Nasal intubation

[VentMedic]

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

Wow! You have managed to try to make this a pissing match.

I presented a fact about how we now ventilate patients differently and you found cause to be sarcastic. Have you studied the various methods of ventilation in the ICUs extensively? Do you know how ventilation and oxygenation practices have evolved? This is not about getting "gold stars" but improving the ways of medicine for advancement. Long term paralytics are not longer used extensively in the critical care units. I really don't see a need for sarcasism if you disagree. However, I would like to know why you disagree about the long term use of paralytics and prolonged vent days.

NTI was promoted by some because it was easier and more convenient for the provider regardless of the patients' opinions. After all, we tell people it is for their own good when we are inflicting pain. I don't have to rely just on articles since I have has first hand experience with NTI and the patients.

The articles you pulled up are from European sources and pertain to specific situations in the OR which I have already said the RAE tubes are used for NTI when the vent days will be limited. It is difficult to compare a few cases requiring such intensive knowledge of intubation in special precedures with what is done everyday in critical care units. Yes, case studies are abundant and it is important to understand these as well. However, I am talking in broad accepted practices and not the rare ones which can be successfully implimented in common practice in the many ICUs across the country.

I also see you have wasted alot of time finiding articles about the rare situations instead of looking at what is accepted practice in the United States.

I think you could have an easier time researching the correlation between sinusitis and lung infection. But, let me help you out: (multiple pages)

http://scholar.google.com/scholar?q=VAP+si...p;hl=en&lr=

Here is a good link to help with your search if you don't have access to a good medical search engine.

http://scholar.google.com

Again, I am not talking about "sticking holes in necks" (your words) as done emergently in the field. Please try to see the difference between this emergency procedure and a tracheotomy or tracheotomy that is done in the hospital to facilitate weaning and give them back their voice. Also, do not confuse the "holes" with the stoma made for laryngectomy patients. Those are very different as is their purpose.

Edited March 20, 2009 by VentMedic

[Camulos]

Wow! You have managed to try to make this a pissing match.

I bet mine goes futher than yours!!! Just jokes, no pissing match. I'm just highlighting what I feel are important points.

Have you studied the various methods of ventilation in the ICUs extensively?

Yes

Do you know how ventilation and oxygenation practices have evolved?

Yes

This is not about getting "gold stars" but improving the ways of medicine for advancement. Long term paralytics are not longer used extensively in the critical care units. I really don't see a need for sarcasism if you disagree.

I agree long term paralytics are no longer used as extensively as they were in the past. I never disagreed. More gold stars for everybody.

However, I would like to know why you disagree about the long term use of paralytics and prolonged vent days.

Huh?? When did I state this????

I don't have to rely just on articles since I have has first hand experience with NTI and the patients.

I thought you said your employers mandated that you keep up to date with the current articles??? And what first hand experience do you have of NTI considering this earlier comment of yours "I honestly can not remember resorting to a nasal intubation in or out of hospital in 15 years at least." Certainly not recent experience that's for sure.

The articles you pulled up are from European sources and pertain to specific situations in the OR which I have already said the RAE tubes are used for NTI when the vent days will be limited. It is difficult to compare a few cases requiring such intensive knowledge of intubation in special precedures with what is done everyday in critical care units. Yes, case studies are abundant and it is important to understand these as well. However, I am talking in broad accepted practices and not the rare ones which can be successfully implimented in common practice in the many ICUs across the country.

Seems a lot of people are going to a lot of trouble to study such a rare event. It didn't take you long to read ALL these articles. Whilst some do concentrate on the OR setting some do not. These articles were actually just the most recent one's published on NTI to highlight the incorrect statement that there was not much current info out there.

I also see you have wasted alot of time finiding articles about the rare situations instead of looking at what is accepted practice in the United States.

There is a big world beyond your shores.

I think you could have an easier time researching the correlation between sinusitis and lung infection. But, let me help you out: (multiple pages)

http://scholar.google.com/scholar?q=VAP+si...p;hl=en&lr=

Have not read through all these however certainly do hope they answer my specific question on exhibiting the causality between sinusitis and VAP. If so, as I said, I am eternally greatful.

