A left bevelled tube is easier inserted from the right side

Impact of choice of nostril on nasotracheal intubation when using video rigid stylet: a randomized clinical trial

BACKGROUND

Patients undergoing oral and maxillofacial surgeries under general anesthesia usually require nasotracheal intubation. When presented with patients with equally patent nostrils, selection of the nostril to use for intubation is an important decision for facilitating intubation. The objective of this trial is to determine whether choice of nostril impacts nasotracheal intubation when using a video rigid stylet in patients undergoing oral and maxillofacial surgery.

METHODS

Fifty patients scheduled for elective oral and maxillofacial surgery requiring nasotracheal intubation were randomly allocated into two groups to undergo nasotracheal intubation through the left nostril (Group L, n = 25) or the right nostril (Group R, n = 25). Intubation was performed by experienced anesthesiologists using a video rigid stylet. The primary endpoint was time to successful intubation, which was defined as the duration from when the tip of the stylet-tube assembly entered the selected nostril to when the tube entered the trachea. Secondary outcomes included: length of time for device insertion; length of time for tube insertion; total success rate; first-attempt success rate; number of intubation attempts; requirement of airway assisted maneuvers; incidence and severity of epistaxis. Intubation-related adverse events were monitored for up to postoperative 24 h.

RESULTS

Median time (interquartile range) to tracheal intubation was 25.3 seconds (20.7 to 27.6) in Group L and 26.8 seconds (22.5 to 30.0) in Group R (median difference (MD) = 1.9; 95% confidence interval (CI) -1.8 to 5.7, P = 0.248). Nasotracheal intubation was successful in all patients in both groups and the first-attempt success rates in both groups were similar (Group L: 96% (24/25); Group R: 96% (24/25); relative risk (RR) 1.0; 95% CI 0.9 to 1.1; P > 0.999). No significant difference of requirement of assisted maneuvers was noted between the two groups (Group L: 36% (9/25); Group R: 28% (7/25); RR 0.8; 95% CI 0.3-1.8; P = 0.544). Furthermore, all patients showed a high quality of visualization of the glottis (Cormack and Lehane Grade I). For safety outcomes, the incidence and severity of epistaxis during intubation was comparable between the two groups. There were no significant differences between the selection of nostrils and intubation-related adverse events up to 24 h after surgery.

CONCLUSIONS

When considering which nostril to use for intubation with video rigid stylet, either nostril can be used similarly.

TRIAL REGISTRATION

Clinicaltrials.gov . Identifier: NCT05218590.

Validation of Simple Methods to Select a Suitable Nostril for Nasotracheal Intubation

Background

Nasotracheal intubation is a blind procedure that may lead to complications; therefore, several tests were introduced to assess a suitable nostril for nasotracheal intubation. However, the value of simple tests in clinical practice was insufficient to evaluate.

Method

A diagnostic prospective study was conducted in 42 patients, ASA classes I–III, undergoing surgery requiring nasotracheal intubation for general anesthesia. Two simple methods for assessing the patency of nostrils were investigated. Firstly, the occlusion test was evaluated by asking for the patient's own assessment of nasal airflow during occlusion of each contralateral nostril while in a sitting posture. Secondly, patients breathed onto a spatula held 1 cm below the nostrils while in a sitting posture. All patients were assessed using these two simple tests. Nasal endoscopic examination of each patient was used as a gold standard.

Results

The diagnostic value of the occlusion test (sensitivity of 91.7%, specificity of 61.1%, PPV of 75.9%, NPV of 84.6%, LR+ of 2.36, and LR− of 0.14) seemed better than that of the spatula test (sensitivity of 95.8%, specificity of 25.0%, PPV of 63.0%, NPV of 81.8%, LR+ of 1.28, and LR− of 0.17). When both tests were combined in series, the diagnostic value increased (sensitivity of 87.9%, specificity of 70.8%, PPV of 80.1%, NPV of 81.4%, LR+ of 3.01, and LR− of 0.17).

Conclusion and Recommendations

The simple occlusion test is more useful than the spatula test. However, combining the results from both tests in series helped to improve the diagnostic value for selecting a suitable nostril for nasotracheal intubation.