Anesth Pain Med.  2021 Jul;16(3):232-247. 10.17085/apm.21040.

Nasotracheal intubation for airway management during anesthesia

Affiliations
  • 1Department of Anesthesiology and Pain Medicine, Daejeon Eulji Medical Center, Eulji University, School of Medicine, Daejeon, Korea

Abstract

Nasotracheal intubation is used as a basic method for airway management, along with orotracheal intubation under anesthesia and intensive care. It has become an effective alternative method to orotracheal intubation with increased benefits of offering better mobility and surgical field in oral and maxillofacial surgery and possibly in trauma and critically ill patients. Nasotracheal intubation is performed through a relatively narrow nasal cavity; therefore, additional precautions are needed. Accordingly, nasotracheal intubation methods have evolved over the years with accumulated clinical experience and improved instruments to facilitate safe intubation with reduced complications. Therefore, in this review article, we summarize the basic anatomy of the nasal airways to clarify the precautions, delineate the history and development of various methods and instruments, and describe the indications, contraindications, complications, and preventive methods of nasotracheal intubation.

Keyword

Airway management; Anesthesia; Endotracheal intubation; Nasal cavity

Figure

  • Fig. 1. Parker Flex-tip nasal endotracheal tube.


Reference

1. Duncan JA. Intubation of the trachea in the conscious patient. Br J Anaesth. 1977; 49:619–23.
2. Dauphinee K. Nasotracheal intubation. Emerg Med Clin North Am. 1988; 6:715–23.
3. Prasanna D, Bhat S. Nasotracheal intubation: an overview. J Maxillofac Oral Surg. 2014; 13:366–72.
4. Holzapfel L. Nasal vs oral intubation. Minerva Anestesiol. 2003; 69:348–52.
5. Hall CE, Shutt LE. Nasotracheal intubation for head and neck surgery. Anaesthesia. 2003; 58:249–56.
6. Tintinalli JE, Claffey J. Complications of nasotracheal intubation. Ann Emerg Med. 1981; 10:142–4.
7. Roppolo LP, Vilke GM, Chan TC, Krishel S, Hayden SR, Rosen P, et al. Nasotracheal intubation in the emergency department, revisited. J Emerg Med. 1999; 17:791–9.
8. Sun Y, Jiang H, Zhu Y, Xu H, Huang Y. Blind intubation device for nasotracheal intubation in 100 oral and maxillofacial surgery patients with anticipated difficult airways: a prospective evaluation. Eur J Anaesthesiol. 2009; 26:746–51.
9. Chauhan V, Acharya G. Nasal intubation: a comprehensive review. Indian J Crit Care Med. 2016; 20:662–7.
10. Luckhaupt H, Brusis T. [History of intubation]. Laryngol Rhinol Otol (Stuttg). 1986; 65:506–10. German.
11. Robinson DH, Toledo AH. Historical development of modern anesthesia. J Invest Surg. 2012; 25:141–9.
12. Magill IW. Technique in endotracheal anaesthesia. Br Med J. 1930; 2:817–9.
13. Magill IW. Blind nasal intubation. Anaesthesia. 1975; 30:476–9.
14. Rowbotham S. Intratracheal anaesthesia by the nasal route for operations on the mouth and lips. Br Med J. 1920; 2:590–1.
15. O'Reilly MJ, Reddick EJ, Black W, Carter PL, Erhardt J, Fill W, et al. Sepsis from sinusitis in nasotracheally intubated patients. A diagnostic dilemma. Am J Surg. 1984; 147:601–4.
16. Raj PP, Forestner J, Watson TD, Morris RE, Jenkins MT. Technics for fiberoptic laryngoscopy in anesthesia. Anesth Analg. 1974; 53:708–14.
17. Arrowsmith JE, Robertshaw HJ, Boyd JD. Nasotracheal intubation in the presence of frontobasal skull fracture. Can J Anaesth. 1998; 45:71–5.
18. Teul I, Slawinski G, Lewandowski J, Dzieciolowska-Baran E, Gawlikowska-Sroka A, Czerwinski F. Nasal septum morphology in human fetuses in computed tomography images. Eur J Med Res. 2010; 15(Suppl 2):202–5.
19. Kemper M, Dullenkopf A, Schmidt AR, Gerber A, Weiss M. Nasotracheal intubation depth in paediatric patients. Br J Anaesth. 2014; 113:840–6.
20. Santillanes G, Gausche-Hill M. Pediatric airway management. Emerg Med Clin North Am. 2008; 26:961–75.
21. Shohara K, Goto T, Kuwahara G, Isakari Y, Moriya T, Yamamuro T. Validity of rhinometry in measuring nasal patency for nasotracheal intubtion. J Anesth. 2017; 31:1–4.
22. Pearce A. Evaluation of the airway and preparation for difficulty. Best Pract Res Clin Anaesthesiol. 2005; 19:559–79.
23. Prasad A, Yu E, Wong DT, Karkhanis R, Gullane P, Chan VW. Comparison of sonography and computed tomography as imaging tools for assessment of airway structures. J Ultrasound Med. 2011; 30:965–72.
24. Chi SI, Park S, Joo LA, Shin TJ, Kim HJ, Seo KS. Identifying the more suitable nostril for nasotracheal intubation using radiographs. J Dent Anesth Pain Med. 2016; 16:103–9.
25. Rajan S, Arora V, Tosh P, Mohan P, Kumar L. Effectiveness of transtracheal lidocaine as an adjunct to general anesthesia in providing patient immobility during total parotidectomy: a comparison with dexmedetomidine infusion. J Anaesthesiol Clin Pharmacol. 2017; 33:193–6.
26. Gold MI, Buechel DR. Translaryngeal anesthesia: a review. Anesthesiology. 1959; 20:181–5.
27. Baraka AS, Taha SK, Aouad MT, El-Khatib MF, Kawkabani NI. Preoxygenation: comparison of maximal breathing and tidal volume breathing techniques. Anesthesiology. 1999; 91:612–6.
28. Nimmagadda U, Salem MR, Crystal GJ. Preoxygenation: physiologic basis, benefits, and potential risks. Anesth Analg. 2017; 124:507–17.
29. Tan P, Dennis AT. High flow humidified nasal oxygen in pregnant women. Anaesth Intensive Care. 2018; 46:36–41.
30. Patel A, Nouraei SA. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia. 2015; 70:323–9.
31. Pillai A, Daga V, Lewis J, Mahmoud M, Mushambi M, Bogod D. High-flow humidified nasal oxygenation vs. standard face mask oxygenation. Anaesthesia. 2016; 71:1280–3.
32. Humphreys S, Lee-Archer P, Reyne G, Long D, Williams T, Schibler A. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) in children: a randomized controlled trial. Br J Anaesth. 2017; 118:232–8.
33. Andel H, Klune G, Andel D, Felfernig M, Donner A, Schramm W, et al. Propofol without muscle relaxants for conventional or fiberoptic nasotracheal intubation: a dose-finding study. Anesth Analg. 2000; 91:458–61.
34. Ide M, Sunada K, Katsuyama N. Are muscle relaxants needed for nasal intubation in propofol and remifentanil anesthesia? J Oral Maxillofac Surg. 2014; 72:2134–9.
35. Tramèr MR, Fuchs-Buder T. Omitting antagonism of neuromuscular block: effect on postoperative nausea and vomiting and risk of residual paralysis. A systematic review. Br J Anaesth. 1999; 82:379–86.
36. Kihara S, Komatsuzaki T, Brimacombe JR, Yaguchi Y, Taguchi N, Watanabe S. A silicone-based wire-reinforced tracheal tube with a hemispherical bevel reduces nasal morbidity for nasotracheal intubation. Anesth Analg. 2003; 97:1488–91.
