Nasal intubation - Revision history

Jchen900 at 22:11, 16 August 2023

2023-08-16T22:11:39Z

← Older revision		Revision as of 15:11, 16 August 2023
Line 46:		Line 46:

	After dilating Nares sequentially with Nasal Airways, insert Red Rubber Urethral catheter into nares, with RAE ET tube attached to trailing end. Under DL, carefully pull out leading edge of red catheter from pharynx, and detach, looking away. Proceed under DL to intubate with or without McGill. May need to rotate ET tube to direct the leading edge through the vocal chords.		After dilating Nares sequentially with Nasal Airways, insert Red Rubber Urethral catheter into nares, with RAE ET tube attached to trailing end. Under DL, carefully pull out leading edge of red catheter from pharynx, and detach, looking away. Proceed under DL to intubate with or without McGill. May need to rotate ET tube to direct the leading edge through the vocal chords.

			Alternatively, if patient has narrow mouth opening, can attempt placement utilizing Glidescope. After placing RAE ETT in nare, perform laryngoscopy using Glidescope. Once vocal cord is in view, minimalize the upward force of the Glidescope blade such that the glottis and vocal cords are sitting in the lowest position on the screen and centered. Advance RAE ETT until visualized on Glidescope screen. Line up the tip of the nasal RAE with glottic opening and advance. If the glottis appears higher than tip of ETT, inflate balloon until tip is aligned with glottis and advance.

	==Complications ==		==Complications ==

ChristosK: Added procedural notes, and alternatives for preparation.

2023-01-20T16:25:51Z

Added procedural notes, and alternatives for preparation.

← Older revision		Revision as of 09:25, 20 January 2023
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	===Topical anesthesia and vasoconstriction===		===Topical anesthesia and vasoconstriction===
	Vasoconstriction of the nasal mucosa may be achieved using oxymetazoline 0.05%. If topical anesthesia is also desirable, lidocaine 3-4% (with phenylephrine 0.25-1%) or cocaine 4-10% may also be used.<ref name=":0" /> Prepare for any potential hemodynamic effects from systemic absorption of the drugs and/or additives used.		Vasoconstriction of the nasal mucosa may be achieved using oxymetazoline 0.05%. If topical anesthesia is also desirable, lidocaine 3-4% (with phenylephrine 0.25-1%) or cocaine 4-10% may also be used.<ref name=":0" /> Prepare for any potential hemodynamic effects from systemic absorption of the drugs and/or additives used.

			Consider, alternatively mixing small but equal amounts of 0.2mg glycopyrrolate, with 100mcg /cc phenylephrine, which should balance out heart rate perturbations during induction. Spray 2-3 cc of each onto 4X4, and add lubricant.

	===Mechanical dilation===		===Mechanical dilation===
	Serial mechanical dilation of the nares with nasal trumpets prior to nasal intubation is controversial and in some studies has been associated with higher rates of trauma and hemorrhage to friable nasal mucosa.<ref>{{Cite journal\|last=Adamson\|first=D. N.\|last2=Theisen\|first2=F. C.\|last3=Barrett\|first3=K. C.\|date=1988\|title=Effect of mechanical dilation on nasotracheal intubation\|url=https://pubmed.ncbi.nlm.nih.gov/3163370\|journal=Journal of Oral and Maxillofacial Surgery: Official Journal of the American Association of Oral and Maxillofacial Surgeons\|volume=46\|issue=5\|pages=372–375\|doi=10.1016/0278-2391(88)90220-0\|issn=0278-2391\|pmid=3163370\|via=}}</ref> <ref>{{Citation\|last=Folino\|first=Thomas B.\|title=Nasotracheal Intubation\|date=2022\|url=http://www.ncbi.nlm.nih.gov/books/NBK499967/\|work=StatPearls\|place=Treasure Island (FL)\|publisher=StatPearls Publishing\|pmid=29763142\|access-date=2022-08-17\|last2=Mckean\|first2=George\|last3=Parks\|first3=Lance J.}}</ref>		Serial mechanical dilation of the nares with nasal trumpets prior to nasal intubation is controversial and in some studies has been associated with higher rates of trauma and hemorrhage to friable nasal mucosa.<ref>{{Cite journal\|last=Adamson\|first=D. N.\|last2=Theisen\|first2=F. C.\|last3=Barrett\|first3=K. C.\|date=1988\|title=Effect of mechanical dilation on nasotracheal intubation\|url=https://pubmed.ncbi.nlm.nih.gov/3163370\|journal=Journal of Oral and Maxillofacial Surgery: Official Journal of the American Association of Oral and Maxillofacial Surgeons\|volume=46\|issue=5\|pages=372–375\|doi=10.1016/0278-2391(88)90220-0\|issn=0278-2391\|pmid=3163370\|via=}}</ref> <ref>{{Citation\|last=Folino\|first=Thomas B.\|title=Nasotracheal Intubation\|date=2022\|url=http://www.ncbi.nlm.nih.gov/books/NBK499967/\|work=StatPearls\|place=Treasure Island (FL)\|publisher=StatPearls Publishing\|pmid=29763142\|access-date=2022-08-17\|last2=Mckean\|first2=George\|last3=Parks\|first3=Lance J.}}</ref> Robertazzi aiways size 28-34 usually sufficient.