Here is a good link to help with your search if you don't have access to a good medical search engine.

http://scholar.google.com

Thanks for that. I have work ones that are very useful and would love to share them however they are unfortunately password protected.

Again, I am not talking about "sticking holes in necks" (your words) as done emergently in the field. Please try to see the difference between this emergency procedure and a tracheotomy or tracheotomy that is done in the hospital to facilitate weaning and give them back their voice.

Definitely see and understand the difference between field and hospital surgical airways. However, as crude as it sounds, it is still a hole in the pt's neck. Of course if you are implementing "holeless" trachies I'm coming over to learn this technique.

Also, do not confuse the "holes" with the stoma made for laryngectomy patients. Those are very different as is their purpose.

Would never confuse them. When I was a kid my uncle had a laryngectomy. It used to absolutely freak me out. Actually most of them still do these days!!!

Stay safe,

Curse

[VentMedic]

Wow! You have managed to try to make this a pissing match.

I bet mine goes futher than yours!!! Just jokes, no pissing match. I'm just highlighting what I feel are important points.

Have you studied the various methods of ventilation in the ICUs extensively?

Yes

Do you know how ventilation and oxygenation practices have evolved?

Yes

This is not about getting "gold stars" but improving the ways of medicine for advancement. Long term paralytics are not longer used extensively in the critical care units. I really don't see a need for sarcasism if you disagree.

I agree long term paralytics are no longer used as extensively as they were in the past. I never disagreed. More gold stars for everybody.

However, I would like to know why you disagree about the long term use of paralytics and prolonged vent days.

Huh?? When did I state this????

I don't have to rely just on articles since I have has first hand experience with NTI and the patients.

I thought you said your employers mandated that you keep up to date with the current articles??? And what first hand experience do you have of NTI considering this earlier comment of yours "I honestly can not remember resorting to a nasal intubation in or out of hospital in 15 years at least." Certainly not recent experience that's for sure.

The articles you pulled up are from European sources and pertain to specific situations in the OR which I have already said the RAE tubes are used for NTI when the vent days will be limited. It is difficult to compare a few cases requiring such intensive knowledge of intubation in special precedures with what is done everyday in critical care units. Yes, case studies are abundant and it is important to understand these as well. However, I am talking in broad accepted practices and not the rare ones which can be successfully implimented in common practice in the many ICUs across the country.

Seems a lot of people are going to a lot of trouble to study such a rare event. It didn't take you long to read ALL these articles. Whilst some do concentrate on the OR setting some do not. These articles were actually just the most recent one's published on NTI to highlight the incorrect statement that there was not much current info out there.

I also see you have wasted alot of time finiding articles about the rare situations instead of looking at what is accepted practice in the United States.

There is a big world beyond your shores.

I think you could have an easier time researching the correlation between sinusitis and lung infection. But, let me help you out: (multiple pages)

http://scholar.google.com/scholar?q=VAP+si...p;hl=en&lr=

Have not read through all these however certainly do hope they answer my specific question on exhibiting the causality between sinusitis and VAP. If so, as I said, I am eternally greatful.

Here is a good link to help with your search if you don't have access to a good medical search engine.

http://scholar.google.com

Thanks for that. I have work ones that are very useful and would love to share them however they are unfortunately password protected.

Again, I am not talking about "sticking holes in necks" (your words) as done emergently in the field. Please try to see the difference between this emergency procedure and a tracheotomy or tracheotomy that is done in the hospital to facilitate weaning and give them back their voice.

Definitely see and understand the difference between field and hospital surgical airways. However, as crude as it sounds, it is still a hole in the pt's neck. Of course if you are implementing "holeless" trachies I'm coming over to learn this technique.

Also, do not confuse the "holes" with the stoma made for laryngectomy patients. Those are very different as is their purpose.

Would never confuse them. When I was a kid my uncle had a laryngectomy. It used to absolutely freak me out. Actually most of them still do these days!!!