37. Kim H, Lee JM, Lee J, Hwang JY, Chang JE, No HJ, et al. Effect of neck extension on the advancement of tracheal tubes from the nasal cavity to the oropharynx in nasotracheal intubation: a randomized controlled trial. BMC Anesthesiol. 2019; 19:158.
38. Horton WA, Fahy L, Charters P. Defining a standard intubating position using "angle finder". Br J Anaesth. 1989; 62:6–12.
39. Vivian V, van Zundert AA. Nasotracheal intubation and epistaxis. Anaesthesia. 2016; 71:722–3.
40. Zhang J, Lamb A, Hung O, Hung C, Hung D. Blind nasal intubation: teaching a dying art. Can J Anaesth. 2014; 61:1055–6.
41. Dubey PK, Dubey P, Kumar N, Bhardwaj G, Kumar N. Blind nasal intubation revisited: no longer a blind technique? J Emerg Med. 2017; 52:231–4.
42. Jones PM, Armstrong KP, Armstrong PM, Cherry RA, Harle CC, Hoogstra J, et al. A comparison of glidescope videolaryngoscopy to direct laryngoscopy for nasotracheal intubation. Anesth Analg. 2008; 107:144–8.
43. Puchner W, Drabauer L, Kern K, Mayer C, Bierbaumer J, Rehak PH, et al. Indirect versus direct laryngoscopy for routine nasotracheal intubation. J Clin Anesth. 2011; 23:280–5.
44. Lim D, Ma BC, Parumo R, Shanmuhasuntharam P. Thirty years of submental intubation: a review. Int J Oral Maxillofac Surg. 2018; 47:1161–5.
45. Kwon MA, Song J, Kim S, Ji SM, Bae J. Inspection of the nasopharynx prior to fiberoptic-guided nasotracheal intubation reduces the risk epistaxis. J Clin Anesth. 2016; 32:7–11.
46. Park YH, Choi YJ, Choi WC, Lee UL. Partially withdrawn nasotracheal tube: an alternative to the nasal trumpet. Anesth Prog. 2015; 62:166–7.
47. Halligan M, Charters P. A clinical evaluation of the Bonfils intubation fibrescope. Anaesthesia. 2003; 58:1087–91.
48. Byhahn C, Nemetz S, Breitkreutz R, Zwissler B, Kaufmann M, Meininger D. Brief report: tracheal intubation using the Bonfils intubation fibrescope or direct laryngoscopy for patients with a simulated difficult airway. Can J Anaesth. 2008; 55:232–7.
49. Iseki K, Murakawa M, Tase C, Otsuki M. Use of a modified lightwand for nasal intubation. Anesthesiology. 1999; 90:635.
50. Dong Y, Li G, Wu W, Su R, Shao Y. Lightwand-guided nasotracheal intubation in oromaxillofacial surgery patients with anticipated difficult airways: a comparison with blind nasal intubation. Int J Oral Maxillofac Surg. 2013; 42:1049–53.
51. Abrons RO, Vansickle RA, Ouanes JP. Seldinger technique for nasal intubation: a case series. J Clin Anesth. 2016; 34:609–11.
52. Mahajan R, Ahmed P, Shafi F, Bassi R. Dual bougie technique for nasotracheal intubation. Anesth Prog. 2012; 59:85–6.
53. Arisaka H, Sakuraba S, Furuya M, Higuchi K, Yui H, Kiyama S, et al. Application of gum elastic bougie to nasal intubation. Anesth Prog. 2010; 57:112–3.
54. Cooper RM. Conversion of a nasal to an orotracheal intubation using an endotracheal tube exchanger. Anesthesiology. 1997; 87:717–8.
55. McKay WP, Klonarakis J, Pelivanov V, O'Brien JM, Plewes C. Tracheal palpation to assess endotracheal tube depth: an exploratory study. Can J Anaesth. 2014; 61:229–34.
56. Ji SM. Estimation of optimal nasotracheal tube depth in adult patients. J Dent Anesth Pain Med. 2017; 17:307–12.
57. Okuyama M, Imai M, Sugawara K, Okuyama A, Kemmotsu O. [Finding appropriate tube position by the cuff palpation method in children]. Masui. 1995; 44:845–8. Japanese.
58. Pollard RJ, Lobato EB. Endotracheal tube location verified reliably by cuff palpation. Anesth Analg. 1995; 81:135–8.