			Consider preparing a Red Rubber Urethral Catheter. Size 12Fr is ideal in most cases. Above this size, the catheter is too stiff and can cause trauma. Smaller sizes are too soft and cannot be easily directed. Lubricate the nasal airways and catheter, with 2-3 drops of vasoconstricting agent.

	==Selection of Endotracheal Tube==		==Selection of Endotracheal Tube==
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	*[[Microlaryngeal endotracheal tube\|Microlaryngeal tubes]] may be used if a smaller diameter is desirable		*[[Microlaryngeal endotracheal tube\|Microlaryngeal tubes]] may be used if a smaller diameter is desirable
	**Typically 5.0 mm and 6.0 mm internal diameter are sufficiently long to be used for nasotracheal intubation		**Typically 5.0 mm and 6.0 mm internal diameter are sufficiently long to be used for nasotracheal intubation


			Prepare Nasal RAE by leaving in a container of warm saline. Have half a size up and below available and similarly prepared. Traditionally this is necessary with clear plastic RAE's due to their stiffness. Consider using softer tube to minimize pharyngeal trauma (such as Smiths Medical Portex), but and more difficult to direct /manipulate, and require McGill Forceps.

			After dilating Nares sequentially with Nasal Airways, insert Red Rubber Urethral catheter into nares, with RAE ET tube attached to trailing end. Under DL, carefully pull out leading edge of red catheter from pharynx, and detach, looking away. Proceed under DL to intubate with or without McGill. May need to rotate ET tube to direct the leading edge through the vocal chords.

	==Complications ==		==Complications ==
Line 60:		Line 69:

	=== Other complications ===		=== Other complications ===
	Rarely, more serious complications occur such as avulsion of turbinates or nasal polyps, posterior pharyngeal wall laceration, and sinusitis.		Rarely, more serious complications occur such as avulsion of turbinates or nasal polyps, posterior pharyngeal wall laceration, dissection, and sinusitis.

	== References ==		== References ==
	<references />		<references />

Sremick: added reference for possible increased complications without benefit of serial dilation

2022-08-17T13:49:24Z

added reference for possible increased complications without benefit of serial dilation

← Older revision		Revision as of 06:49, 17 August 2022
Line 26:		Line 26:

	===Mechanical dilation===		===Mechanical dilation===
	Serial mechanical dilation of the nares with nasal trumpets prior to nasal intubation is controversial and in some studies has been associated with higher rates of trauma and hemorrhage to friable nasal mucosa.<ref>{{Cite journal\|last=Adamson\|first=D. N.\|last2=Theisen\|first2=F. C.\|last3=Barrett\|first3=K. C.\|date=1988\|title=Effect of mechanical dilation on nasotracheal intubation\|url=https://pubmed.ncbi.nlm.nih.gov/3163370\|journal=Journal of Oral and Maxillofacial Surgery: Official Journal of the American Association of Oral and Maxillofacial Surgeons\|volume=46\|issue=5\|pages=372–375\|doi=10.1016/0278-2391(88)90220-0\|issn=0278-2391\|pmid=3163370\|via=}}</ref>		Serial mechanical dilation of the nares with nasal trumpets prior to nasal intubation is controversial and in some studies has been associated with higher rates of trauma and hemorrhage to friable nasal mucosa.<ref>{{Cite journal\|last=Adamson\|first=D. N.\|last2=Theisen\|first2=F. C.\|last3=Barrett\|first3=K. C.\|date=1988\|title=Effect of mechanical dilation on nasotracheal intubation\|url=https://pubmed.ncbi.nlm.nih.gov/3163370\|journal=Journal of Oral and Maxillofacial Surgery: Official Journal of the American Association of Oral and Maxillofacial Surgeons\|volume=46\|issue=5\|pages=372–375\|doi=10.1016/0278-2391(88)90220-0\|issn=0278-2391\|pmid=3163370\|via=}}</ref> <ref>{{Citation\|last=Folino\|first=Thomas B.\|title=Nasotracheal Intubation\|date=2022\|url=http://www.ncbi.nlm.nih.gov/books/NBK499967/\|work=StatPearls\|place=Treasure Island (FL)\|publisher=StatPearls Publishing\|pmid=29763142\|access-date=2022-08-17\|last2=Mckean\|first2=George\|last3=Parks\|first3=Lance J.}}</ref>

