Nasal Intubation

Nasal intubation is a form of endotracheal intubation where the tube is passed through one of the nares as opposed to the usual route through the mouth. 

Indications, Contraindications, Complications, and Limitations

Many of the same indications, contraindications, and complications as traditional endotracheal intubation apply to nasal intubation. Those factors are reviewed in detail in the section "Endotracheal intubation." The factors that differ are discussed here.

INDICATIONS: Nasal intubation is performed in patients for whom intubation is indicated, but direct laryngoscopy is contraindicated due to facial trauma, soft tissue swelling in the oropharynx, or an anticipated difficult airway that requires the patient to be awake during the process of intubation.

CONTRAINDICATIONS: The contraindications of nasal intubation differ from direct laryngoscopy in that factors relating to swelling of the mouth/face are no longer concerns. However, nasal intubation adds the following contraindications: Suspected basilar skull fracture, CSF rhinorrhea, nasal polyps, or known bleeding disorder. The other contraindications of standard endotracheal intubation still apply.

COMPLICATIONS: The complications of nasal intubation are largely identical to standard direct laryngoscopy, minus the risks to the teeth, gums, and tongue. Nasal intubation adds several complications unique to the nose: Infection of the sinuses, epistaxis (nosebleed), and a slight increase in the risk of tube occlusion during insertion.

LIMITATIONS: Laryngeal pathology will limit nasal intubation effectiveness, just as with all other endotracheal methods. The risk of brain trauma in patients with basilar skull fractures must not be underestimated, especially since this is usually an intervention of choice in facial trauma patients. Patients with a history of a deviated septum may be difficult to intubate nasally. This may also be a contraindication in some jurisdictions. 

Procedure

The procedure for nasal intubation is as follows:

1. Explain the procedure to conscious patients.
2. Preoxygenate the patient with 100% O2 for 30 seconds
3. While oxygenating the patient, assemble the correct equipment, including suction, safety glasses, the correct-sized ET tube (making sure to choose the Endotrol style, not the standard ET style), syringes to inflate the pilot balloon on the tube, ETCO2 device, means to secure the tube after intubation, and water-soluble lubrication. A whistle device such as a BAAM (Beck Airway Airflow Monitor) is also very useful during nasal intubation.
4. Check the ability of the tube cuff to fully inflate.
5. Open the patient’s airway or remove the present adjunct, insert the lubricated tube (no stylet should be in place) into the R nostril (or whichever nostril is not deviated) with the bevel toward the septum, taking care to insert it smoothly and to follow the nasopharynx down into the hypopharynx and then into the laryngopharynx. Do not force the tube and do not insert toward the top of the head (which can cause severe bleeding and is very painful).
6. Gently pull the controllable tip handle on the Endotrol, sending the tip of the tube anterior into the trachea.

7. Once the tube is hovering over the epiglottis, (if using a BAAM whistle you should hear a loud sharp whistling noise during each exhale,) instruct the patient to take a deep breath in.

   • During inspiration, the epiglottis closes over the esophagus and allows for direct placement into the trachea between the vocal cords. If the tube is placed correctly, an even louder, sharper whistle should be heard through the BAAM upon exhalation, and the patient should not be able to talk. Ask them to speak their name if conscious; if they cannot produce sound, the tube is correctly placed. If resistance is met, the provider should roll the tube between their fingers causing the distal tip to gently move from side to side, while continuing to advance the tube upon patient inspiration.

8. Once the tube is placed, remove the BAAM whistle, and inflate the pilot balloon with the manufacturer-suggested amount of air.

9. Confirm tube placement, secure the tube, and monitor the security of the tube in route. The procedure to confirm tube placement is reviewed in the section "endotracheal intubation."

Post-intubation reassessment and management 

Immediately following intubation carefully monitor every vital sign as countless complications are possible; heart rate, blood pressure, SPO2, ETCO2, and respiratory rate are all critical. 

Following the immediate post-intubation period, use the mnemonic DOPE for factors that could affect your now intubated patient while they are in transit.

• D – Displacement/Dislodged tube.
• O – Obstruction or clamped tube.
• P – Placement in the R mainstem bronchus or esophagus.
• E –Equipment: the tube or other equipment may have malfunctioned requiring replacement.