Nasotracheal Intubation

Abstract

Articles comparing the use of long-term orotracheal tubes and elective tracheostomy for ventilatory support have frequented the medical literature. Recently, some authors have re-emphasized that nasotracheal tubes are better tolerated by awake patients. Generally, however, most physicians now rely on oral airways and orotracheal intubation in emergency circumstances, such as cardiopulmonary resuscitation, distress from retained secretions and laryngospasm. Early in these situations the patient is conscious, alert, reactive and frequently resistant to manipulation within the mouth and pharynx. Thus, when intubation is most advantageous, it is most difficult to maneuver an orotracheal tube. Either the condition worsens and the patient becomes unconscious or sedation and/or pharmacologic paralysis is required. It is the purpose of this communication to point out the great value of nasotracheal intubation in the reactive patient in emergent or semi-emergent situations. A No. 32 through No. 36, gently curved, cuffed, firm rubber endotracheal tube can be placed through a nostril and into the trachea with “blind” technique in most cases. Direct visualization of the glottis and use of the Magill forceps is usually not required. With the occiput slightly extended, the configuration of the nasopharynx seems to guide the tube to the glottis, especially during active inspiration, cough and expiration. The tongue may be pulled forward or actively extended by the helpful patient. Xylocaine ointment applied to the nasal mucosa with cotton applicator sticks will render the alert patient to be more cooperative. One hand can be used to hold the larynx cephalad and posterior. The tube is advanced to the glottis and on inspiration it is pushed into the trachea. Care of these tubes, including minimal cuff inflation and frequent intermittent deflation when off a respirator, assures minimal injury to tracheal mucosa. The patient should not be allowed pillows under the head as this can pre-dispose the kinking of the tube. With precautions the patient's acute needs may well be served by a single short intubation.