaesth. 2017 Dec. 64 (12):1176-1181. [Medline]. [Full Text].

Song J. A comparison of the effects of epinephrine and xylometazoline in decreasing nasal bleeding during nasotracheal intubation. J Dent Anesth Pain Med. 2017 Dec. 17 (4):281-287. [Medline]. [Full Text].

Jerome J. An unusual complication of nasotracheal intubation – unilateral vocal cord palsy. Internet J Anesthesiol. 2007. 12 (1):1-4. [Full Text].

Hirabayashi Y. GlideScope videolaryngoscope facilitates nasotracheal intubation. Can J Anaesth. 2006 Nov. 53 (11):1163-4. [Medline].

Marina Shindell, DO Assistant Professor, Department of Anesthesiology, University of Colorado School of Medicine

Marina Shindell, DO is a member of the following medical societies: American Society of Anesthesiologists, Society for Airway Management, Association of Anesthesia Clinical Directors

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care Medicine, Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women’s Guild Lung Institute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society

Disclosure: Nothing to disclose.

The author would like to thank Thomas K. Henthorn, MD, Professor and Chair, Department of Anesthesiology University of Colorado.

Nasotracheal Intubation

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