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Nasotracheal Intubation

Overview. Indications/ContraindicationsBasic techniqueAdjusting placement. Nasotracheal Intubation. IndicationsNeed for definitive airway and oral access not an option (trismus, trauma, etc)Imminent resp failure (concerned about RSI)Unable to align for oral intubationContraindicationsApneaNasal/maxillofacial trauma (*?basal skull

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Nasotracheal Intubation

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    1. Nasotracheal Intubation Steve Lan

    2. Overview Indications/Contraindications Basic technique Adjusting placement

    3. Nasotracheal Intubation Indications Need for definitive airway and oral access not an option (trismus, trauma, etc) Imminent resp failure (concerned about RSI) Unable to align for oral intubation Contraindications Apnea Nasal/maxillofacial trauma (*?basal skull #) Coagulopathy

    4. Complications Epistaxis Vomit/aspiration

    5. Set Up “Awake” intubation, usually sitting “sniffing” position Tube 0.5-1.0mm smaller than for oral Topical anesthesia, vasoconstrictor, ++lube Usual monitors

    6. Technique Advance tube with bevel towards septum Straight back Slight twisting action Don’t force it! “Give” at 6-7cm as tube goes past 90 degree turn

    7. Technique Auscultate proximal end listening for breath sounds May also see fogging Loudest point should be just in front of laryngeal inlet Advance during inspiration Males: 28cm at nares, women: 26cm

    8. Where did it go? Operating Room study found <50% trachea placement on first try Possible placements: Anterior to epiglottis (vallecula) Piriform fossa Esophagus

    9. Where did it go?

    10. Tube Placement – In Trachea Breath sounds persist Able to advance tube Coughing No voice

    11. Tube Placement – Anterior to Epiglottis Signs Tube gets stuck ~15cm Breath sounds may continue Cough “through tube” Adjustment Pull back 2 cm Slightly flex neck

    12. Tube Placement – Piriform sinus Signs Tube gets stuck Breath sounds stop, no cough reflex Pt able to phonate Bulge to lateral neck above larynx Adjustment Pull back tube Slight twist away from bulge and advance

    13. Tube Placement – Esophagus Signs No breath sounds Tube can still be advanced No cough Pt able to vocalize Adjustment Pull back tube, slightly extend neck Slight pressure to larynx Stick tongue out

    14. Another Trick (if c-spine is a concern) Pull back 1cm from point where breath sounds are lost Inflate cuff with 15cc

    15. Another possible problem Tube caught on aretynoid cartilage Pull back Rotate tube 90 degrees (bevel posterior) and advance

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