Nasal intubation

[stcommodore]

In Pa your not permitted to "induce" intubation with anything but Etomidate, and very very few services carry the drug.

[AnthonyM83]

Would you usually intubate dead patients? Usually a skill used to prevent them from becoming dead . . .

Meant to say would you normally NASALLY intubate dead people?

As in they're not actually dead yet if you're performing that skill, usually...spontaneous breathing is usually required...

[logos]

Hmmmm, pic won't show

Oh well, check this out: http://bp3.blogger.com/_oAQI4j4B9Zc/R4JvMi...600-h/ryles.jpg

http://bp0.blogger.com/_oAQI4j4B9Zc/R4JvMy...00-h/ryles3.jpg

Cool picture.

Is that the relatively famous case where the anesthetist put an NG tube in a patient that was recently s/p skull base surgery?

[Camulos]

Whilst nasal intubation can offer many advantages in a hospital setting, I personally find the practice of limited value in the pre hospital arena. I am however lucky enough to have the option of RSI and surgical airway capability and recognise that my decision may be different if this were not so. As an emergent pre hospital airway I have only ever utilised blind nasal intubation (BNI) once. This was on a pt with ankylosing spondylitis who presented a very difficult airway challenge. But that is another story and shall be told another time.

Without the ability to use RSI or provide a surgical airway, BNI may be a potential alternative – particularly in the case of trismus that was mentioned by the original poster. BNI is of course not without its disadvantages and difficulties though. BNI certainly has a higher complication rate, cannot be used in the apnoeic pt, is more traumatic and is less frequently successful. In this sense one should obviously use BNI with caution and as always the benefits should outweigh the risks.

I note some earlier replies on this topic mentioning BOS # as a contraindication is outdated. However I cannot determine if they are only referring to nasopharyngeal airways (NPA)or nasotracheal tubes (NTT). I recognise the risk of NPA is “probably” low given their flexibility however feel that the same cannot be said of NTT. BOS # is certainly still on my contraindication list for pre hospital NT intubation and I believe rightly so. Whilst it is true that the actual incidence of cerebral NTT is low , I would hazard using this statistic as a reason for advocating that clinically evident BOS # is an outdated contraindication. Perhaps the low incidence is due to the fact that EMS providers have been correctly following the guidelines and not inserting these tubes when the clinical signs of basilar skull # are evident. In that sense, the low incidence is a measure of the success of BOS # being a contraindication and would support the continuation of this practice rather than refute it.

I also believe that although the actual incidence of cerebral NTT’s is low we cannot extrapolate that the RISK of this procedure is also low. In order to assess this we only have to look at the many case reports, and x-rays such as that kindly provided by Mobey, of nasogastric tubes that have been cerebrally placed. As BOS # has been an established relative contraindication for some time, I believe the impetus here should be to disprove, rather than prove, this practice in order to effect change. That of course, I imagine, would be hard to do however if there is something out there I would be more than keen to hear about it.

It would be great to hears others actual experiences with BNI – both good and bad.

Stay safe,

Curse

[VentMedic]

Whilst nasal intubation can offer many advantages in a hospital setting, I personally find the practice of limited value in the pre hospital arena.

Nasal intubation has been frowned upon in hospitals for well over 10 years since the CDC posted their position on hospital acquired infections and complications by this route. The only time it is acceptable at many hospitals is for special facial surgeries where a RAE tube might be used. Any field nasal tube will usually be changed in the ED or ICU at most hospitals.

I honestly can not remember resorting to a nasal intubation in or out of hospital in 15 years at least. But, I also have RSI capabilities.

[Camulos]

Nasal intubation has been frowned upon in hospitals for well over 10 years since the CDC posted their position on hospital acquired infections and complications by this route. The only time it is acceptable at many hospitals is for special facial surgeries where a RAE tube might be used.

