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An Aid to Blind Nasal Intubation
The Journal of Emergency Medicine, Vol 16, No 1, pp 93–95, 1998 Copyright © 1998 Elsevier Science Inc. Printed in the USA. All rights reserved 0736-4679/98 $19.00 1 .00
PII S0736-4679(97)00246-1
Techniques and Procedures
AN AID TO BLIND NASAL INTUBATION Roger D. Harris,
MBBS,
Mark J. Gillett, MBBS, FRACGP, FACEM, Anthony P. Joseph, John D. Vinen, MBBS, FACEM, MHP
MBBS, MRCP, FACEM,
and
Department of Emergency Medicine, Royal North Shore Hospital, St. Leonards, New South Wales, Australia Reprint Address: Roger D. Harris, MBBS, Senior Registrar, Department of Emergency Medicine, Royal North Shore Hospital, Pacific Highway, St. Leonards, NSW 2065, Australia
e Abstract—Blind nasal intubation remains an important technique in the management of the difficult airway. Many aids to this technique have been described, but unfortunately, these often require additional expense, training, and equipment. Methods that involve listening at the end of the endotracheal tube and observing moisture condensation in the tube are relatively insensitive and may expose the operator to the patient’s bodily fluids. Our aim was to devise an aid to blind nasal intubation that was effective, inexpensive, simple to learn, and easy to assemble. It is essential that breath sounds can be monitored through the endotracheal tube, as it is felt that this helps to minimize retropharyngeal perforation caused by the tube abutting the posterior pharyngeal wall. We describe the use of an endotracheal tube stethoscope in conjunction with either ‘inline’ or ‘sidestream’ capnometry and present a case of successful nasotracheal intubation using this device. The total cost of this aid is less than $10 Australian. © 1998 Elsevier Science Inc.
availability of modern muscle relaxants (1–3). With the advances in modern anesthetic pharmacology, the practice of this technique has become less common. Despite this, it remains an important adjunct in the management of the difficult airway. Indications for this procedure include potentially difficult orotracheal intubations and patients in whom muscle relaxants or a surgical airway are undesirable or contraindicated. The former situation may include patients with dental fractures, arthritis or dislocation of the temperomandibular joint, a small mouth, a short neck, a large tongue, a history of previous head and neck surgery, or cervical spine immobility (4). This technique is often performed with the patient sitting upright in bed and so is useful when the patient cannot or should not be placed supine. Contraindications include acute epiglottitis, apnea, basilar skull fractures with or without cerebrospinal fluid rhinorrhoea, bleeding diathesis, upper airway foreign body, large bilateral nasal polyps, abscesses, and severe laryngeal trauma (4,5). Complications are rarely serious, but can include nasopharyngeal hemorrhage, laryngeal trauma, retropharyngeal perforation, and paranasal sinusitis. Infection and local trauma to the nasal septum and turbinates can be minimized by limiting the duration of nasotracheal intubation (6 – 8). The risk of retropharyngeal perforation may be reduced by monitoring airflow through the endotracheal tube once it has passed beyond the turbinates.
e Keywords— blind nasal intubation; retropharyngeal perforation; endotracheal tube stethescope; capnography; difficult intubation
INTRODUCTION Blind nasal intubation is an important skill for the emergency physician, anesthesiologist, and critical care physician. This procedure was initially described during World War I and gained some popularity before the
Techniques and Procedures is coordinated by George Sternbach,
RECEIVED: 25 April 1997; FINAL ACCEPTED: 28 July 1997
SUBMISSION RECEIVED:
14 July 1997; 93
MD,
of Stanford University, Stanford, California
94
R. D. Harris et al.
Figure 1. Equipment. Figure 2. Equipment assembled.
Loss of airflow at this point usually indicates that the tube is abutting the posterior pharyngeal wall, and further pressure could cause perforation (9). The technique described here provides a means of averting this problem, as airflow through the tube is continuously monitored. Once the endotracheal tube has passed into the nasopharynx, the monitoring of breath sounds then becomes the key for successful tracheal intubation. At each inspiratory effort, the tube should be advanced while constantly monitoring breath sounds. If advancing the tube results in loss of or reduction in breath sounds, then the tube should be withdrawn to the point at which the breath sounds are maximally auscultated. The endotracheal tube then can be turned slightly and readvanced with each inspiratory effort. Successful tracheal intubation will be denoted by continued auscultation of distinct breath sounds, some resistance as the tube passes through the vocal cords, the patient coughing, and the capnography reading and waveform. If intubation continues to be difficult, there are several other maneuvers briefly described in the discussion that can be used in conjunction with our technique.