Stay safe,

Curse

You have made very broad statements and assumptions about hospital practice.

Where and how have you studied ventilators in the ICU? Or worked extensively in ICU which if you have and do you would not be questionly VAP issues and ventilators.

This is one subject I rarely joke about since it is my specialty and I have seen the consequences of what happens when people don't understand ventilators, tubes or meds such as paralytics.

I could take time to give you individual links or spoon feed you as I do for some in EMS but you stated you know how to search. I did post Google Scholar link which if you look at all the many pages of studies listed they pertain also to nasal intubation and are current. If you look at the CDC updated guidelines you will also find a list of references they use. Also, the infection control office at a hospital that you may be working at or transport you to can give you their policies and references. If you really insist on a bunch of individual links I can post and I many anyway later as those that know me here usually expect to see my latest data.

Over 10 years ago, we may have seen 10% or 10 out of 100 ventilator patients in the adult world with NTI. Now, it will only be seen from the OR for specific surgeries that will not be intubated for more than 48 hours. It was banished in peds and neo before the adults.

Yes I still see short term NTI either from the OR or a field intubation. I still know how to do NTI but prefer not to if at all possible. I also see those that get shipped to my hospital for specialty ventilation and reconstructive surgery as the result of NTI or mucked up ventilator management. I also see those that require nasal antibiotics long term and those that need dialysis from long term IV antibiotic use.

Edited March 20, 2009 by VentMedic

[Camulos]

You have made very broad statements and assumptions about hospital practice.

Where?? Examples please.

Where and how have you studied ventilators in the ICU?

Where - In a hospital (ICU and anaesthetics) to be exact

How - Experience, research, text books, idiots guide to ventilators etc

Or worked extensively in ICU which if you have and do you would not be questionly VAP issues and ventilators.

I never questioned the association between ventilators and VAP. Read again - I asked where sinusitus has been proven as a causative factor in VAP.

This is one subject I rarely joke about since it is my specialty and I have seen the consequences of what happens when people don't understand ventilators, tubes or meds such as paralytics.

I joke often. Why not - it worked for Patch Adams right? He even got his own movie!!! I wonder who will play me in my movie? Shame John Candy is no longer with us.

I could take time to give you individual links or spoon feed you as I do for some in EMS but you stated you know how to search.

I'll only take spoon feeding if you tell me it's an aeroplane and make it fly into my mouth. And who said I was EMS??

If you really insist on a bunch of individual links I can post and I many anyway later as those that know me here usually expect to see my latest data

I thought you didn't need the data?? You stated you have your first hand experience with your pt's.

Over 10 years ago, we may have seen 10% or 10 out of 100 ventilator patients in the adult world with NTI. Now, it will only be seen from the OR for specific surgeries that will not be intubated for more than 48 hours.

There is a big world outside your hospital.

I still know how to do NTI but prefer not to if at all possible.

Me too!!

I also see those that get shipped to my hospital for specialty ventilation and reconstructive surgery as the result of NTI or mucked up ventilator management.

Me too!!

I also see those that require nasal antibiotics long term and those that need dialysis from long term IV antibiotic use.

We don't routinely give the AB's nasally and more commonly administer them systemically. And I hate dialysis.

I'm going to bed. My brain hurts!!!

Stay safe,

Curse

[VentMedic]

If you work in a hospital then the information about VAP and the CDC's stance on NTI should have already been covered somewhere unless you hospital is one of those I may have insulted in an earlier post which would be why you are continuing with further insults.

Read again - I asked where sinusitus has been proven as a causative factor in VAP.

Have not read through all these however certainly do hope they answer my specific question on

exhibiting the causality between sinusitis and VAP.

You haven't read the articles in the link I posted? There were 12 pages of links pertaining to VAP and sinusitis. Sinusitis and VAP wsa the title of the search that brought up all of those links.

idiots guide to ventilators etc

I think this statement sums up why you are having a difficult time understanding these concepts. There is much more than that little guide which even the nurses laugh at when they see it.

