Chapter 29: Nasotracheal Intubation

INTRODUCTION

Nasotracheal intubation is a relatively simple procedure that is performed rapidly without the aid or risks of neuromuscular blockade.¹ This method of intubation is sometimes favored in difficult airway cases, especially when oral access is limited or impossible. Such conditions include trismus, oral injuries, and obstructive oral processes such as angioedema. Nasotracheal intubation is also the method of intubation preferred by some for acute epiglottitis.² It is the most common method of inducing anesthesia for oral surgery cases to ensure optimal surgical access.³

Nasotracheal intubation is well tolerated by most patients and produces less reflex salivation than orotracheal intubation, thus leading to fewer attempts at self-extubation. The nasotracheal tube is more easily stabilized and is generally easier to care for than an orotracheal tube. This method prevents biting of the tube by the patient and manipulation by the patient’s tongue.^2,4

INDICATIONS

Nasotracheal intubation is indicated in any patient with spontaneous respirations, especially those whose period of intubation is anticipated to be brief.^1-4 It is indicated in patients who are unable to lay supine due to respiratory distress from severe asthma, chronic obstructive pulmonary disease (COPD), or congestive heart failure. It is also indicated in patients who are unable to open their mouths due to facial trauma, mandibular trauma, or trismus. Nasotracheal intubation can be performed in patients with limited airway patency due to obstruction from neoplasm or tongue swelling. Nasotracheal intubation is an appropriate method of intubation in patients who require neck immobilization for suspected cervical spine injuries, patients unable to move their necks due to cervical kyphosis, patients with severe cervical arthritis limiting neck movement, or patients with postradiation fibrosis. Because they are often intubated for a short time, patients with severe alcohol intoxication or drug overdose whose level of consciousness is decreased are good candidates for nasotracheal intubation.^1,2,4 Nasotracheal intubation may be performed in patients who have contraindications to the use of succinylcholine (Table 16-2).

CONTRAINDICATIONS

Nasotracheal intubation is contraindicated in patients with apnea, severe facial or maxillofacial fractures, basilar skull fractures, head injury with an elevated intracranial pressure, penetrating neck injury, nasal obstruction, recent nasal surgery, or nasopharyngeal obstruction; patients receiving thrombolytics or parenteral anticoagulants; and in the presence of a coagulopathy.^1-5

Nasotracheal blind intubation should not be performed in neonates, infants, or very young children. The more anterior and cephalic position of the airway in these age groups makes blind passage of an endotracheal tube (ETT) almost impossible. A patient must provide a degree of cooperation during the procedure. A crying, kicking, and struggling child who must be restrained is not a candidate for nasotracheal intubation.

EQUIPMENT

• Nasal mucosa vasoconstrictor (e.g., 4% cocaine, 0.05% oxymetazoline, 0.25% phenylephrine)

• Nasal mucosa anesthetic (e.g., viscous ...