Constructing an Endotracheal Tube Stethoscopy with Capnometry Our aim was to devise an aid to blind nasal intubation that combines several previously described methods, but is easy to construct, requires minimal additional equipment or cost, and is safe for the operator and patient. The equipment used is demonstrated in Figure 1. A basic stethoscope costing $8.00 Australian has the bell/ diaphragm removed from the conducting tube. A 10-mL Terumo® syringe is then inserted via its needle-port end into the conducting tube and the two are fixed together with tape. The plunger is removed from the syringe and discarded and an ‘inline’ capnometer sampling tube inserted into the syringe. The syringe is then connected
with an endotracheal tube, as shown in Figure 2. Alternatively, a connecting tube with ‘‘sideline’’ sampling for capnometry can be used. Finally, a hole is cut in the conducting tube of the stethoscope approximately 10 cm from the syringe, as illustrated in Figure 3. This hole allows any airflow or secretions from the patient to be directed away from the operator. After successful intubation, the apparatus is discarded, at a total cost of less than $10.00 Australian.
CASE REPORT A 47-year-old man with a 20-year history of moderate intellectual disability after a motor vehicle accident presented to the emergency department with fever and respiratory distress. The patient was a heavy smoker and was producing thick sputum that he was unable to clear without repeated nasopharyngeal suctioning. Intubation was required because of progressive hypoxemia and to facilitate tracheal toilet. It was decided that a nasotracheal tube should be inserted, as this would be better tolerated by the conscious patient and facilitate cooperation with chest physiotherapy. The technique of blind nasal intubation was chosen because examination of the
Figure 3. A hole cut in the stethescope conducting tube.
An Aid to Blind Nasal Intubation
95
patient’s oropharynx revealed a small mouth and a large tongue, raising the concern for a difficult airway. The patient’s nasal passages were sprayed with Cophenylcaine Forte (lidocaine 50 mg/mL/phenylephrine 5 mg/mL/benzalkonium chloride). A 7.5-mm Portex blueline endotracheal tube was then connected to the ‘‘endotracheal tube stethoscope’’ and an inline capnometer, as described above. The tube was advanced beyond the nasal turbinates, and continuous airflow was monitored to minimize trauma to the posterior pharyngeal wall. As the tube was advanced, the breath sounds and capnography trace both increased. Two initial insertions beyond 23 cm resulted in immediate loss of audible breath sounds and capnography, suggesting esophageal placement. At the third attempt, the patient coughed, the breath sounds increased further, and upon inflation of the tube cuff, capnography confirmed placement in the trachea. The patient remained intubated for 24 h and at extubation had no evidence of complications related to placement of the nasotracheal tube.
DISCUSSION Many aids to nasotracheal intubation have been described. The Lightwand® and fiberoptic instruments are effective, but are costly, easily damaged, and require frequent use to maintain proficiency (10 –12). Capnometry has been used as an aid (13), but this technique alone requires that attention be devoted to the capnometer and not to the manipulation of the endotracheal tube. It also
does not allow close monitoring of airflow through the tube in the posterior nasopharynx where retropharyngeal perforation may occur. The Audiocapnometer combines capnography with an amplified audio signal and is effective, but unfortunately requires additional costly equipment (14). The use of the binaural stethoscope inserted down the lumen of the endotracheal tube has been described (15), but we believe our technique is cleaner, safer for the operator, and allows inclusion of the capnometer as an additional guide. This technique can be used in conjunction with other methods for facilitating blind nasotracheal intubation, such as inflation of the endotracheal tube cuff in the pharynx (16) or the use of a suction catheter down the tube (17). If repeated insertions of the endotracheal tube fail to enter the trachea, then the tube should be withdrawn to the point where the breath sounds are heard loudest. At this point, 10 mL of air can be introduced into the tube cuff (this directing the tube tip anteriorly away from the posterior pharyngeal wall) and the endotracheal tube can be advanced a further 2 cm without loss of breath sounds. The cuff is then deflated and the tube advanced further into the trachea (16). This method is simple, effective, and inexpensive. It combines several previously described techniques in a simplified form that requires no additional equipment and is safer for both the patient and operator. Blind nasotracheal intubation is one technique that can be used in the management of the difficult airway; however, consideration should be given to the alternative techniques, and the relative risks and benefits should be compared.
