Nasotracheal Intubation

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Nasotracheal Intubation – Core Concepts

As with every sick patient – put on monitors, establish IV access, place on supplemental oxygen. Consider calling for physician backup including another ED provider, anesthesia, or even surgery if available to assist with procedure and possible transition to surgical airway
 

1. Examine
   1. Examine the mouth - look for posterior swelling, anatomical abnormalities
   2. Examine the nose – See if one nares appears more patent than the other
   3. Examine the neck – Identify surgical landmarks in case patient requires a surgical airway
2. Prep the patient
   1. Goal is analgesia and vasoconstriction of the nose
   2. Fill 10cc syringe with 5cc 4% lidocaine, 5cc oxymetazoline
   3. Alternatively use 5% liquid cocaine
   4. Inject with atomizer into the nares
3. Prep the patient – AGAIN
   1. Coat a nasal trumpet with visous lidocaine and insert into the nose
   2. Can dilate up 6 NPA -> 8 NPA (NPA = "Nasal Trumpet")
   3. Consider ketamine during this step, 0.5 – 1.0 mg/kg for pain control and sedation
4. Prep yourself
   1. Start with a 7.0 ETT tube but also grab a 6.5 or 6.0 as backup
   2. Prep your fiberoptic scope – check camera, attach suction
   3. Have available Yankhauer or other oral suction devices 
   4. Supplemental oral airway gear – laryngoscope blade or wooden tongue blade
   5. Surgical airway supplies OPEN at the bedside. If you are unable to perform nasotracheal intubation, patient will most likely require cricothyrotomy 
5. Load the tube
   1. Remove the nasal trumpet and insert your ETT first to ensure that it will fit as well as clear out gel and secretions to keep your camera view clear
   2. Advance ~ 15cm with bevel pointed laterally
6. Advance scope into preloaded ETT
   1. Identify epiglottitis, cords
   2. If no structures are obviously identifiable, withdraw ETT and endoscope 2-3cm at a time until you can recognize airway structures
7. Intubate
   1. Pass endoscope through cords and advance to carina
   2. If vocal cord spasm or spontaneous breathing makes advancement difficult, push paralytics ONLY if you have clearly identified the cords
8. Secure your tube
   1. Use either tape or even consider suturing tube to nose to ensure that it is not dislodged