Nasal intubation
OVERVIEW
- nasal intubation may be performed blind or with fiberoptic assistance
INDICATIONS
When oral intubation is not feasible
- angioedema of the tongue
- mechanical obstructions to mouth opening from mandibular fixation or other oral pathology
- fixed neck contracture and limited mouth opening
CONTRA-INDICATIONS
- siginificant hypoxia or other situation requiring emergency cricothyroidotomy
- base of skull fracture
- coagulopathy
- disruption of the midface, nasopharynx or roof of the mouth
METHOD
Blind nasal intubation as described by Rich Levitan: ‘Spray-Trumpet-Spray-Tube-Spray’
- Anaesthetic spray into naris (5-10cc of 4% topical lidocaine with oxymetazoline, either via disposable single patient bottle or via disposable spray pump atomizer or syringe)
- Insert nasal trumpet lubricated with 2% lidocaine jelly (leave in place for 1 min)
- Spray anesthetic spray through trumpet and remove trumpet
- Insert “trigger” tracheal tube (as large as will be tolerated, at least 7.0) to approximately 14–16 cm, keeping the proximal end of the tube directed toward the patient’s contralateral nipple (this helps to direct the tip of the tube toward the midline). There should be loud breath sounds audible through the tube. This verifies location above the laryngeal inlet.
- Spray anesthetic once through tube again. The patient will cough and buck
- Pass tracheal tube through cords during inhalation
- Confirm placement, sedate, and administer muscle relaxants as needed
OTHER INFORMATION
- deliver oxygen using a nasal cannula through the contralateral naris or through the mouth
- In the patient who is too agitated to permit the procedure consider using small aliquots of ketamine (10 mg IV, repeated up to 40-50 mg total, although more can be given if needed)
- when passing a nasal trumpet or ETT ensure the bevel faces the turbinates (laterally) and that the tube is advanced along the septum (medially) and the floor of the nasal cavity (which is perpendicular to the plane of the face)
- adjustment of head positioning, tube twisting, or laryngeal manipulation may assist in directing the tube forward into the trachea
- patient may need restraint once he ETT passes the cords
- typically 26cm at the nose for women and 28cm at the nose for men
References and Links
CCC Airway Series
Emergencies: Can’t Intubate, Can’t Intubate, Can’t Oxygenate (CICO), Laryngospasm, Surgical Cricothyroidotomy
Conditions: Airway Obstruction, Airway in C-Spine Injury, Airway mgmt in major trauma, Airway in Maxillofacial Trauma, Airway in Neck Trauma, Angioedema, Coroner’s Clot, Intubation of the GI Bleeder, Intubation in GIH, Intubation, hypotension and shock, Peri-intubation life threats, Stridor, Post-Extubation Stridor, Tracheo-esophageal fistula, Trismus and Restricted Mouth Opening
Pre-Intubation: Airway Assessment, Apnoeic Oxygenation, Pre-oxygenation
Paediatric: Paediatric Airway, Paeds Anaesthetic Equipment, Upper airway obstruction in a child
Airway adjuncts: Intubating LMA, Laryngeal Mask Airway (LMA)
Intubation Aids: Bougie, Stylet, Airway Exchange Catheter
Intubation Pharmacology: Paralytics for intubation of the critically ill, Pre-treatment for RSI
Laryngoscopy: Bimanual laryngoscopy, Direct Laryngoscopy, Suction Assisted Laryngoscopy Airway Decontamination (SALAD), Three Axis Alignment vs Two Curve Theory, Video Laryngoscopy, Video Laryngoscopy vs. Direct
Intubation: Adverse effects of endotracheal intubation, Awake Intubation, Blind Digital Intubation, Cricoid Pressure, Delayed sequence intubation (DSI), Nasal intubation, Pre-hospital RSI, Rapid Sequence Intubation (RSI), RSI and PALM
Post-intubation: ETT Cuff Leak, Hypoxia, Post-intubation Care, Unplanned Extubation
Tracheostomy: Anatomy, Assessment of swallow, Bleeding trache, Complications, Insertion, Insertion timing, Literature summary, Perc. Trache, Perc. vs surgical trache, Respiratory distress in a trache patient, Trache Adv. and Disadv., Trache summary
Misc: Airway literature summaries, Bronchoscopic Anatomy, Cuff Leak Test, Difficult airway algorithms, Phases of Swallowing
FOAM and web resources
- EP Monthly — Nasal Intubation by Rich Levitan (2013)
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC
