North Polar Tube Reduces the Risk of Epistaxis during Nasotracheal Intubation: A prospective, Randomized Clinical Trial

Nasotracheal intubation in pediatrics: a narrative review

Nasotracheal intubation (NTI) plays an important role in pediatric airway management, offering advantages in specific situations, such as oral and maxillofacial surgery and situations requiring stable tube positioning. However, compared to adults, NTI in children presents unique challenges owing to anatomical differences and limited space. This limited space, in combination with a large tongue and short mandible, along with large tonsils and adenoids, can complicate intubation. Owing to the short tracheal length in pediatric patients, it is crucial to place the tube at the correct depth to prevent it from being displaced due to neck movements, and causing injury to the glottis. The equipment used for NTI includes different tube types, direct laryngoscopy vs. video laryngoscopy, and fiberoptic bronchoscopy. Considering pediatric anatomy, the advantages of video laryngoscopy have been questioned. Studies comparing different techniques have provided insights into their efficacy. Determining the appropriate size and depth of nasotracheal tubes for pediatric patients remains a challenge. Various formulas based on age, weight, and height have been explored, including the recommendation of depth-mark-based NTI. This review provides a comprehensive overview of NTI in pediatric patients, including the relevant anatomy, equipment, clinical judgment, and possible complications.

Experimental Analysis of the Efficiency and Usability of Tylke Versus Magill Forceps

INTRODUCTION

The procedure of nasotracheal intubation (NI) has long been performed utilizing the Magill forceps as developed by Sir Ivan Magill in the 1920s. While used for nearly a century, several serious patient safety concerns remain including torn tube cuffs, vocal cord trauma, and inefficient tube placement. The Tylke forceps have been developed as a modification to the largely unchanged form of Magill forceps.

METHODS

In the present investigation we compared the efficacy, number of clasps, and muscle activation involved in NI using the Tylke forceps versus the Magill forceps in previously untrained individuals.

RESULTS

Tylke forceps showed faster successful NI over the standard Magill forceps at an average intubation time of 6.54s vs. 13.73s, respectively. Tylke forceps also had fewer clasps per intubation over the Magill. The trapezius, deltoid, and brachioradialis muscle activation was also compared in Tylke vs Magill forceps intubation trials. Tylke forceps required less lower muscle activation in the brachioradialis and trapezius over the Magill forceps with Tylke forceps resulting in higher deltoid muscle activation.

CONCLUSION

Tylke forceps were more efficacious and reduced the number of clasps over the Magill forceps when used in successful NI with different muscle activation patterns.

Comparison of Success Rate and Safety of Nasotracheal Intubation by Conventional and Finger-Guided Method in Patients Undergoing Maxillofacial Surgery

Background

Different techniques have been introduced to reduce the complications of nasotracheal intubation. The aim of this study was to compare the incidence of nasotracheal intubation complications in finger-guided and conventional methods.

Materials and Methods

In this double-blind randomized trial study, 70 patients who were candidates for oral and maxillofacial surgery who required nasal intubation were included in the study finally of which 33 patients with conventional method and 35 patients with finger-guided tubes in the nasopharynx were analyzed at the end of the study. Variables such as success rate, hemodynamic response, and complications of intubation were compared between the two groups.

Results

There was no significant difference between the two groups in terms of hemodynamic response to intubation (P > 0.05). There was a significant difference between the two groups in terms of success in tracheal intubation (P < 0.05). There was a significant difference between the two groups in terms of epistaxis immediately after intubation (P < 0.05). There was no significant difference between the two groups in terms of nasal turbine fractures (P > 0.05). However, the frequency of submucosal intubation in the conventional method was significantly higher than the other group (P = 0.02).

Conclusion

Nasotracheal intubation using the finger guiding technique in the nasopharynx is associated with a higher success rate and less complications after intubation such as epistaxis and submucosal intubation compared to the conventional method.

Ephedrine pretreatment for nasotracheal intubation-related epistaxis in maxillofacial surgery with sufficient lubrication: A randomized clinical trial

WHAT IS KNOWN AND OBJECTIVE

Prior to nasotracheal intubation (NTI), topical nasal vasoconstrictors are used to prevent NTI-related epistaxis (NTIRE). Since we learned that there is no significant increase in NTIRE among hypertensive patients undergoing NTI with adequate lubrication but without vasoconstrictors, we initiated this randomized controlled study to assess the necessity of vasoconstrictor use in reducing NTIRE.

METHODS

Patients with the American Society of Anesthesiologists Physical Status Classification 1 and normal coagulation function, planned to undergo maxillofacial surgery with NTI were enrolled. Patients were randomly (1:1) assigned to each of the treatment groups: nasal treatment using pure oxybuprocaine gel with adequate lubrication (group G) or 1% ephedrine in addition to oxybuprocaine gel with adequate lubrication (group EG). In addition, the incidence and severity of NTIRE and intubation adjustments were studied.

RESULTS

A total of 844 patients, 429 and 415 (groups G and EG, respectively), were included in the analysis. No significant differences were observed in the NTIRE incidence rates in groups G (28%) and EG (27%; p = 0.75, relative risk [RR] = 0.95, 95% confidence interval [CI] 0.70-1.29). No significant differences in the NTIRE incidence rates between the two nostrils were observed in both groups (group G: left, 27.9% vs. right, 28% [p = 0.98, RR = 1.01, 95% CI 0.67-1.51]; group EG: left, 25.8% vs. right, 27.9% [p = 0.63, RR = 1.12, 95% CI 0.72-1.73]. No significant difference was observed in the severity of NTIRE (p = 0.74). In case of difficult advancement of the endotracheal tube, NTIRE incidence was 71% vs. 12% with smooth intubation (p < 0.01, RR = 18.33, 95% CI 12.55-26.77).

WHAT IS NEW AND CONCLUSION

Well-lubricated nasotracheal intubation does not require pretreatment with ephedrine to reduce NTIRE.

A comparison of McGrath MAC, Pentax AWS, and Macintosh direct laryngoscopes for nasotracheal intubation: a randomized controlled trial

Purpose

Videolaryngoscopy in nasotracheal intubation has been reported to be better than direct laryngoscopy. The most suitable type of videolaryngoscope remains unknown. This study aimed to compare two videolaryngoscopes (McGrath MAC and Pentax AWS) with a Macintosh laryngoscope during nasotracheal intubation.

Methods

Overall, 123 patients older than 18 with normal airways who needed nasotracheal intubation were randomly allocated into three groups: Macintosh (n=41), McGrath (n=41), and Pentax (n=41). Intubation time was the primary outcome and subdivided into three steps: nose to oropharynx, oropharynx to laryngeal inlet, and laryngeal inlet to trachea. Time required, ease of each step, glottic view grade, modified nasal intubation–difficulty score, and subjective difficulty were evaluated.

Results

Intubation time among the three groups was not significantly different (Macintosh 34.6±8.1 seconds, McGrath 35.2±7.9 seconds, Pentax 36.2±9.7 seconds; p=0.727). While the glottal view was better with videolaryngoscopes (I/IIa/IIb/III 36.6%/36.6%/19.5%/7.3% vs 82.9%/9.8%/7.3%/0%, vs 63.4%/29.3%/4.9%/2.4%, p=0.000), modified nasal intubation–difficulty score and subjective difficulty and ease of each step were not significantly different. However, the Pentax took longest for the second step (11.8±6.3 vs 10.3±3.5 vs 15.1±7.6 seconds, p=0.001) but was shortest for the third step (2.9±2.6 vs 4.4±5.6 vs 1.7±0.7 seconds, p=0.001).

Conclusion

The McGrath MAC and Pentax AWS showed no benefits in intubation time or difficulty, despite better glottal views, compared to the Macintosh laryngoscope in nasotracheal intubation. Additionally, videolaryngoscopes had variable performance at different steps of nasotracheal intubation.