Intubation difficile : aide apportée par le gonflement du ballonnet de la sonde d'intubation nasotrachéale

A case is reported of an unexpected difficult nasotracheal intubation for respiratory distress syndrome in a 72-yr-old obese woman with chronic obstructive pulmonary disease. After positioning the tip of the tracheal tube in the oropharynx, direct laryngoscopy did not allow exposure neither of the glottis nor of the corniculate cartilages. Fibreoptic tracheal intubation was decided. While preparing fibreoptic instruments, an attempt at blind intubation was performed. The tracheal tube cuff was inflated with 15 mL of air and then advanced gently until slight resistance was felt as the inflated cuff made contact with the vocal cords. At that time it was deflated and the tracheal tube advanced into the trachea. In the presence of normal pharyngeal anatomy, inflation of the tracheal tube cuff in the oropharynx is assumed to centre the tip of the tube and to direct it anteriorely towards the larynx. A recent prospective and randomized study has shown that tracheal tube cuff inflation in the oropharynx is effective in improving the success rate of blind nasotracheal intubation in paralysed patients with normal pharyngeal anatomy. Only case reports have shown the efficacy of tracheal tube cuff inflation in the pharynx as an aid to difficult blind nasotracheal intubation in emergency. Further controlled studies in this area would be valuable.     

The GlideScope for videolaryngoscopy-assisted nasotracheal-to-orotracheal tube exchange in the intensive care unit in a patient with a known difficult airway

A 77 year old, nasally intubated man with a history of repeated episodes of airway obstruction requiring intubation due to recurrent laryngitis and a hypopharyngeal mass, needed nasotracheal-to-orotracheal tube exchange. The GlideScope videolaryngoscope was inserted, achieving a full view of the glottic inlet with the nasotracheal tube in situ. An endotracheal tube (ETT) loaded on a GlideRite Rigid Stylet was advanced through the oropharynx into view. Advancement of this ETT to the glottic opening was tested and achieved. With both tracheal tubes in view, the nasotracheal tube cuff was deflated and withdrawn from the glottic opening. While maintaining videoscopic visualization, the orotracheal tube was advanced through the vocal cords into the trachea. The benefits of this technique versus existing alternatives are discussed.     

A modified lightwand-guided nasotracheal intubation technique for oromaxillofacial surgical patients

Study ObjectiveTo investigate the efficiency of a double curve nasotracheal tube on lightwand-guided nasotracheal intubation.DesignProspective, randomized, controlled trial.SettingUniversity medical center hospital.Patients60 ASA physical status I and II patients undergoing oromaxillofacial surgery.Interventions and MeasurementsPatients undergoing surgery with nasotracheal intubation and general anesthesia were randomly enrolled in the laryngoscopy group or the lightwand group. The same type of double curve nasotracheal tube was used in both groups. In the laryngoscopy group, intubation was assisted with a Macintosh No. 3 standard curved blade and Magill forceps. In the lightwand group, intubation was aided with a flexible lightwand device (without the inner stiff stylet). Intubation time was divided into two parts: Part one, from selected naris to oropharynx; Part two, from oropharynx into trachea. Part one, Part two, and total intubation time, hemodynamic responses to nasotracheal intubation, and adverse events or complications were recorded.Main ResultsTotal intubation times in the lightwand group and the laryngoscopy group were 22.8 ± 8.0 sec vs 30.3 ± 8.2 sec (P < 0.001), respectively. The lightwand group had comparable hemodynamic responses to those of the laryngoscopy group. Adverse events and complications were all self-limited, with similar occurrence in both groups.ConclusionFor patients undergoing oromaxillofacial surgery, modified lightwand-guided nasotracheal intubation is feasible with a double curve nasotracheal tube and is an efficient alternative technique.     