59. Dennington D, Vali P, Finer NN, Kim JH. Ultrasound confirmation of endotracheal tube position in neonates. Neonatology. 2012; 102:185–9.
60. Massoth C, Schülke C, Köppe J, Weiss R, Pöpping D, Dahrmann M, et al. Nasolaryngeal distances in the adult population and an evaluation of commercially available nasotracheal tubes. Anesth Analg. 2020; 130:1018–25.
61. Koshika K, Hoshino T, Shibata Y, Ouchi T, Koitabashi T. New device for securing nasotracheal intubation tube during oral and maxillofacial surgery. Bull Tokyo Dent Coll. 2020; 61:275–9.
62. Phipps LM, Thomas NJ, Gilmore RK, Raymond JA, Bittner TR, Orr RA, et al. Prospective assessment of guidelines for determining appropriate depth of endotracheal tube placement in children. Pediatr Crit Care Med. 2005; 6:519–22.
63. Weiss M, Balmer C, Dullenkopf A, Knirsch W, Gerber ACh, Bauersfeld U, et al. Intubation depth markings allow an improved positioning of endotracheal tubes in children. Can J Anaesth. 2005; 52:721–6.
64. Goel S, Lim SL. The intubation depth marker: the confusion of the black line. Paediatr Anaesth. 2003; 13:579–83.
65. Conrardy PA, Goodman LR, Lainge F, Singer MM. Alteration of endotracheal tube position. Flexion and extension of the neck. Crit Care Med. 1976; 4:8–12.
66. Donn SM, Kuhns LR. Mechanism of endotracheal tube movement with change of head position in the neonate. Pediatr Radiol. 1980; 9:37–40.
67. Oji M, Koyama Y, Oshika H, Kohno M, Nakahashi Y, Fukushima S, et al. Effect of endotracheal tube lubrication on cuff pressure increase during nitrous oxide exposure: a laboratory and prospective randomized controlled trial. BMC Anesthesiol. 2019; 19:169.
68. Bradford KE, Siegelman LI, Psoter WJ. The effects of mouth opening and throat pack placement on uncuffed nasal endotracheal tube leakage and delivered tidal volumes in mechanically ventilated pediatric patients undergoing dental procedures. Anesth Prog. 2018; 65:237–43.
69. Yao K, Goto K, Nishimura A, Shimazu R, Tachikawa S, Iijima T. A formula for estimating the appropriate tube depth for intubation. Anesth Prog. 2019; 66:8–13.
70. Hosseinzadeh H, Taheri Talesh K, Golzari SE, Gholizadeh H, Lotfi A, Hosseinzadeh P. Warming endotracheal tube in blind nasotracheal intubation throughout maxillofacial surgeries. J Cardiovasc Thorac Res. 2013; 5:147–51.
71. Kim EM, Chung MH, Lee MH, Choi EM, Jun IJ, Yun TH, et al. Is tube thermosoftening helpful for videolaryngoscope-guided nasotracheal intubation?: a randomized controlled trial. Anesth Analg. 2019; 129:812–8.
72. Sanuki T, Hirokane M, Matsuda Y, Sugioka S, Kotani J. The Parker Flex-Tip tube for nasotracheal intubation: the influence on nasal mucosal trauma. Anaesthesia. 2010; 65:8–11.
73. Xue FS, Xiong J, Yuan YJ, Wang Q. The Parker Flex-Tip tube for nasotracheal intubation. Anaesthesia. 2010; 65:417; author reply 417-8.
74. Earle R, Shanahan E, Vaghadia H, Sawka A, Tang R. Epistaxis during nasotracheal intubation: a randomized trial of the Parker Flex-Tip™ nasal endotracheal tube with a posterior facing bevel versus a standard nasal RAE endotracheal tube. Can J Anaesth. 2017; 64:370–5.
75. Lee JH, Kim CH, Bahk JH, Park KS. The influence of endotracheal tube tip design on nasal trauma during nasotracheal intubation: Magill-tip versus Murphy-tip. Anesth Analg. 2005; 101:1226–9.
76. Collins SR. Direct and indirect laryngoscopy: equipment and techniques. Respir Care. 2014; 59:850–62; discussion 862-4.
