Simple tracheal tube—an alternative to the modified nasal trumpet

Abstract

Editor—In the case report by Metz and Beattie,1Metz S Beattie C A modified nasal trumpet to facilitate fibreoptic intubation.Br J Anaesth. 2003; 90: 388-391Crossref PubMed Scopus (14) Google Scholar the authors have described the use of the modified nasal trumpet to facilitate fibreoptic intubation. The authors used a prepackaged nasopharyngeal airway (Kendall–Arygle, Mansfield, USA) for the purpose. They added one or two distal fenestrations by cutting holes near the distal end. The proximal end of the nasal airway was attached to a size 15 mm tracheal tube adaptor. Once the airway was passed through one of the nostrils, the adaptor was connected to an anaesthesia breathing system for inhalation anaesthesia followed subsequently by oral or nasal fibreoptic intubation. I have been using a tracheal tube (Portex limited, Hythe, Kent, UK) instead of a standard nasopharyngeal airway to aid fibreoptic intubation in a similar way. This can also be used for procedures where the operative field will not permit inhalation anaesthesia by mask or where a proper mask fit is difficult, as in Pierre Robin syndrome. The traditional method of determining the length of such a nasopharyngeal airway is used, which involves measuring the distance from the tip of the nose to the external auditory meatus.2Dorsch JA Dorsch SE Face masks and airway.in: Dorsch JA Dorsch SE Understanding Anesthesia Equipment. 4th Edn. William and Wilkins, Baltimore2000: 441-461Google Scholar Alternatively, the length can be determined by correlating it with the height of the patient, as described by Stoneham.3Stoneham MD The nasopharyngeal airway. Assessment of position by fibreoptic laryngoscopy.Anaesthesia. 1993; 48: 575-580Crossref PubMed Scopus (54) Google Scholar The tracheal tube is cut at this length and the standard adaptor supplied with the tracheal tube is firmly reinserted into the proximal end. Both the nostrils are pretreated with nasal vasoconstrictor and lidocaine 2% spray. The tracheal tube is lubricated with lidocaine 2% or KY jelly. With the patient awake or following induction of inhalation anaesthesia, this nasopharyngeal airway is passed through the most patent nostril, using minimum force, until the connector is flush with the skin. Once properly positioned, the opposite nostril and mouth are tightly closed and the adaptor is connected to the anaesthesia circuit allowing spontaneous ventilation of halothane or sevoflurane in oxygen. Such an arrangement allows both for oxygenation and general anaesthesia while maintaining spontaneous ventilation. The patency of the airway is confirmed by observing the reservoir bag and capnography. Thereafter, nasal fibreoptic intubation through the other nostril or oral fibreoptic intubation can be carried out while the patient is breathing spontaneously. Metz and Beattie have rightly pointed out1Metz S Beattie C A modified nasal trumpet to facilitate fibreoptic intubation.Br J Anaesth. 2003; 90: 388-391Crossref PubMed Scopus (14) Google Scholar that despite the nasopharyngeal airway being available for a hundred years, its use in primary airway management has declined. This is probably related to the use of the tracheal tube.3Stoneham MD The nasopharyngeal airway. Assessment of position by fibreoptic laryngoscopy.Anaesthesia. 1993; 48: 575-580Crossref PubMed Scopus (54) Google Scholar 4Bagshaw ONT Southee R Ruiz K A comparison of the nasal mask and the nasopharyngeal airway in paediatric chair dental anaesthesia.Anaesthesia. 1997; 52: 786-796Crossref PubMed Scopus (11) Google Scholar A nasopharyngeal airway resembles a shortened tracheal tube with a flange or moveable disc on the outside end to prevent it from passing into the nares.5Mobbs AP Retained nasopharyngeal airway. A reply.Anaesthesia. 1989; 44: 447Crossref PubMed Scopus (1) Google Scholar The adaptor of the tracheal tube has flanges on its sides which serve the same function. However, any movement of the neck in rotation or anteroposteriorly can result in obstruction of the lumen of either tube. Use of a multifenestrated nasopharyngeal airway as used by Metz and Beattie is recommended to overcome this problem.1Metz S Beattie C A modified nasal trumpet to facilitate fibreoptic intubation.Br J Anaesth. 2003; 90: 388-391Crossref PubMed Scopus (14) Google Scholar A Portex tracheal tube has an inbuilt Murphy eye and this obviates the need to cut additional holes. Use of the tracheal tube confers the advantage that unlike a standard nasopharyngeal airway, the length can be easily tailored to the individual patient. In conclusion, a simple tracheal tube can readily be used with equal efficacy to the modified nasal trumpet to facilitate fibreoptic intubation. Editor—We are pleased that Dr Mahajan’s use of a modified tracheal tube corroborates our success with the modified nasal trumpet. We believe that the softer and more pliable construction of the nasal trumpet provides a lesser chance of nasal trauma than a tracheal tube, though we are not aware of any data to support this. Nonetheless, we applaud Dr Mahajan’s creative approach to airway management. S. Metz C. Beattie Philadelphia, USA