	==Selection of Endotracheal Tube==		==Selection of Endotracheal Tube==

Barrett.Larson at 16:21, 5 September 2021

2021-09-05T16:21:19Z

← Older revision		Revision as of 09:21, 5 September 2021
Line 62:		Line 62:
	Rarely, more serious complications occur such as avulsion of turbinates or nasal polyps, posterior pharyngeal wall laceration, and sinusitis.		Rarely, more serious complications occur such as avulsion of turbinates or nasal polyps, posterior pharyngeal wall laceration, and sinusitis.

			== References ==
	<references />		<references />

Chris.Rishel: More formatting

2021-09-03T04:23:43Z

More formatting

← Older revision		Revision as of 21:23, 2 September 2021
Line 14:		Line 14:
	* Severe bleeding diathesis		* Severe bleeding diathesis
	*Anticoagulation		*Anticoagulation
	* ~~Base of~~ skull fractures		* Basilar skull fractures
	**Advancing a nasal tube ~~of any kind~~ in a patient with a ~~base of~~ skull fracture risks penetration into the brain.<ref name=":0">{{Cite journal\|last=Hall\|first=C. E. J.\|last2=Shutt\|first2=L. E.\|date=2003\|title=Nasotracheal intubation for head and neck surgery\|url=https://pubmed.ncbi.nlm.nih.gov/12603455\|journal=Anaesthesia\|volume=58\|issue=3\|pages=249–256\|doi=10.1046/j.1365-2044.2003.03034.x\|issn=0003-2409\|pmid=12603455\|via=}}</ref>		**Advancing a nasal tube in a patient with a basilar skull fracture risks penetration into the brain.<ref name=":0">{{Cite journal\|last=Hall\|first=C. E. J.\|last2=Shutt\|first2=L. E.\|date=2003\|title=Nasotracheal intubation for head and neck surgery\|url=https://pubmed.ncbi.nlm.nih.gov/12603455\|journal=Anaesthesia\|volume=58\|issue=3\|pages=249–256\|doi=10.1046/j.1365-2044.2003.03034.x\|issn=0003-2409\|pmid=12603455\|via=}}</ref>

	== Patient evaluation ==		==Patient evaluation==
	A history of nasal septal deviation, polyps, and prior nasal surgery should be elicited. Patients with previous reconstructive orofacial surgery or nasal stenosis may have nasal anatomy that does not permit passage of an nasal endotracheal tube. In these cases, preoperative endoscopic airway examination ([[PEAE]]) and craniofacial CT imaging is helpful to determine feasibility of nasal intubation.<ref name=":0" />		A history of nasal septal deviation, polyps, and prior nasal surgery should be elicited. Patients with previous reconstructive orofacial surgery or nasal stenosis may have nasal anatomy that does not permit passage of an nasal endotracheal tube. In these cases, preoperative endoscopic airway examination ([[PEAE]]) and craniofacial CT imaging is helpful to determine feasibility of nasal intubation.<ref name=":0" />

	==Preparation of Nasal Mucosa==		==Preparation of Nasal Mucosa==
	Vasoconstriction of the nasal mucosa may be achieved using oxymetazoline 0.05%, lidocaine 3-4% with phenylephrine 0.25-1%, or cocaine 4-10%.<ref name=":0" /> The hemodynamic effects of cocaine and phenylephrine should be anticipated and planned for accordingly.

			===Topical anesthesia and vasoconstriction===
			Vasoconstriction of the nasal mucosa may be achieved using oxymetazoline 0.05%. If topical anesthesia is also desirable, lidocaine 3-4% (with phenylephrine 0.25-1%) or cocaine 4-10% may also be used.<ref name=":0" /> Prepare for any potential hemodynamic effects from systemic absorption of the drugs and/or additives used.

			===Mechanical dilation===
	Serial mechanical dilation of the nares with nasal trumpets prior to nasal intubation is controversial and in some studies has been associated with higher rates of trauma and hemorrhage to friable nasal mucosa.<ref>{{Cite journal\|last=Adamson\|first=D. N.\|last2=Theisen\|first2=F. C.\|last3=Barrett\|first3=K. C.\|date=1988\|title=Effect of mechanical dilation on nasotracheal intubation\|url=https://pubmed.ncbi.nlm.nih.gov/3163370\|journal=Journal of Oral and Maxillofacial Surgery: Official Journal of the American Association of Oral and Maxillofacial Surgeons\|volume=46\|issue=5\|pages=372–375\|doi=10.1016/0278-2391(88)90220-0\|issn=0278-2391\|pmid=3163370\|via=}}</ref>		Serial mechanical dilation of the nares with nasal trumpets prior to nasal intubation is controversial and in some studies has been associated with higher rates of trauma and hemorrhage to friable nasal mucosa.<ref>{{Cite journal\|last=Adamson\|first=D. N.\|last2=Theisen\|first2=F. C.\|last3=Barrett\|first3=K. C.\|date=1988\|title=Effect of mechanical dilation on nasotracheal intubation\|url=https://pubmed.ncbi.nlm.nih.gov/3163370\|journal=Journal of Oral and Maxillofacial Surgery: Official Journal of the American Association of Oral and Maxillofacial Surgeons\|volume=46\|issue=5\|pages=372–375\|doi=10.1016/0278-2391(88)90220-0\|issn=0278-2391\|pmid=3163370\|via=}}</ref>

	== Selection of Endotracheal Tube ==		==Selection of Endotracheal Tube==
	Tubes placed via the nasotracheal route must be of smaller diameter and increased length compared to tubes used for orotracheal intubation. Nasal RAE tubes have a preformed bend at a set depth depending on the internal diameter of the tube~~. Therefore, they must~~ be sized appropriately by comparing them to the patient's profile in order to ensure that the cuff will lie at the appropriate depth. Most patients require a size 7.0 mm internal diameter nasal RAE or larger~~. Alternatively, microlaryngeal~~ tubes may be used as smaller ~~sizes (~~5.0 mm and 6.0 mm internal diameter) are sufficiently long to be used for nasotracheal intubation.
			Tubes placed via the nasotracheal route must be of smaller diameter and increased length compared to tubes used for orotracheal intubation.

			*[[Ring-Adair-Elwyn endotracheal tube\|Nasal RAE tubes]] have a preformed bend at a set depth depending on the internal diameter of the tube
			** Must be sized appropriately by comparing them to the patient's profile in order to ensure that the cuff will lie at the appropriate depth
			**Most patients require a size 7.0 mm internal diameter nasal RAE or larger
			*[[Microlaryngeal endotracheal tube\|Microlaryngeal tubes]] may be used if a smaller diameter is desirable
			**Typically 5.0 mm and 6.0 mm internal diameter are sufficiently long to be used for nasotracheal intubation

			==Complications ==

			=== Epistaxis ===

			* Most common complication of nasal intubation epistaxis from nasal trauma
			* Causes include<ref name=":0" />
			** Inadequate vasoconstriction
			** Larger diameter endotracheal tubes
			** Excessive force
			** Repeated insertion attempts.
			* Softening the endotracheal tube in hot water may reduce risk<ref>{{Cite journal\|last=Lu\|first=P. P.\|last2=Liu\|first2=H. P.\|last3=Shyr\|first3=M. H.\|last4=Ho\|first4=A. C.\|last5=Wang\|first5=Y. L.\|last6=Tan\|first6=P. P.\|last7=Yang\|first7=C. H.\|date=1998\|title=Softened endothracheal tube reduces the incidence and severity of epistaxis following nasotracheal intubation\|url=https://pubmed.ncbi.nlm.nih.gov/10399514\|journal=Acta Anaesthesiologica Sinica\|volume=36\|issue=4\|pages=193–197\|issn=0254-1319\|pmid=10399514\|via=}}</ref>
			* If bleeding occurs, intubation should be completed quickly if possible.
			** If rapid intubation is not possible, the endotracheal tube should be withdrawn into the post-nasal space and the balloon inflated to tamponade bleeding<ref name=":0" />

	==~~Complications~~==		=== Alar necrosis ===
	The most common complication of nasal intubation is mucosal trauma leading to epistaxis. This most commonly occurs in the setting of inadequate vasoconstriction, larger diameter endotracheal tubes, excessive force, and repeated insertion attempts.<ref name=~~":0" /> Softening the endotracheal tube in hot water may reduce the risk of epistaxis.<ref>{{Cite journal\|last~~=Lu\|first=P. P.\|last2=Liu\|first2=H. P.\|last3=Shyr\|first3=M. H.\|last4=Ho\|first4=A. C.\|last5=Wang\|first5=Y. L.\|last6=Tan\|first6=P. P.\|last7=Yang\|first7=C. H.\|date=1998\|title=Softened endothracheal tube reduces the incidence and severity of epistaxis following nasotracheal intubation\|url=https://pubmed.ncbi.nlm.nih.gov/10399514\|journal=Acta Anaesthesiologica Sinica\|volume=36\|issue=4\|pages=193–197\|issn=0254-1319\|pmid=10399514\|via=}}</ref> If bleeding occurs, intubation should be completed quickly if possible. If rapid intubation is not possible, the endotracheal tube should be withdrawn into the post-nasal space and the balloon inflated, in an attempt to tamponade bleeding.<ref name=":0" />

	~~Another possible serious complication is necrosis of the nasal ala, which occurs~~ due to pressure from the nasal tube~~. Alar necrosis may~~ occur quickly~~: it has~~ been reported in nasal intubations of even short duration.<ref name=":0" /> ~~Careful securement of~~ the ~~nasal~~ tube that ~~avoid~~ pressure on the nasal ala ~~is essential for preventing this complication.~~		* Occurs due to pressure from the nasal tube
			* May occur quickly
			** Has been reported in nasal intubations of even short duration.<ref name=":0" />
			* Prevented by securing the tube such that pressure is avoided on the nasal ala

			=== Other complications ===
	Rarely, more serious complications occur such as avulsion of turbinates or nasal polyps, posterior pharyngeal wall laceration, and sinusitis.		Rarely, more serious complications occur such as avulsion of turbinates or nasal polyps, posterior pharyngeal wall laceration, and sinusitis.

	<references />		<references />

Chris.Rishel: Formatting

2021-09-03T03:41:20Z

Formatting

← Older revision		Revision as of 20:41, 2 September 2021
Line 1:		Line 1:
	'''~~Introduction~~'''		'''Nasal intubation''' is an approach to [[endotracheal intubation]] often used to increase intraoral exposure during head & neck surgery.

	~~Nasal~~ intubation ~~is often used to increase intraoral exposure during head & neck surgery. Indications include:~~		== Indications==
			*Transoral robotic surgery
			*Maxillofacial surgery
			*Dental surgery
			* Restricted mouth opening
			*Cervical spine instability
			*Lower facial trauma
			*Structural abnormalities that preclude oral intubation

	* transoral robotic surgery		==Contraindications==
	* maxillofacial surgery
	* dental surgery
	* restricted mouth opening
	* cervical spine instability
	* lower facial trauma
	* structural abnormalities that preclude oral intubation

			* Severe bleeding diathesis
			*Anticoagulation
			* Base of skull fractures
			**Advancing a nasal tube of any kind in a patient with a base of skull fracture risks penetration into the brain.<ref name=":0">{{Cite journal\|last=Hall\|first=C. E. J.\|last2=Shutt\|first2=L. E.\|date=2003\|title=Nasotracheal intubation for head and neck surgery\|url=https://pubmed.ncbi.nlm.nih.gov/12603455\|journal=Anaesthesia\|volume=58\|issue=3\|pages=249–256\|doi=10.1046/j.1365-2044.2003.03034.x\|issn=0003-2409\|pmid=12603455\|via=}}</ref>

	Contraindications to nasal intubation include severe bleeding diathesis, anticoagulation, and base of skull fractures. Advancing a nasal tube of any kind in a patient with a base of skull fracture risks penetration into the brain.<ref name=~~":0">{{Cite journal\|last~~=~~Hall\|first~~=~~C. E. J.\|last2~~=Shutt\|first2=L. E.\|date=2003-03\|title=Nasotracheal intubation for head and neck surgery\|url=https://pubmed.ncbi.nlm.nih.gov/12603455\|journal=Anaesthesia\|volume=58\|issue=3\|pages=249–256\|doi=10.1046/j.1365-2044.2003.03034.x\|issn=0003-2409\|pmid=12603455}}</ref>		== Patient evaluation ==

