Nasal intubation

[VentMedic]

When done correctly nasal intubation is possible without creating epistaxis.

When the patient is on anticoagulants or their platelets are low, which these are concerns of many patients with chronic illnesses, it will be difficult to prevent bleeding. Quite often, the patient with the field tube will have the nare packed for a couple of days after the tube is removed.

No one disputes the use of NTI in prehospital care unless the Paramedic is doing it out of laziness.

[tniuqs]

I Hate the crunchy noises when doing an NTI.

cheers

Edited March 21, 2009 by tniuqs

[Camulos]

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.

Sorry for the late reply, I had to pull a few night shifts down at the NTI clinic.

Despite my credentials being questioned MANY times, I don’t believe I questioned anyone’s credentials and would appreciate an example of this. To be entirely honest I don’t care for anyone’s credentials on here. It doesn't bother me how much experience someone has, how many conferences they have been to or spoken at or indeed what they do for a job. I’m more interested in what they have to SAY. Having said that you are otherwise completely correct and I am more than happy to get back to the facts.

I feel chbare is the only one that really gets it so far. A lot of what we have said is not disputed. The original statement that I disagreed with was “The ONLY time it is acceptable at many hospitals is for special facial surgeries where a RAE tube might be used”. I am wary of using words like only, always, never, when it comes to treatment options in medicine as I feel it does recognise, or at least limits, individualised care. I am certainly not immune to using these words at times though and ALWAYS catch myself doing it – DOH, Did it again!!

If many hospitals ONLY utilise NTI for special facial surgeries then so be it – it doesn’t bother me. However I still believe that NTI is a treatment option that should be considered in certain circumstances that extend beyond the operating room. Times where I have personally used this emergently in the past have included;

• Altered anatomy due to previous facial surgery

• Retrunded mandible – eg. Arthritis, ankylosing spondylitis

• Alert, conscious pt's in whom RSI may cause more potential problems than benefits

• Pts with laryngeal fibrosis secondary to radiation that may require a period of prolonged intubation as it has been our experience that it is usually better tolerated than an oral tube.

I have not seen much of a need to do blind nasal in hospital and indeed have not personally utilised this practice in this setting as all nasal tubes have been visually assisted, as I stated earlier.

The main point I am highlighting is that although NTI is not as prevalent as it once was, I believe it would be sad to completely wipe it off your list of options when considering airway management outside the OR. It has certainly helped me out in certain circumstances beyond the operating room in avoiding the need for a surgical airway. If you ONLY use NTI in the OR then go right ahead – you obviously have your reasons. But please don’t denigrate me or my hospital, as was done, when we use it outside the OR when it is indicated and provides the best option available THAT time. I guess it is sometimes just a matter of agreeing to disagree - perhaps this is one of them.

Stay safe,

Curse

PS – Please tell me "idiots guide to ventilators" is not really a book!!!

[VentMedic]

PS – Please tell me "idiots guide to ventilators" is not really a book!!!

It is a little manual that is now passed out in some CCEMTP classes for RN and EMT-Ps who have little knowledge of ventilators and is horrifying to read for anyone that has an education in the principles of ventilators. We usually send one of our own hospital staff if we know that is all the training the have when transport of an ICU ventilator patient is required. Idiots don't need to be touching ventilators or anything else that resembles critical care.

Pts with laryngeal fibrosis secondary to radiation that may require a period of prolonged intubation as it has been our experience that it is usually better tolerated than an oral tube.

These patients get a trach so that Speech Therapy can start working with them to regain some function for swallowing and speech. NTI will only prolong and enhance the problem since the tube still goes through the cords.

Alert, conscious pt's in whom RSI may cause more potential problems than benefits

Are they going to be on a ventilator? Alert and conscious may not be the best to start their ventilator stay.

Altered anatomy due to previous facial surgery

How do you know you'll have any success blindly do NTI? FiberOptic scope and oral is a more direct route. The patient may also have sinus problems if their face has been damaged.

I'm not picking on you but just pointing out somethings that you should be researching and thinking about before doing NTI on some patients. If you are not working in the ICU you may not be aware of the long term potential problems. I'm just telling you have we treat various situations to get the patient back to some type of normal life with the least complications.

You also don't seem to think there are many hospitals that have advanced enough to have the appropriate equipment to intubate in ways that may be best for the patient. I hope you don't think this is all science fiction.

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.

If you don't like the links, too bad. If you have reached the Paramedic level, even at Florida's standards, you should be able to do some reading on your own especially since I did give you a start by posting the links. I shouldn't have to copy and paste every article or spoon feed you.

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

The discussion moved away from EMS slightly and yes, for the areas we are discussing credentials are important.

Edited March 23, 2009 by VentMedic

[Camulos]

The pt’s with laryngeal fibrosis that we nasally intubate are not candidates for a surgical airway. We see quite a few of these at the hospital I work at due to our proximity to a nearby regional cancer centre. These pt’s have stiff, immobile larynx’s and our hospital ENT team will not go near them with a surgical airway so far be it for us to from an anaesthetic / ICU point of view. Mind you, these pt’s are not intubated for TREATMENT of their laryngeal fibrosis per se but for other reasons associated with their often fragile state of health. We, as with any pt, aim to pull the tube out ASAP, however sometimes that just is not possible and if we anticipate a prolonged intubation in one of these pt’s we prefer the nasal route as it seems better tolerated during the conscious weaning phase.

There are sometimes advantages in intubating pts whilst still awake as loss of a spontaneous airway from RSI can cause more potential difficulty than benefit. Some of these pt’s will be immediately sedated once the airway has been secured, some will not – it depends on each individual case and what our treatment goals are.

As for intubating pt’s with altered anatomy due to facial surgery I’m talking more about mandibular/ oral abnormalities that may make the oral route difficult or near impossible. As far as NTI I DO NOT do this BLINDLY in the hospital as keeps getting suggested. I don’t mean to seem as though I am shouting here however I have mentioned this on several occasions in previous posts and it seems to be getting missed . ALL NTI’s I have done in hospital have been FIBRE OPTICALLY ASSISTED and not done blindly. I have only done one blind NTI and that was pre hospital – unfortunately my fibre optic gear just didn’t fit in my kit that night.

I am very cognisant of the advanced technology available in hospitals to assist with intubation. However sometimes, even with that technology, orotracheal intubation is just not possible. When this is the case you have to decide between surgical and nasal. If it is your preference to provide a surgical airway in all of these cases then so be it – I just hope you can justify it. However I personally do not take the decision to use a surgical airway lightly and have managed to avoid it by using NTI on many occasions – and I can justify my reasons for each one of these cases. Mind you, sometimes the indications for surgical airway are clear and if so you have to escalate to that level immediately. Don’t get me wrong here. I don’t go around sticking tubes in pt’s noses preferentially. Oral is BY FAR preferable – I have stated that before. However I also feel that sometimes nasal offers advantages over a surgical airway when the oral route, for whatever reason, is not possible.

I understand the research that is out there regarding NTI. However the research does not say that NTI is completely outdated as I feel you are suggesting – outside the OR anyway. There are obvious risks, I am aware of these and have stated that numerous times previously. Sometimes these risks are an accepted part of the procedure we are adopting, sometimes they are not. It would be like saying that no pt should EVER be intubated orally as this also causes sinusitis which can lead to VAP. However in deciding to intubate someone orally we recognise and ACCEPT this because the benefit of the tube is greater than the associated risk. As I keep saying it is risk v’s benefit. And that is the challenge for us as clinicians – to evaluate this balance and decide what is BEST for our pt’s. Mind you we don’t always get that assessment right and hindsight can sometimes come and bite you on the ass.

If you insist on wanting to know what I am and what position I am in I'll tell you. I am a human (I hope) and I am currently in the Savasana position - I love Yoga!!!

Stay safe,

Curse