Nasal intubation is rarely an ideal first choice airway however does offer advantages when it is indicated in a hospital setting. Some advantages include;

* Surgical field avoidance - cases include dental procedures and certain maxillofacial surgeries - particularly of the mandible when wiring is utilised.

* Poor oral access - eg. Arthritis and ankylosing spondylitis (my only prehospital case)

* Inability or difficulty in elevating the epiglottis

* Prolonged ventilation - where the nasal route is often more comfortable.

Despite these advantages it can sometimes be a difficult decision to decide between nasal v's surgical airway when the oral route is not an option. It should also be kept in mind that the inhospital procedure is not usually done blindly and more often involves fibreoptic assistance in order to facilitate the insertion.

Stay safe,

Curse

[VentMedic]

Nasal intubation is rarely an ideal first choice airway however does offer advantages when it is indicated in a hospital setting. Some advantages include;

* Surgical field avoidance - cases include dental procedures and certain maxillofacial surgeries - particularly of the mandible when wiring is utilised.

* Poor oral access - eg. Arthritis and ankylosing spondylitis (my only prehospital case)

* Inability or difficulty in elevating the epiglottis

* Prolonged ventilation - where the nasal route is often more comfortable.

Despite these advantages it can sometimes be a difficult decision to decide between nasal v's surgical airway when the oral route is not an option. It should also be kept in mind that the inhospital procedure is not usually done blindly and more often involves fibreoptic assistance in order to facilitate the insertion.

Stay safe,

Curse

You are very misinformed about the hospital advantages of nasal intubation. Do you not understand the complications of nasal intubation especially if the tube is left in for extended periods of time? It is definitely not more comfortable and will increase ventilator days with the increased work of breathing that causes failure to wean by the smaller tube and resistance through the nares. More sedation may be required to relax the patient to allow the ventilator to do the majority of work. That is not a good thing. As I stated, I have not seen NTI done except in very special surgical cases and even those may get a trach to avoid prolonged nasal intubation. It is not a difficult decision to do what will benefit the patient in the healing process without additional risks the nasal intubation will cause especially with infections and prolonged antibiotic use.

This is a recommendation with guidelines issued by the CDC when the VAP campaign started over a decade ago. This is also one thing that Medicare will look at and will not reimburse the hospital for. Hospitals should not have to resort to nasal intubation with the other technology they have. Granted, there are some very bad hospitals out there that should be scrutinized closer when they can not provide decent care to their patients. Even the worst rinky dink hospitals should know about the various infection control protocols in place throughout this country for the year 2009.

[Camulos]

You are very misinformed about the hospital advantages of nasal intubation. Do you not understand the complications of nasal intubation especially if the tube is left in for extended periods of time? It is definitely not more comfortable and will increase ventilator days with the increased work of breathing that causes failure to wean by the smaller tube and resistance through the nares. More sedation may be required to relax the patient to allow the ventilator to do the majority of work. That is not a good thing. As I stated, I have not seen NTI done except in very special surgical cases and even those may get a trach to avoid prolonged nasal intubation. It is not a difficult decision to do what will benefit the patient in the healing process without additional risks the nasal intubation will cause especially with infections and prolonged antibiotic use.

This is a recommendation with guidelines issued by the CDC when the VAP campaign started over a decade ago. This is also one thing that Medicare will look at and will not reimburse the hospital for. Hospitals should not have to resort to nasal intubation with the other technology they have. Granted, there are some very bad hospitals out there that should be scrutinized closer when they can not provide decent care to their patients. Even the worst rinky dink hospitals should know about the various infection control protocols in place throughout this country for the year 2009.

As I said, it is rarely an ideal first choice airway. However it can be of benefit when it is indicated. I am not advocating that all pt's should be nasally intubated however nasotracheal intubation is definitely another option in the list airway strategies that can, and have, been beneficial to pt's. As I also said before, it is not without it's risks, which I am very cognisant of. These of course must be weighed up in the decision making process and again as I said earlier it can sometimes be a difficult decision between nasal v's surgical airway.

I disagree that nasotracheal tubes are not more comfortable. There is a whole host of anaesthetic literature outlining that nasotracheal tubes are usually better tolerated than orally inserted tubes. This has certainly been my anecdotal experience also.

Increased work of breathing is one POTENTIAL disadvantage of NTI due to the smaller tube that has to be inserted. In the short term this is usually not much of an issue and long term can certainly be minimised, or overcome, with good ventilator strategies.

I understand you are quite passionate about not using NTI however I would hope you don't completely wipe it off your list of possible options when considering airway management. There are cases when it provides a good alternative and doesn't mean a large hole and scar in some poor pt's neck.

Stay safe,

Curse

[VentMedic]

I disagree that nasotracheal tubes are not more comfortable. There is a whole host of anaesthetic literature outlining that nasotracheal tubes are usually better tolerated than orally inserted tubes. This has certainly been my anecdotal experience also.

Increased work of breathing is one POTENTIAL disadvantage of NTI due to the smaller tube that has to be inserted. In the short term this is usually not much of an issue and long term can certainly be minimised, or overcome, with good ventilator strategies.

I understand you are quite passionate about not using NTI however I would hope you don't completely wipe it off your list of possible options when considering airway management. There are cases when it provides a good alternative and doesn't mean a large hole and scar in some poor pt's neck.

Stay safe,

Curse

Have you even been nasally intubated? You will not find much current information about NTI since it is no longer accepted in the hospitals except under rare circumstances. The way we venitilate patients have also changed. We no longer paralyze and sedate for 7 days and then trach. We try to get patients off the vents in as few days as possible.

To say NTI is more comfortable is in the same ball park as saying babies don't feel pain which was the reason for doing surgery without sedation for many years. I think medicine has advanced enough to move on from some of the old "traditions" and ways of thinking.

A trach done in the hospital in not like the ones done in the field. I am talking about critical care medicine. You need to see a broader view.

My stance on NTI is because I have done this for a long time and have participated in the research that has gone into making the guidelines. I do stay current with the medical literature because that is an expectation of my employers. I do understand the many reasons why it is avoided if at all possible in the hospital. I don't need passion one way or another when I have current medical science and examples of patients before me. It could be said you have an adversion to trachs when they have been around for centuries.

[Camulos]

Have you even been nasally intubated? You will not find much current information about NTI since it is no longer accepted in the hospitals except under rare circumstances. The way we venitilate patients have also changed. We no longer paralyze and sedate for 7 days and then trach. We try to get patients off the vents in as few days as possible.

To say NTI is more comfortable is in the same ball park as saying babies don't feel pain which was the reason for doing surgery without sedation for many years. I think medicine has advanced enough to move on from some of the old "traditions" and ways of thinking.

A trach done in the hospital in not like the ones done in the field. I am talking about critical care medicine. You need to see a broader view.

My stance on NTI is because I have done this for a long time and have participated in the research that has gone into making the guidelines. I do stay current with the medical literature because that is an expectation of my employers. I do understand the many reasons why it is avoided if at all possible in the hospital. I don't need passion one way or another when I have current medical science and examples of patients before me. It could be said you have an adversion to trachs when they have been around for centuries.

Have you even been nasally intubated?

No

You will not find much current information about NTI since it is no longer accepted in the hospitals except under rare circumstances.

Please see;

Sugiyama, Kazuna DDS, PhD; Takahashi, Naoki DDS, PhD; Kohjitani, Atsushi DDS, PhD The EndoFlex® Tube Enhances Navigability Through the Nasal Cavity During Nasotracheal Intubation. Anesthesia & Analgesia. 108(4):1358-1359, April 2009.

Lallo, Alexandre MD, FRCPC *+; Billard, Valerie MD *; Bourgain, Jean-Louis MD * A Comparison of Propofol and Remifentanil Target-Controlled Infusions to Facilitate Fiberoptic Nasotracheal Intubation. Anesthesia & Analgesia. 108(3):852-857, March 2009.

Kitagawa, H.; Sai, Y.; Tarui, K.; Imashuku, Y.; Yamazaki, T.; Nosaka, S. Airway Scope®-assisted nasotracheal intubation. Anaesthesia. 64(2):229, February 2009.

Muallem, Musa; Baraka, Anis The use of the GlideScope to facilitate nasotracheal intubation: in patients with a difficult airway. European Journal of Anaesthesiology. 26(2):179, February 2009.

Sharma, Rajeev MD; Kumar, Rakesh DA, MD; Kumar, Sunil DA; Gupta, Neera R. MD Connector Assembly to Improve Performance of the Lighted Stylet (Trachlight) for Nasotracheal Intubation. Anesthesia & Analgesia. 107(6):2095-2096, December 2008.

XUE, FU SHAN; Luo, MAO PING; LIAO, XU; ZHANG, YAN MING Lightwand guided nasotracheal intubation in children with difficult airways. Pediatric Anesthesia. 18(12):1276-1278, December 2008.

MONCLUS, ENRIC MD; GARCES, ANTONIO MD; ARTES, DAVID MD; MABROCK, MAGED MD Oral to nasal tube exchange under fibroscopic view: a new technique for nasal intubation in a predicted difficult airway. Pediatric Anesthesia. 18(7):663-666, July 2008.

Note the oldest article here is from July 2008. Does that count as recent? There certainly seems to be an abundance of rare circumstances occurring and I can keep going if required but don't want to bore people.

The way we venitilate patients have also changed. We no longer paralyze and sedate for 7 days and then trach. We try to get patients off the vents in as few days as possible.

Good on you. So do we. Gold stars all around!!!

To say NTI is more comfortable is in the same ball park as saying babies don't feel pain which was the reason for doing surgery without sedation for many years. I think medicine has advanced enough to move on from some of the old "traditions" and ways of thinking.

I personally don't get this comparison and for the record definitely think babies feel pain. It used to really hurt when I was continually dropped on my head as a baby!!! Perhaps that is my problem - LOL. NTI is frequently documented as being better tolerated than oral tubes on awake pts - both during insertion and afterwards. Come on - I'm sure you have read this or do I really need to provide some links for this also?

A trach done in the hospital in not like the ones done in the field. Agreed. Put me in a hospital any day over a dirty paddock to be performing surgical airways.

I am talking about critical care medicine. You need to see a broader view.

I believe I do have the broader view as I am not the one saying that nasotracheal intubation is outdated and only rarely performed.

My stance on NTI is because I have done this for a long time and have participated in the research that has gone into making the guidelines.

Excellent!!! I have wanted to question someone who has made these guidelines so am cherishing this chance. I preferentially choose oral over nasal intubation in most circumstances - as suggested in the guidelines and I also stated earlier. However my understanding of the guidelines, and correct me if I am wrong, is that NTI is not preferred due to its increased association with ventilator associated pneumonia (VAP) secondary to tube induced sinusitis. However what does seem to be lacking in the guidelines is the actual research that exhibits causality between sinusitis and VAP. As you have participated in this research I'm sure you can provide these findings and when you do I shall be eternally greatful.

I do stay current with the medical literature because that is an expectation of my employers.

I hope the above references assist you in this task as it seemed you may have been unaware of these by your earlier comment of not finding much current information about NTI.

It could be said you have an adversion to trachs when they have been around for centuries.

Example please. When a surgical airway is indicated I perform them. However I certainly don't go around sticking holes in pt's necks willy nilly without seeking possible alternatives. One of my closest friends is a neurosurgical trainee - I should tell him that burr holes have also been around for centuries and therefore he can get his drill out even before the CT scan in future. I could go all night but as I said earlier don't want to bore people - (Get the pun??)

Stay safe,

Curse

Edited March 20, 2009 by Curse