Yes, there is a big world outside of my hospital and even EMS. That is why we link to other facilities with our research data. I also spend part of my time on another coast in another hospital system that is involved in research. This is besides the numerous seminars and conferences that I attend and may even lecture at occasionally.

I could take time to give you individual links or spoon feed you as I do for some in EMS but you stated you know how to search.

I'll only take spoon feeding if you tell me it's an aeroplane and make it fly into my mouth. And who said I was EMS??

I never said you were in EMS. You stated something about an ICU and hospital but yet are unaware of the common causes of problems associated with ventilators and tubes so it is hard to tell what training you actually have.

If you really insist on a bunch of individual links I can post and I many anyway later as those that know me here usually expect to see my latest data

I thought you didn't need the data?? You stated you have your first hand experience with your pt's.

The data is for you. You seem to have a difficult time with the Yahoo search for good literature.

Yes, I do have lots of first hand experience with ventilator patients who have tubes of all types. I have often pointed out on the forums that there are over 300 different airways to choose from.

We don't routinely give the AB's nasally and more commonly administer them systemically. And I hate dialysis.

Then you may not understand the various treatments that must be made available for sinusitis when systemic antibiotics are creating more problems than they are solving. I also see you have missed the point about dialysis and antibiotics.

I don't know what you are or what position you have, but your posts have not been the most convincing that you have adequate ICU experience to be judging such issues as VAP, ventilators or even NIT in the critical care setting.

[Spock]

I really am not trying to get into the middle of this but I have to agree with VentMedic. I will do a nasal in the OR for maxilofacial cases and place a nasal RAE tube under direct laryngoscopy with magill forceps. These patients are usually extubated in the OR after the case or in the PACU within an hour. Blind NTI is a lost art in the hospital although I have done it on rare occasions using an endotrol tube and a whistler.

NTI will remain a tool for prehopital use because RSI is not available everywhere and I would favor NTI over a needle cric any day. We don't do true surgical airways in my region and we don't have RSI or even etomidate. Using benzo's for intubation is a poor choice although sometimes the only one available.

Live long and prosper.

Spock

[FL_Medic]

Your discussion is becoming less educating and more heated. Please don't give in to this type of thing. Both of you should be better than that. One of the biggest problems in our world (EMS) are the egos that medics may possess. Instead of questioning each other's credentials, keep the responses factual. Don't just post a link, add the exert that assists your rebuttal. I am by no means the forum police, but this stuff gets ridiculous.

[chbare]

I really am not trying to get into the middle of this but I have to agree with VentMedic. I will do a nasal in the OR for maxilofacial cases and place a nasal RAE tube under direct laryngoscopy with magill forceps. These patients are usually extubated in the OR after the case or in the PACU within an hour. Blind NTI is a lost art in the hospital although I have done it on rare occasions using an endotrol tube and a whistler.

NTI will remain a tool for prehopital use because RSI is not available everywhere and I would favor NTI over a needle cric any day. We don't do true surgical airways in my region and we don't have RSI or even etomidate. Using benzo's for intubation is a poor choice although sometimes the only one available.

Live long and prosper.

Spock

Thanks Spock. The funny thing being, after reading this thread, both parties appear to have similar points of view.

Take care,

chbare.

[VentMedic]

Thanks Spock. The funny thing being, after reading this thread, both parties appear to have similar points of view.

Take care,

chbare.

For prehospital intubation, yes.

However curse still didn't see issues for long term nasal intubation or infection in the ICUs.

As far comfort, since Spock also mentioned the OR tubes, the surgeons will often suture these to the nare. Very little compares to watching someone levitate off the bed when the vent circuit or NT is bumped.

[DirteMedic]

I work for a fairly busy service in Louisville Ky, we do not have the option of RSI or DAI, so we use BNI. Having intubated several patients with this technique I find it an invaluable resource to have for pt's who are desaturating due to a variety of reasons. I have never seen a trauma pt that has been nasally intubated have a tube insert into the cribiform plate or basal skull. When done correctly nasal intubation is possible without creating epistaxis. We are very aggresive with airway in my service so we use this technique quite frequently with great success. Without it several pt's would be far much worse for wear.