	A history of nasal septal deviation, polyps, and prior nasal surgery should be elicited. Patients with previous reconstructive orofacial surgery or nasal stenosis may have nasal anatomy that does not permit passage of an nasal endotracheal tube. In these cases, preoperative endoscopic airway examination ([[PEAE]]) and craniofacial CT imaging is helpful to determine feasibility of nasal intubation.<ref name=":0" />		A history of nasal septal deviation, polyps, and prior nasal surgery should be elicited. Patients with previous reconstructive orofacial surgery or nasal stenosis may have nasal anatomy that does not permit passage of an nasal endotracheal tube. In these cases, preoperative endoscopic airway examination ([[PEAE]]) and craniofacial CT imaging is helpful to determine feasibility of nasal intubation.<ref name=":0" />

	~~'''~~Preparation of Nasal Mucosa~~'''~~		==Preparation of Nasal Mucosa==

	Vasoconstriction of the nasal mucosa may be achieved using oxymetazoline 0.05%, lidocaine 3-4% with phenylephrine 0.25-1%, or cocaine 4-10%.<ref name=":0" /> The hemodynamic effects of cocaine and phenylephrine should be anticipated and planned for accordingly.		Vasoconstriction of the nasal mucosa may be achieved using oxymetazoline 0.05%, lidocaine 3-4% with phenylephrine 0.25-1%, or cocaine 4-10%.<ref name=":0" /> The hemodynamic effects of cocaine and phenylephrine should be anticipated and planned for accordingly.

	Serial mechanical dilation of the nares with nasal trumpets prior to nasal intubation is controversial and in some studies has been associated with higher rates of trauma and hemorrhage to friable nasal mucosa.<ref>{{Cite journal\|last=Adamson\|first=D. N.\|last2=Theisen\|first2=F. C.\|last3=Barrett\|first3=K. C.\|date=1988~~-05~~\|title=Effect of mechanical dilation on nasotracheal intubation\|url=https://pubmed.ncbi.nlm.nih.gov/3163370\|journal=Journal of Oral and Maxillofacial Surgery: Official Journal of the American Association of Oral and Maxillofacial Surgeons\|volume=46\|issue=5\|pages=372–375\|doi=10.1016/0278-2391(88)90220-0\|issn=0278-2391\|pmid=3163370}}</ref>		Serial mechanical dilation of the nares with nasal trumpets prior to nasal intubation is controversial and in some studies has been associated with higher rates of trauma and hemorrhage to friable nasal mucosa.<ref>{{Cite journal\|last=Adamson\|first=D. N.\|last2=Theisen\|first2=F. C.\|last3=Barrett\|first3=K. C.\|date=1988\|title=Effect of mechanical dilation on nasotracheal intubation\|url=https://pubmed.ncbi.nlm.nih.gov/3163370\|journal=Journal of Oral and Maxillofacial Surgery: Official Journal of the American Association of Oral and Maxillofacial Surgeons\|volume=46\|issue=5\|pages=372–375\|doi=10.1016/0278-2391(88)90220-0\|issn=0278-2391\|pmid=3163370\|via=}}</ref>

	~~'''Selection of Endotracheal Tube'''~~

			== Selection of Endotracheal Tube ==
	Tubes placed via the nasotracheal route must be of smaller diameter and increased length compared to tubes used for orotracheal intubation. Nasal RAE tubes have a preformed bend at a set depth depending on the internal diameter of the tube. Therefore, they must be sized appropriately by comparing them to the patient's profile in order to ensure that the cuff will lie at the appropriate depth. Most patients require a size 7.0 mm internal diameter nasal RAE or larger. Alternatively, microlaryngeal tubes may be used as smaller sizes (5.0 mm and 6.0 mm internal diameter) are sufficiently long to be used for nasotracheal intubation.		Tubes placed via the nasotracheal route must be of smaller diameter and increased length compared to tubes used for orotracheal intubation. Nasal RAE tubes have a preformed bend at a set depth depending on the internal diameter of the tube. Therefore, they must be sized appropriately by comparing them to the patient's profile in order to ensure that the cuff will lie at the appropriate depth. Most patients require a size 7.0 mm internal diameter nasal RAE or larger. Alternatively, microlaryngeal tubes may be used as smaller sizes (5.0 mm and 6.0 mm internal diameter) are sufficiently long to be used for nasotracheal intubation.