77. Doherty JS, Froom SR, Gildersleve CD. Pediatric laryngoscopes and intubation aids old and new. Paediatr Anaesth. 2009; 19 Suppl 1:30–7.
78. Kaplan MB, Hagberg CA, Ward DS, Brambrink A, Chhibber AK, Heidegger T, et al. Comparison of direct and video-assisted views of the larynx during routine intubation. J Clin Anesth. 2006; 18:357–62.
79. Rajendram R, Kale V. The use of advanced airway management devices in clinical practice. Eur J Anaesthesiol. 2016; 33:469–70.
80. Kido H, Komasawa N, Ishio J, Minami T. Use of a modified McGRATH MAC and tracheal tube introducer for difficult nasal intubation. J Clin Anesth. 2016; 34:255–6.
81. Arslan Zİ, Türkyılmaz N. Which nostril should be used for nasotracheal intubation with Airtraq NT®: the right or left? A randomized clinical trial. Turk J Med Sci. 2019; 49:116–22.
82. Agrò F, Hung OR, Cataldo R, Carassiti M, Gherardi S. Lightwand intubation using the Trachlight: a brief review of current knowledge. Can J Anaesth. 2001; 48:592–9.
83. Manabe Y, Seto M, Iwamoto S, Tominaga S, Taniguchi S. The success rate of nasotracheal intubation using lightwand does not depend on the laryngoscopic view. J Anesth. 2011; 25:350–5.
84. Liberman H. A new intubating forceps. Anaesth Intensive Care. 1978; 6:162–3.
85. Sim L, Patel A, Enderby D. Modified Magill's forceps revisited. Anaesthesia. 2004; 59:97.
86. Boedeker BH, Bernhagen MA, Miller DJ, Doyle DJ. Comparison of the Magill forceps and the Boedeker (curved) intubation forceps for removal of a foreign body in a Manikin. J Clin Anesth. 2012; 24:25–7.
87. Munshey FN, Gamble JJ, McKay WP. Modified pediatric Magill forceps effect on nasal intubation time. Paediatr Anaesth. 2016; 26:221–2.
88. Driver BE, Prekker ME, Klein LR, Reardon RF, Miner JR, Fagerstrom ET, et al. Effect of use of a bougie vs endotracheal tube and stylet on first-attempt intubation success among patients with difficult airways undergoing emergency intubation: a randomized clinical trial. JAMA. 2018; 319:2179–89.
89. Bączek M, Zagańczyk-Bączek M. Flexible tip bougie - the new introducer for intubation during cardiopulmonary resuscitation: a randomized crossover manikin study. Medicine (Baltimore). 2020; 99:e18452.
90. Seo KS, Kim JH, Yang SM, Kim HJ, Bahk JH, Yum KW. A new technique to reduce epistaxis and enhance navigability during nasotracheal intubation. Anesth Analg. 2007; 105:1420–4.
91. Elwood T, Stillions DM, Woo DW, Bradford HM, Ramamoorthy C. Nasotracheal intubation: a randomized trial of two methods. Anesthesiology. 2002; 96:51–3.
92. Watt S, Pickhardt D, Lerman J, Armstrong J, Creighton PR, Feldman L. Telescoping tracheal tubes into catheters minimizes epistaxis during nasotracheal intubation in children. Anesthesiology. 2007; 106:238–42.
93. Morimoto Y, Sugimura M, Hirose Y, Taki K, Niwa H. Nasotracheal intubation under curve-tipped suction catheter guidance reduces epistaxis. Can J Anaesth. 2006; 53:295–8.
94. Dougherty TB, Nguyen DT. Anesthetic management of the patient scheduled for head and neck cancer surgery. J Clin Anesth. 1994; 6:74–82.
95. Nagarkar R, Kokane G, Wagh A, Kulkarni N, Roy S, Tandale R, et al. Airway management techniques in head and neck cancer surgeries: a retrospective analysis. Oral Maxillofac Surg. 2019; 23:311–5.
Full Text Links
  • APM
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr