Teaching guided fibreoptic nasotracheal intubation

An anaesthetic technique suitable for training in fibreoptic intubation is described. It uses a capped oropharyngeal airway which leaves the nose free for fibreoptic intubation and allows the airway to be maintained and ventilation to be controlled if necessary. An assessment is made of the technique after 50 fibreoptic intubations with the Olympus LF-1 fibrescope. There were no failed intubations and no serious complications.     

Light-wand (Trachlight) guided nasotracheal intubation

We report that Trachlight-guided nasotracheal intubation might be achieved successfully and traumatically without removal of a stiff internal stylet. Endotracheal tube was mounted on a Trachlight with the stylet in position and bent to form a less sharp curvature than a right angle, namely 40-60 degree, at 7 cm proximal to the endotracheal tube tip. Forty-six patients scheduled for nasal intubation were studied to measure the intubation time and the success rate with the use of Trachlight. The tracheas were successfully intubated in 89% of patients. We suggest that Trachlight-guided nasotracheal intubation could be clinically feasible without traumatic complication when applied with a stiff stylet in position and this approach is a useful method for nasal intubation.     

A nasal adhesion following prolonged nasotracheal intubation

A patient who presented with nasal obstruction 4 months after prolonged pernasal tracheal intubation is described. The cause of the obstruction was an adhesion which extended from the septum to the inferior turbinate. The evidence in support of long-term pernasal tracheal intubation is presented and the aetiology of this complication is discussed.     

Aspiration of an oropharyngeal airway during nasotracheal intubation

The oropharyngeal airway (OPA) has been a remarkably safe device since its invention by Guedel in 1933. This plastic device is easily placed in the mouth and used for aiding in mask ventilation. We report a case of the aspiration of an OPA causing near total upper airway obstruction.     

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.     

Incidence and predictors of difficult nasotracheal intubation with airway scope

Purpose

The airway scope (AWS) improves views of the larynx during orotracheal intubation. However, the role of the AWS in routine nasotracheal intubation has not been studied adequately.

Methods

One hundred and three patients undergoing dental and maxillofacial surgery that required general anesthesia and nasotracheal intubation were enrolled. The study was approved by our Institution Review Board, and written informed consent was obtained from all patients. We evaluated the success rate of AWS intubation and the incidence of difficult nasotracheal intubation using a modified intubation difficulty scale (IDS) to examine preoperative characteristics and intubation profiles. Categories were difficult intubation (IDS ≥5), mildly difficult (IDS = 1–4), and intubation without difficulty (IDS = 0). We also assessed the incidence of the use of Magill forceps or cuff inflation (the cuff of endotracheal tube is inflated with 10–15 ml air) to guide the endotracheal tube into the glottis.

Results

AWS nasotracheal intubation was 100 % successful. The cuff inflation technique was used in 37 patients. Neither Magill forceps nor other devices were needed for any patient during AWS use. The incidence of difficult nasotracheal intubation was 10 % (n = 10). Of the patients, 61 % (n = 63) had mildly difficult intubation and 29 % (n = 30) had no difficulty. Patients with difficult intubation were more likely to be male and to have a larger tongue and a higher Cormack grade than in the other two groups. Complications, involving minor soft tissue injury, were observed in only 1 patient (1 %).

Conclusion

The AWS achieves a high success rate for nasotracheal intubation with cuff inflation in patients undergoing dental and maxillofacial surgery.     

Reliability of assessment of nasal flow rate for nostril selection during nasotracheal intubation

Study ObjectiveTo evaluate the reliability of assessments of nasal flow rate for improved nostril selection for nasotracheal intubation.DesignProspective, randomized, double-blinded study.SettingOperating room of a university-affiliated hospital.Patients118 ASA physical status 1 and 2 patients, aged 18-65 years, scheduled for elective maxillofacial and oral surgery requiring nasotracheal intubation.InterventionsPatients were randomized to the left or right nostril groups. Forced vital capacity (FVC) and forced expiratory volume in one second (FEV₁) through the mouth and each nostril were measured before anesthesia induction.MeasurementsThe relationship between the rate of airflow through the selected nostril and frequency of epistaxis and navigability of the nasotracheal tube were evaluated.Main ResultsThere were no significant differences in the frequency of epistaxis and degree of navigability of the tracheal tube between the left and right nostril groups. In both nostril groups, patients who suffered epistaxis showed significantly less FEV₁ and FEV₁/FVC values than did patients without epistaxis (P < 0.05). In addition, in both groups patients who passed the tube easily showed significantly higher FEV₁ and FEV₁/FVC values than did patients who passed the tube with resistance or failed tube passage (P < 0.05).ConclusionMeasurement of nasal flow rate is a useful clinical method for choosing a nostril for nasotracheal intubation.     

Oral and nasotracheal light wand guided intubation after failed fibreoptic bronchoscopy

Fibreoptic bronchoscopic guided tracheal intubation is often the first choice for clinicians familiar with the technique, when faced with a patient in whom tracheal intubation presents known or possible difficulties. Regardless of the technique chosen, anticipated and unanticipated problems may arise. We report three patients with known difficult airways that illustrate the utility of light wand guided oral and nasotracheal intubation when tracheal intubation with fibreoptic bronchoscopy proved impossible.     

Cuff protection for nasotracheal intubation

The passage of a tube through the nose to the epipharynx is potentially dangerous during the nasotracheal intubation because of the possibility of cuff damage, obstruction of the tube, the impossibility of advancing the tube and contamination. It seems therefore useful to protect the cuff e.g. by a finger stall, but using this procedure complications can occur which are reported. A better solution to protect the cuff will be shown.