REFERENCES 1. Rowbotham S. Intratracheal anaesthesia by the nasal route for operations on the mouth and lips. Br Med J. 1920;2:590. 2. Magill IW. Technique in endotracheal anaesthesia. Br Med J. 1930;2:817. 3. Magill IW. Endotracheal anaesthesia. Am J Surg. 1936;34:450 –5. 4. Danzl DF, Thomas DM. Nasotracheal intubations in the emergency department. Crit Care Med. 1980;8:677– 82. 5. Iserson KV. Blind nasotracheal intubation. Ann Emerg Med. 1981; 10:468 –70. 6. Deutschmann CS, Wilton P, Sinow J, Dibbell D, Konstantinides F, Cerra F. Paranasal sinusitis associated with nasotracheal intubation: A frequently unrecognised and treatable source of sepsis. Crit Care Med. 1986;14:111–14. 7. Grindlinger GA, Niehoff S, Hughes L, Humphrey M, Simpsom G. Acute paranasal sinusitis related to nasotracheal intubation of head-injured patients. Crit Care Med. 1987;15:214 –17. 8. O’Connell SE, Stevenson DS, Stokes MA. Pathological changes associated with short term nasal intubation. Anaesthesia. 1996;51: 347–50. 9. Tintinalli JE, Claffey J. Complications of nasotracheal intubation. Ann Emerg Med. 1981;10:142– 4.
10. Hung OR, Steward RD. Lightward intubation: I—A new lightward device. Can J Anaesth. 1995;42(A):820 –5. 11. Hung OR, Pytka S, Morris I, Murphy M, Stewart R. Lightward intubation: II—Clinical trial of a new lightward for tracheal intubation in patients with difficult airways. Can J Anaesth. 1995; 42(A):836 –30. 12. David NJ. A new fibreoptic laryngoscope for nasal intubation. Anesth Analg. 1973;52:807– 8. 13. Temporley AD, Walker PJ. Blind nasal intubation by monitoring capnography in a neonate with congenital microstomia. Anaesth Intens Care. 1995;23:490 –2. 14. Omoigui S, Glass P, Martel DLJ, et al. Blind nasal intubation with audio-capnometry. Anesth Analg. 1991;72:392–3. 15. Shapiro H, Unger R. Blind, but not deaf or dirty. Intubations. Anesthesiology. 1986;64:297. 16. Gorback MS. Inflation of the endotracheal tube cuff as an aid to blind nasal endotracheal intubation. Anesth Analg. 1978;66: 917. 17. Meyer RM. Suction catheter to facilitate blind nasal intubation. Anesth Analg. 1989;68:701.
PII S0736-4679(97)00246-1
Techniques and Procedures
AN AID TO BLIND NASAL INTUBATION Roger D. Harris,
MBBS,
Mark J. Gillett, MBBS, FRACGP, FACEM, Anthony P. Joseph, John D. Vinen, MBBS, FACEM, MHP
MBBS, MRCP, FACEM,
and
Department of Emergency Medicine, Royal North Shore Hospital, St. Leonards, New South Wales, Australia Reprint Address: Roger D. Harris, MBBS, Senior Registrar, Department of Emergency Medicine, Royal North Shore Hospital, Pacific Highway, St. Leonards, NSW 2065, Australia
e Abstract—Blind nasal intubation remains an important technique in the management of the difficult airway. Many aids to this technique have been described, but unfortunately, these often require additional expense, training, and equipment. Methods that involve listening at the end of the endotracheal tube and observing moisture condensation in the tube are relatively insensitive and may expose the operator to the patient’s bodily fluids. Our aim was to devise an aid to blind nasal intubation that was effective, inexpensive, simple to learn, and easy to assemble. It is essential that breath sounds can be monitored through the endotracheal tube, as it is felt that this helps to minimize retropharyngeal perforation caused by the tube abutting the posterior pharyngeal wall. We describe the use of an endotracheal tube stethoscope in conjunction with either ‘inline’ or ‘sidestream’ capnometry and present a case of successful nasotracheal intubation using this device. The total cost of this aid is less than $10 Australian. © 1998 Elsevier Science Inc.
availability of modern muscle relaxants (1–3). With the advances in modern anesthetic pharmacology, the practice of this technique has become less common. Despite this, it remains an important adjunct in the management of the difficult airway. Indications for this procedure include potentially difficult orotracheal intubations and patients in whom muscle relaxants or a surgical airway are undesirable or contraindicated. The former situation may include patients with dental fractures, arthritis or dislocation of the temperomandibular joint, a small mouth, a short neck, a large tongue, a history of previous head and neck surgery, or cervical spine immobility (4). This technique is often performed with the patient sitting upright in bed and so is useful when the patient cannot or should not be placed supine. Contraindications include acute epiglottitis, apnea, basilar skull fractures with or without cerebrospinal fluid rhinorrhoea, bleeding diathesis, upper airway foreign body, large bilateral nasal polyps, abscesses, and severe laryngeal trauma (4,5). Complications are rarely serious, but can include nasopharyngeal hemorrhage, laryngeal trauma, retropharyngeal perforation, and paranasal sinusitis. Infection and local trauma to the nasal septum and turbinates can be minimized by limiting the duration of nasotracheal intubation (6 – 8). The risk of retropharyngeal perforation may be reduced by monitoring airflow through the endotracheal tube once it has passed beyond the turbinates.
e Keywords— blind nasal intubation; retropharyngeal perforation; endotracheal tube stethescope; capnography; difficult intubation
INTRODUCTION Blind nasal intubation is an important skill for the emergency physician, anesthesiologist, and critical care physician. This procedure was initially described during World War I and gained some popularity before the
Techniques and Procedures is coordinated by George Sternbach,
RECEIVED: 25 April 1997; FINAL ACCEPTED: 28 July 1997
SUBMISSION RECEIVED:
14 July 1997; 93
MD,
of Stanford University, Stanford, California
94
R. D. Harris et al.
Figure 1. Equipment. Figure 2. Equipment assembled.
Loss of airflow at this point usually indicates that the tube is abutting the posterior pharyngeal wall, and further pressure could cause perforation (9). The technique described here provides a means of averting this problem, as airflow through the tube is continuously monitored. Once the endotracheal tube has passed into the nasopharynx, the monitoring of breath sounds then becomes the key for successful tracheal intubation. At each inspiratory effort, the tube should be advanced while constantly monitoring breath sounds. If advancing the tube results in loss of or reduction in breath sounds, then the tube should be withdrawn to the point at which the breath sounds are maximally auscultated. The endotracheal tube then can be turned slightly and readvanced with each inspiratory effort. Successful tracheal intubation will be denoted by continued auscultation of distinct breath sounds, some resistance as the tube passes through the vocal cords, the patient coughing, and the capnography reading and waveform. If intubation continues to be difficult, there are several other maneuvers briefly described in the discussion that can be used in conjunction with our technique.
Constructing an Endotracheal Tube Stethoscopy with Capnometry Our aim was to devise an aid to blind nasal intubation that combines several previously described methods, but is easy to construct, requires minimal additional equipment or cost, and is safe for the operator and patient. The equipment used is demonstrated in Figure 1. A basic stethoscope costing $8.00 Australian has the bell/ diaphragm removed from the conducting tube. A 10-mL Terumo® syringe is then inserted via its needle-port end into the conducting tube and the two are fixed together with tape. The plunger is removed from the syringe and discarded and an ‘inline’ capnometer sampling tube inserted into the syringe. The syringe is then connected
with an endotracheal tube, as shown in Figure 2. Alternatively, a connecting tube with ‘‘sideline’’ sampling for capnometry can be used. Finally, a hole is cut in the conducting tube of the stethoscope approximately 10 cm from the syringe, as illustrated in Figure 3. This hole allows any airflow or secretions from the patient to be directed away from the operator. After successful intubation, the apparatus is discarded, at a total cost of less than $10.00 Australian.
CASE REPORT A 47-year-old man with a 20-year history of moderate intellectual disability after a motor vehicle accident presented to the emergency department with fever and respiratory distress. The patient was a heavy smoker and was producing thick sputum that he was unable to clear without repeated nasopharyngeal suctioning. Intubation was required because of progressive hypoxemia and to facilitate tracheal toilet. It was decided that a nasotracheal tube should be inserted, as this would be better tolerated by the conscious patient and facilitate cooperation with chest physiotherapy. The technique of blind nasal intubation was chosen because examination of the
Figure 3. A hole cut in the stethescope conducting tube.
An Aid to Blind Nasal Intubation
95
patient’s oropharynx revealed a small mouth and a large tongue, raising the concern for a difficult airway. The patient’s nasal passages were sprayed with Cophenylcaine Forte (lidocaine 50 mg/mL/phenylephrine 5 mg/mL/benzalkonium chloride). A 7.5-mm Portex blueline endotracheal tube was then connected to the ‘‘endotracheal tube stethoscope’’ and an inline capnometer, as described above. The tube was advanced beyond the nasal turbinates, and continuous airflow was monitored to minimize trauma to the posterior pharyngeal wall. As the tube was advanced, the breath sounds and capnography trace both increased. Two initial insertions beyond 23 cm resulted in immediate loss of audible breath sounds and capnography, suggesting esophageal placement. At the third attempt, the patient coughed, the breath sounds increased further, and upon inflation of the tube cuff, capnography confirmed placement in the trachea. The patient remained intubated for 24 h and at extubation had no evidence of complications related to placement of the nasotracheal tube.
DISCUSSION Many aids to nasotracheal intubation have been described. The Lightwand® and fiberoptic instruments are effective, but are costly, easily damaged, and require frequent use to maintain proficiency (10 –12). Capnometry has been used as an aid (13), but this technique alone requires that attention be devoted to the capnometer and not to the manipulation of the endotracheal tube. It also
does not allow close monitoring of airflow through the tube in the posterior nasopharynx where retropharyngeal perforation may occur. The Audiocapnometer combines capnography with an amplified audio signal and is effective, but unfortunately requires additional costly equipment (14). The use of the binaural stethoscope inserted down the lumen of the endotracheal tube has been described (15), but we believe our technique is cleaner, safer for the operator, and allows inclusion of the capnometer as an additional guide. This technique can be used in conjunction with other methods for facilitating blind nasotracheal intubation, such as inflation of the endotracheal tube cuff in the pharynx (16) or the use of a suction catheter down the tube (17). If repeated insertions of the endotracheal tube fail to enter the trachea, then the tube should be withdrawn to the point where the breath sounds are heard loudest. At this point, 10 mL of air can be introduced into the tube cuff (this directing the tube tip anteriorly away from the posterior pharyngeal wall) and the endotracheal tube can be advanced a further 2 cm without loss of breath sounds. The cuff is then deflated and the tube advanced further into the trachea (16). This method is simple, effective, and inexpensive. It combines several previously described techniques in a simplified form that requires no additional equipment and is safer for both the patient and operator. Blind nasotracheal intubation is one technique that can be used in the management of the difficult airway; however, consideration should be given to the alternative techniques, and the relative risks and benefits should be compared.
REFERENCES 1. Rowbotham S. Intratracheal anaesthesia by the nasal route for operations on the mouth and lips. Br Med J. 1920;2:590. 2. Magill IW. Technique in endotracheal anaesthesia. Br Med J. 1930;2:817. 3. Magill IW. Endotracheal anaesthesia. Am J Surg. 1936;34:450 –5. 4. Danzl DF, Thomas DM. Nasotracheal intubations in the emergency department. Crit Care Med. 1980;8:677– 82. 5. Iserson KV. Blind nasotracheal intubation. Ann Emerg Med. 1981; 10:468 –70. 6. Deutschmann CS, Wilton P, Sinow J, Dibbell D, Konstantinides F, Cerra F. Paranasal sinusitis associated with nasotracheal intubation: A frequently unrecognised and treatable source of sepsis. Crit Care Med. 1986;14:111–14. 7. Grindlinger GA, Niehoff S, Hughes L, Humphrey M, Simpsom G. Acute paranasal sinusitis related to nasotracheal intubation of head-injured patients. Crit Care Med. 1987;15:214 –17. 8. O’Connell SE, Stevenson DS, Stokes MA. Pathological changes associated with short term nasal intubation. Anaesthesia. 1996;51: 347–50. 9. Tintinalli JE, Claffey J. Complications of nasotracheal intubation. Ann Emerg Med. 1981;10:142– 4.
10. Hung OR, Steward RD. Lightward intubation: I—A new lightward device. Can J Anaesth. 1995;42(A):820 –5. 11. Hung OR, Pytka S, Morris I, Murphy M, Stewart R. Lightward intubation: II—Clinical trial of a new lightward for tracheal intubation in patients with difficult airways. Can J Anaesth. 1995; 42(A):836 –30. 12. David NJ. A new fibreoptic laryngoscope for nasal intubation. Anesth Analg. 1973;52:807– 8. 13. Temporley AD, Walker PJ. Blind nasal intubation by monitoring capnography in a neonate with congenital microstomia. Anaesth Intens Care. 1995;23:490 –2. 14. Omoigui S, Glass P, Martel DLJ, et al. Blind nasal intubation with audio-capnometry. Anesth Analg. 1991;72:392–3. 15. Shapiro H, Unger R. Blind, but not deaf or dirty. Intubations. Anesthesiology. 1986;64:297. 16. Gorback MS. Inflation of the endotracheal tube cuff as an aid to blind nasal endotracheal intubation. Anesth Analg. 1978;66: 917. 17. Meyer RM. Suction catheter to facilitate blind nasal intubation. Anesth Analg. 1989;68:701.