The Laryngeal Mask Airway for exchange of a nasal for an orotracheal tube in a patient with Treacher Collins syndrome

A new method of exchange of nasotracheal to orotracheal tube, using the Laryngeal Mask Airway (LMA), in a patient with difficult airway, is described. A 36-year-old woman with Treacher Collins syndrome was scheduled for a malar apatite cutting and a chin-level osteotomy. It was necessary to exchange a nasotracheal tube for an orotracheal tube during the operation. An LMA was inserted while the nasotracheal tube was left in place; a new tube was inserted in the LMA, then a fiberoptic laryngoscope (fiberscope) was inserted through these devices. The nasotracheal tube cuff was deflated, and the fiberscope was inserted into the trachea alongside the nasotracheal tube. The nasotracheal tube was removed, and the oral tube was then advanced into the trachea.     

Combining the EndoFlex® tube with fiberoptic bronchoscopy in difficult intubation

We applied a combination technique using the EndoFlex^® tube with fiberoptic bronchoscopy for a 69-year-old man presenting with limited mouth opening and neck movement. Awake nasotracheal intubation was performed under conscious sedation with propofol and fentanyl. After positioning the tip of the EndoFlex^® tube in the oropharynx, the fiberoptic bronchoscope was inserted into the tube until the tip reached the bevel of the tube. Anterior flexion of the distal tip of the EndoFlex^® tube facilitated uncomplicated insertion of the tube into the trachea without impingement on the arytenoids. Fiberoptic visualization confirmed that the distal-tip flexing mechanism of the EndoFlex^® tube corrected the direction of the tube tip anteriorly, allowing entry into the trachea. We present a case where this technique proved valuable for tracheal intubation in a patient with limitations of mouth opening and neck movement.     

TRACHEAL TUBE CUFF INFLATION AS AN AID TO BLIND NASOTRACHEAL INTUBATION

We have assessed the efficacy of tracheal tube cuff inflationin the oropharynx as an aid to blind nasotracheal intubationin 20 ASA I and II patients undergoing elective oral surgery.The trachea was intubated once using the technique of trachea/tubecuff inflation in the oropharynx and once keeping the trachea/tubecuff deflated throughout the manoeuvre. With the cuff deflated,intubation was successful in nine of 20 (45%) patients; in eightof 20 (40%) it was successful on the first attempt. With thetrachea/tube cuff inflated, intubation was successful in 19of 20 patients (95%), 15 of 20 (75%) of these on the first attempt.The success rates were significantly different (P < 0.01).Times to intubate were not significantly different (P > 0.05).We conclude that, in normal patients, trachea/tube cuff inflationin the oropharynx increases the success rate of blind nasotrachealintubation. (Br. J. Anaesth. 1993; 70: 691–693)     

One way to ventilate patients during fibreoptic intubation

Occasionally anaesthesiologists find themselves in situations where ventilation during intubation with a fibreoptic bronchoscope (FOB) is desirable. In order to ventilate the patient during the FOB intubation, we used a 90 degree angle swivel connector, normally used for fibreoptic bronchoscopia in an intubated patient. After a nasotracheal tube is placed with the tip in the oropharynx, ventilation of the patient is possible via this tube by closing the mouth and other nostril. The fibrescopic procedure is done through the right-angle connector with suction port and the tube is used to guide the tip of the FOB to the aditus laryngis. The method has been used in 7 patients who were impossible to intubate with a conventional procedure. In all patients ventilation was possible and intubation was performed in 5 min (range 1-15).     

Nasotracheal intubation: a randomized trial of two methods.

BACKGROUND: Several techniques have been suggested to reduce the trauma of nasotracheal intubation, although no comparative studies exist. The authors evaluated red-rubber catheters as a guide to nasotracheal intubation. METHODS: Children presenting for elective surgery were randomized to undergo red-rubber catheter-guided nasotracheal intubation or to have the nasotracheal tube alone inserted. After general anesthesia and paralysis with vecuronium, the nares were prepared with topical vasoconstrictor. The nasotracheal tube was softened with warm water. In the catheter-guided group, the nasotracheal tube tip was fitted to the trailing end of the red-rubber catheter, and the two were advanced together. The red-rubber catheter was retrieved from the nasopharynx, disconnected, and removed. In the other group, the nasotracheal tube was advanced blindly into the nasopharynx. In both groups, intubation was then completed during direct laryngoscopy using Magill forceps. A blinded observer swabbed the pharynx and rated the severity of bleeding based on reference photographs. RESULTS: Age, weight, snoring history, and difficulty of intubation were not different between groups. Obvious bleeding was lower using the red-rubber catheter technique (10 vs. 29%, P = 0.013), which took longer to perform (74 vs. 56 s, P = 0.02). CONCLUSIONS: Although the incidence of bleeding in both groups was similar, severity of bleeding was reduced in the catheter-guided group during nasotracheal intubation. Use of a red-rubber catheter may reduce the trauma associated with nasotracheal intubation.     

Case report: Nasotracheal intubation — look before leaping to assess the laryngeal view

PURPOSE: To describe an airway management plan, including oral to nasal endotracheal tube exchange, when nasal intubation is required in the unanticipated difficult airway. CLINICAL FEATURES: A nasal intubation was required for a patient undergoing oropharyngeal surgery. Following loss of consciousness and paralysis, a Cormack-Lehane class 3 view was obtained, and pressure over the thyroid cartilage failed to reveal the vocal cords. An Eschmann bougie was inserted into the oropharynx and blindly entered the trachea. An orotracheal tube was advanced into the trachea over the bougie, and the patient was ventilated with 100% O2 following the bougie's removal. An endotracheal tube was then guided through the right nostril into the hypopharynx. An Eschmann bougie was inserted into the nasal tube, and advanced towards the glottic opening under laryngoscopic view. Digital pressure applied to the oral tube at the base of the tongue brought the vocal cords into view. The oral endotracheal cuff was deflated, and the bougie (inserted into the nasal tube) was advanced into the trachea alongside the orotracheal tube. The orotracheal tube was withdrawn, and the nasal tube was advanced into the trachea over the bougie. The patient's O2 saturation and end-tidal CO2 concentration remained at 99-100% and 30-33 mmHg, respectively, during these maneuvers, which required only a few minutes to perform. CONCLUSION: When nasotracheal intubation is required, a plan of airway management is required to safely secure the airway. We emphasize the importance of direct laryngoscopy prior to insertion of an endotracheal tube through the nose, and describe a strategy for oral to nasal tracheal tube exchange.     

Difficult tracheal extubation

We describe a case of nasotracheal tube fixation with a screw. A second case is described in which a broken drill bit was found to impinge on the wall but not penetrate into the lumen of a nasotracheal tube. Possible sequelae of this complication include airway leak, aspiration, tube obstruction, and trauma from attempts at forceful extubation. We recommend the routine intraoperative testing for tracheal tube movement and routine fibreoptic bronchoscopy through the tube when blind surgical procedures occur in the vicinity of a tracheal tube.     

Nasotracheal Intubation: A Randomized Trial of Two Methods

Background: Several techniques have been suggested to reduce the trauma of nasotracheal intubation, although no comparative studies exist. The authors evaluated red-rubber catheters as a guide to nasotracheal intubation.

Methods: Children presenting for elective surgery were randomized to undergo red-rubber catheter-guided nasotracheal intubation or to have the nasotracheal tube alone inserted. After general anesthesia and paralysis with vecuronium, the nares were prepared with topical vasoconstrictor. The nasotracheal tube was softened with warm water. In the catheter-guided group, the nasotracheal tube tip was fitted to the trailing end of the red-rubber catheter, and the two were advanced together. The red-rubber catheter was retrieved from the nasopharynx, disconnected, and removed. In the other group, the nasotracheal tube was advanced blindly into the nasopharynx. In both groups, intubation was then completed during direct laryngoscopy using Magill forceps. A blinded observer swabbed the pharynx and rated the severity of bleeding based on reference photographs.

Results: Age, weight, snoring history, and difficulty of intubation were not different between groups. Obvious bleeding was lower using the red-rubber catheter technique (10 vs. 29%, P = 0.013), which took longer to perform (74 vs. 56 s, P = 0.02).     

The Parker Flex-Tip™ tube for nasotracheal intubation: the influence on nasal mucosal trauma

We tested our hypothesis that use of the Parker Flex-Tip™ tracheal tube could reduce the incidence of nasal mucosal trauma during nasotracheal intubation when compared with a conventional tip tracheal tube. One hundred and two patients, who were scheduled for elective oral surgery in which nasotracheal intubation was indicated to optimise the surgical approach, were recruited into this study. Either a Flex-Tip tracheal tube or a conventional tip tracheal tube was chosen randomly for each nasotracheal intubation. The incidence of epistaxis using the Flex-Tip tracheal tube (6 (11.8%)) was significantly lower than that with the conventional tip tracheal tube (18 (35.3%); p = 0.009). Nasal pain due to intubation, rated on a 100-mm visual analogue scale, was less intense with the Flex-Tip tracheal tube (median, (10th–90th percentile) 19 (12–28) mm compared with the conventional tip tracheal tube (30 (22–35) mm; p < 0.001). The Flex-Tip tracheal tube thus appeared to reduce the incidence of nasal mucosal trauma during nasotracheal intubation and the incidence of post-intubation nasal pain, compared with the conventional tip tracheal tube.     

A silicone-based wire-reinforced tracheal tube with a hemispherical bevel reduces nasal morbidity for nasotracheal intubation

We tested the hypothesis that a silicone-based wire-reinforced tracheal tube with a hemispherical bevel is superior to a polyvinyl chloride (PVC)-based precurved tube with a conventional diagonal bevel for nasotracheal intubation. Eighty anesthetized paralyzed adults (ASA physical status I-II) requiring nasotracheal intubation for tonsillectomy were randomly allocated into two equal-sized groups for airway management with the silicone tracheal tube or PVC tracheal tube. Intubation was subdivided into three phases: 1). passage through the nose into the pharynx, 2). laryngoscope-guided passage into the glottic inlet, and 3). laryngoscope-guided passage into the trachea. A specific sequence of airway maneuvers was followed at each stage if it was unsuccessful. The number of attempts and intubation time were documented by an unblinded observer. The frequency of epistaxis and postoperative nasal complications was documented by blinded observers. There were no intubation failures. The number of attempts at pharyngeal (47 versus 56; P = 0.04) and tracheal (43 versus 55; P = 0.005) placement was smaller for the silicone tracheal tube, but the number of attempts at glottic placement was more (72 versus 49; P < 0.0001). Intubation time was similar. The frequency (32% versus 80%; P < 0.0001) and severity of epistaxis were less for the silicone tracheal tube. The total number of postoperative nasal symptoms was smaller for the silicone tracheal tube (10 versus 21; P < 0.05). We conclude that the pharyngeal and tracheal placement phases of nasotracheal intubation require fewer attempts with the silicone tracheal tube than the PVC tracheal tube but that the glottic placement phase requires more attempts. Nasal morbidity is less common with the silicone tracheal tube. IMPLICATIONS: The pharyngeal and tracheal placement phases of nasotracheal intubation require fewer attempts with a silicone-based wire-reinforced tracheal tube with a hemispherical bevel than with a polyvinyl chloride-based precurved tracheal tube with a conventional diagonal bevel, but the glottic placement phase requires more attempts. Nasal morbidity is less common with the silicone tracheal tube.     

Fibreoptic bronchoscopic nasotracheal intubation of a neonate with Pierre Robin syndrome

A case of nasotracheal intubation using a fibreoptic bronchoscope and the Seldinger technique is described. A guide wire was passed through the suction channel of the fiberscope after the epiglottis and the vocal cords were seen; the fiberscope was removed and a nasotracheal tube passed over the wire into the trachea.     

Telescoping tracheal tubes into catheters minimizes epistaxis during nasotracheal intubation in children

BACKGROUND: Numerous strategies have been used to reduce epistaxis after nasotracheal intubation. The authors compared the severity of epistaxis after nasotracheal intubation in children with tubes at room temperature, warm tubes, and tubes telescoped into catheters. METHODS: Children who were scheduled for elective dental surgery were randomly assigned to undergo nasotracheal intubation using a tube at room temperature (control), warmed in saline, or whose distal end had been telescoped into a red rubber catheter. After an inhalational induction and intravenous propofol, a lubricated tube or red rubber catheter was inserted into the right naris. Tracheal intubation was achieved by direct laryngoscopy and tube placement using Magill forceps. The pharynx was swabbed for blood by an observer who was blind to the treatment. The severity of bleeding was rated using reference figures. Data were analyzed using Kruskal-Wallis and Fisher exact tests. P < 0.05 was accepted. RESULTS: The demographics of the three groups were similar. The estimated median area of the gauze in the catheter group that was covered with blood (0%) was significantly less than the areas in the control (40%) and warm (20%) groups. The incidence of clinically relevant bleeding (>or= 40% of the gauze area covered in blood) in the catheter group (5%) was significantly less than in the control (56%) and warm (39%) groups. The incidence of no detectable blood in the catheter group (59%) was significantly greater than in the control (21%) and warm (26%) groups. CONCLUSIONS: Telescoping the endotracheal tube into a catheter significantly reduces epistaxis in children undergoing nasotracheal intubation.     

Determination of the site of tracheal tube impingement during nasotracheal fibreoptic intubation

This study examines the incidence and site of tracheal tube impingement during nasotracheal fibreoptic intubation, and the efficacy of anticlockwise tube rotation to overcome the problem. Forty-three patients underwent fibreoptic-assisted nasotracheal intubation using a preformed nasal tube, and a second fibrescope was used to observe any obstruction to passage of the tracheal tube. Impingement occurred in 10 cases, with the most common site being the right arytenoid cartilage. Rotation resulted in successful intubation in all 10 cases, but proximal rotation did not always result in an equal degree of rotation at the tube tip. We conclude that the site of impingement for nasotracheal intubation with preformed nasal tubes is located at the posterior structures of the laryngeal inlet and that anticlockwise rotation is a simple and effective solution.     

Thermosoftening of the Parker Flex-TipTM Tracheal Tube in Preparation for Nasotracheal Intubation

The Parker Flex-Tip tracheal tube (PFTT, Parker Medical, Highlands Ranch, Colo) has a soft, flexible, curved tip with double Murphy eyes. Previous studies have shown that the PFTT reduces the incidence of epistaxis during nasotracheal intubation and the incidence of postintubation nasal pain, as compared to conventional tracheal tubes. Although thermosoftening is a well-known and effective technique for reducing epistaxis during nasotracheal intubation with conventional tracheal tubes, we occasionally encounter difficulties with advancing the tube through the nasal passage when the PFTT is thermosoftened prior to nasotracheal intubation. Consequently, when using the PFTT for nasotracheal intubation, the procedure of thermosoftening should be avoided.Key Words: Thermosoftening, Tracheal tubesNasal intubation is often required for dental and oral surgical procedures to facilitate complete surgical access to the oral cavity. Various complications resulting from nasotracheal intubation have been reported. However, the most common complication of nasotracheal intubation remains nasal epistaxis.¹ The incidence of nasal epistaxis is high, ranging from 18 to 77%.²The Parker Flex-Tip tracheal tube (PFTT, Parker Medical, Highlands Ranch, Colo) has a soft, flexible, curved tip with double Murphy eyes. Prior et al³ reported that the PFTT may be safer by causing less trauma and bleeding than the standard tube for nasotracheal intubation. A previous report from our hospital has demonstrated that the PFTT reduces the incidence of epistaxis during nasotracheal intubation and the incidence of postintubation nasal pain, as compared to conventional tracheal tubes.⁴ Although thermosoftening is a well-known and effective technique for reducing epistaxis during nasotracheal intubation with conventional tracheal tubes,⁵ we occasionally encounter difficulties in the nasal passage when the PFTT is thermosoftened prior to nasotracheal intubation.During nasotracheal intubation, the distal tip of the endotracheal tube is inserted through the naris into the oropharynx. At this point, the endotracheal tube can impinge on the posterior wall of the nasopharynx, where the nasal passage turns acutely.⁶ The soft distal tip of the PFTT becomes softer with thermosoftening,⁷ and may easily collapse upon impact. Xue et al⁸ described how the PFTT may collapse upon impact, even if it has not been thermosoftened. We suspect that the tip of a thermosoftened PFTT does not slide smoothly downward when pressed directly against the posterior wall of the nasopharynx, and can result in decreased navigability through the nasal passage.Since thermosoftening of the PFTT may impair smooth navigability through the nasal passage, the PFTT should be used for nasotracheal intubation without prior thermosoftening of the tip of the tube.     

Une étude de cas d’assistance respiratoire dans un contexte de fissure palatine et de pharyngoplastie

PURPOSE: To describe a practical method of aiding nasotracheal intubation in a cleft palate patient with previous pharyngoplasty using a suction catheter under tactile guidance. Problems of airway management in these patients are also discussed. CLINICAL FEATURES: A 26-yr-old woman presented for elective Le Fort maxillary osteotomy. She had a history of cleft lip and palate and subsequent palatoplasty and pharyngeal flap. She had no symptoms of upper airway obstruction or obstructive sleep apnea. Preoperative examination revealed a hypernasal voice and patent nasal passages. Anesthesia was induced and the patient paralyzed. An attempt to pass a 6.5-mm cuffed endotracheal tube through the right nostril met with resistance. A suction catheter was introduced into the nostril, while a finger was positioned over the flap and the velopharyngeal port, until its tip rested against the flap, the catheter coiled and a small loop could be palpated past the patent velopharyngeal port. The catheter was then hooked into the oropharynx. The endotracheal tube was "railroaded" over it and advanced into the glottis. There was minimal bleeding and no desaturation during the procedure. CONCLUSION: Preoperative determination of the type of pharyngoplasty is essential to understand the anatomy of the patent velopharyngeal port. A history of pharyngeal flap infection, hyponasal voice or upper airway obstruction suggests possible port stenosis. We describe a tactile guided technique that is useful and practical. Use of a flexible suction catheter of small external diameter minimizes the potential for trauma, bleeding and creation of false passages.     

Sore throat and hoarseness after fiberoptic nasotracheal intubation

Fiberoptic nasotracheal intubation is frequently chosen for surgery involving the oral cavity. In such cases, the endotracheal tube passes through the vocal cords into the trachea blindly, which may cause laryngeal trauma. We, therefore, studied the incidence of sore throat and hoarseness after fiberoptic nasotracheal intubation (n=44) and compared the results with those after conventional oral intubation (n=35). The incidence of sore throat was lower in the fiberoptic nasotracheal intubation group than in the conventional oral intubation group but the difference was not statistically significant (25.0%s 42.8%). The incidence of hoarseness after fiberoptic nasotracheal intubation was significantly lower than that after conventional oral intubation (4.5%s 34.3%,P<0.05). This study confirms a low incidence of laryngeal trauma in fiberoptic nasotracheal intubation.     

Nasotracheal tube placement over the fibreoptic laryngoscope

We have assessed the effectiveness of three tracheal tube rotational movements in assisting nasotracheal tube placement over the fibreoptic laryngoscope. Ninety ASA grade 1 or 2 oral surgery patients undergoing fibreoptic nasotracheal intubation under general anaesthesia were studied. After the fibrescope had been positioned in the trachea, patients were randomly allocated to one of three groups. In group 1, no rotation was used and the tube was advanced towards the trachea in the neutral position. In group 2, the tube was rotated by 90° anticlockwise. In group 3, the tube was rotated by 180° anticlockwise, then rotated back to 90° anticlockwise (overcorrected rotation). If resistance to the advance was encountered, up to two more attempts were allowed, after further rotational manoeuvres had been made, in accordance with a standard, graduated sequence. There were significantly more successful tube placements at the first attempt in groups 2 and 3 (93% and 100% respectively) than in group I (63%). It is therefore recommended that 90° anticlockwise or overcorrected 90° anticlockwise tube rotation is used to facilitate nasotracheal tube placement during fibreoptic intubation.