	~~'''~~Complications~~'''~~		==Complications==
			The most common complication of nasal intubation is mucosal trauma leading to epistaxis. This most commonly occurs in the setting of inadequate vasoconstriction, larger diameter endotracheal tubes, excessive force, and repeated insertion attempts.<ref name=":0" /> Softening the endotracheal tube in hot water may reduce the risk of epistaxis.<ref>{{Cite journal\|last=Lu\|first=P. P.\|last2=Liu\|first2=H. P.\|last3=Shyr\|first3=M. H.\|last4=Ho\|first4=A. C.\|last5=Wang\|first5=Y. L.\|last6=Tan\|first6=P. P.\|last7=Yang\|first7=C. H.\|date=1998\|title=Softened endothracheal tube reduces the incidence and severity of epistaxis following nasotracheal intubation\|url=https://pubmed.ncbi.nlm.nih.gov/10399514\|journal=Acta Anaesthesiologica Sinica\|volume=36\|issue=4\|pages=193–197\|issn=0254-1319\|pmid=10399514\|via=}}</ref> If bleeding occurs, intubation should be completed quickly if possible. If rapid intubation is not possible, the endotracheal tube should be withdrawn into the post-nasal space and the balloon inflated, in an attempt to tamponade bleeding.<ref name=":0" />
	The most common complication of nasal intubation is mucosal trauma leading to epistaxis. This most commonly occurs in the setting of inadequate vasoconstriction, larger diameter endotracheal tubes, excessive force, and repeated insertion attempts.<ref name=":0" /> Softening the endotracheal tube in hot water may reduce the risk of epistaxis.<ref>{{Cite journal\|last=Lu\|first=P. P.\|last2=Liu\|first2=H. P.\|last3=Shyr\|first3=M. H.\|last4=Ho\|first4=A. C.\|last5=Wang\|first5=Y. L.\|last6=Tan\|first6=P. P.\|last7=Yang\|first7=C. H.\|date=1998~~-12~~\|title=Softened endothracheal tube reduces the incidence and severity of epistaxis following nasotracheal intubation\|url=https://pubmed.ncbi.nlm.nih.gov/10399514\|journal=Acta Anaesthesiologica Sinica\|volume=36\|issue=4\|pages=193–197\|issn=0254-1319\|pmid=10399514}}</ref> If bleeding occurs, intubation should be completed quickly if possible. If rapid intubation is not possible, the endotracheal tube should be withdrawn into the post-nasal space and the balloon inflated, in an attempt to tamponade bleeding.<ref name=":0" />

	Another possible serious complication is necrosis of the nasal ala, which occurs due to pressure from the nasal tube. Alar necrosis may occur quickly: it has been reported in nasal intubations of even short duration.<ref name=":0" /> Careful securement of the nasal tube that avoid pressure on the nasal ala is essential for preventing this complication.		Another possible serious complication is necrosis of the nasal ala, which occurs due to pressure from the nasal tube. Alar necrosis may occur quickly: it has been reported in nasal intubations of even short duration.<ref name=":0" /> Careful securement of the nasal tube that avoid pressure on the nasal ala is essential for preventing this complication.

	Rarely, more serious complications occur such as avulsion of turbinates or nasal polyps, posterior pharyngeal wall laceration, and sinusitis.		Rarely, more serious complications occur such as avulsion of turbinates or nasal polyps, posterior pharyngeal wall laceration, and sinusitis.

			<references />

BMittal at 01:14, 3 September 2021

2021-09-03T01:14:42Z

← Older revision	Revision as of 18:14, 2 September 2021
Line 1:	Line 1:
		'''Introduction'''

		Nasal intubation is often used to increase intraoral exposure during head & neck surgery. Indications include:

		* transoral robotic surgery
		* maxillofacial surgery
		* dental surgery
		* restricted mouth opening
		* cervical spine instability
		* lower facial trauma
		* structural abnormalities that preclude oral intubation


		Contraindications to nasal intubation include severe bleeding diathesis, anticoagulation, and base of skull fractures. Advancing a nasal tube of any kind in a patient with a base of skull fracture risks penetration into the brain.<ref name=":0">{{Cite journal\|last=Hall\|first=C. E. J.\|last2=Shutt\|first2=L. E.\|date=2003-03\|title=Nasotracheal intubation for head and neck surgery\|url=https://pubmed.ncbi.nlm.nih.gov/12603455\|journal=Anaesthesia\|volume=58\|issue=3\|pages=249–256\|doi=10.1046/j.1365-2044.2003.03034.x\|issn=0003-2409\|pmid=12603455}}</ref>

		A history of nasal septal deviation, polyps, and prior nasal surgery should be elicited. Patients with previous reconstructive orofacial surgery or nasal stenosis may have nasal anatomy that does not permit passage of an nasal endotracheal tube. In these cases, preoperative endoscopic airway examination ([[PEAE]]) and craniofacial CT imaging is helpful to determine feasibility of nasal intubation.<ref name=":0" />

		'''Preparation of Nasal Mucosa'''

		Vasoconstriction of the nasal mucosa may be achieved using oxymetazoline 0.05%, lidocaine 3-4% with phenylephrine 0.25-1%, or cocaine 4-10%.<ref name=":0" /> The hemodynamic effects of cocaine and phenylephrine should be anticipated and planned for accordingly.

		Serial mechanical dilation of the nares with nasal trumpets prior to nasal intubation is controversial and in some studies has been associated with higher rates of trauma and hemorrhage to friable nasal mucosa.<ref>{{Cite journal\|last=Adamson\|first=D. N.\|last2=Theisen\|first2=F. C.\|last3=Barrett\|first3=K. C.\|date=1988-05\|title=Effect of mechanical dilation on nasotracheal intubation\|url=https://pubmed.ncbi.nlm.nih.gov/3163370\|journal=Journal of Oral and Maxillofacial Surgery: Official Journal of the American Association of Oral and Maxillofacial Surgeons\|volume=46\|issue=5\|pages=372–375\|doi=10.1016/0278-2391(88)90220-0\|issn=0278-2391\|pmid=3163370}}</ref>

		'''Selection of Endotracheal Tube'''

		Tubes placed via the nasotracheal route must be of smaller diameter and increased length compared to tubes used for orotracheal intubation. Nasal RAE tubes have a preformed bend at a set depth depending on the internal diameter of the tube. Therefore, they must be sized appropriately by comparing them to the patient's profile in order to ensure that the cuff will lie at the appropriate depth. Most patients require a size 7.0 mm internal diameter nasal RAE or larger. Alternatively, microlaryngeal tubes may be used as smaller sizes (5.0 mm and 6.0 mm internal diameter) are sufficiently long to be used for nasotracheal intubation.

		'''Complications'''

		The most common complication of nasal intubation is mucosal trauma leading to epistaxis. This most commonly occurs in the setting of inadequate vasoconstriction, larger diameter endotracheal tubes, excessive force, and repeated insertion attempts.<ref name=":0" /> Softening the endotracheal tube in hot water may reduce the risk of epistaxis.<ref>{{Cite journal\|last=Lu\|first=P. P.\|last2=Liu\|first2=H. P.\|last3=Shyr\|first3=M. H.\|last4=Ho\|first4=A. C.\|last5=Wang\|first5=Y. L.\|last6=Tan\|first6=P. P.\|last7=Yang\|first7=C. H.\|date=1998-12\|title=Softened endothracheal tube reduces the incidence and severity of epistaxis following nasotracheal intubation\|url=https://pubmed.ncbi.nlm.nih.gov/10399514\|journal=Acta Anaesthesiologica Sinica\|volume=36\|issue=4\|pages=193–197\|issn=0254-1319\|pmid=10399514}}</ref> If bleeding occurs, intubation should be completed quickly if possible. If rapid intubation is not possible, the endotracheal tube should be withdrawn into the post-nasal space and the balloon inflated, in an attempt to tamponade bleeding.<ref name=":0" />

		Another possible serious complication is necrosis of the nasal ala, which occurs due to pressure from the nasal tube. Alar necrosis may occur quickly: it has been reported in nasal intubations of even short duration.<ref name=":0" /> Careful securement of the nasal tube that avoid pressure on the nasal ala is essential for preventing this complication.

		Rarely, more serious complications occur such as avulsion of turbinates or nasal polyps, posterior pharyngeal wall laceration, and sinusitis.

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