The polyurethane nasotracheal tube

Nasal intubation: A comprehensive review

Nasal intubation technique was first described in 1902 by Kuhn. The others pioneering the nasal intubation techniques were Macewen, Rosenberg, Meltzer and Auer, and Elsberg. It is the most common method used for giving anesthesia in oral surgeries as it provides a good field for surgeons to operate. The anatomy behind nasal intubation is necessary to know as it gives an idea about the pathway of the endotracheal tube and complications encountered during nasotracheal intubation. Various techniques can be used to intubate the patient by nasal route and all of them have their own associated complications which are discussed in this article. Various complications may arise while doing nasotracheal intubation but a thorough knowledge of the anatomy and physics behind the procedure can help reduce such complications and manage appropriately. It is important for an anesthesiologist to be well versed with the basics of nasotracheal intubation and advances in the techniques. A thorough knowledge of the anatomy and the advent of newer devices have abolished the negative effect of blindness of the procedure.

Comparison of 4% and 6% topical cocaine solutions for reduction of epistaxis induced by nasotracheal intubation

BACKGROUND

Nasotracheal intubation (NTI) provides a good field for surgeons in patients undergoing oromaxillofacial surgery; however, NTI is often complicated by epistaxis. The aim of this study was to compare the efficacy of 4% and 6% topical cocaine solutions in reducing epistaxis during NTI.

METHODS

A total of 79 patients (16-65 years old) undergoing oromaxillofacial surgery were randomly assigned to two groups treated with either 4% cocaine (n = 39) or 6% cocaine (n = 40). Topical cocaine (1 mL) was sprayed onto the selected nasal cavity prior to NTI. All intubations were performed by an expert anesthesiologist using a GlideScope. The incidence and severity of epistaxis was examined along the nasal cavity up to the nasopharynx using a fiber optic bronchoscope. The hemodynamic responses to stimuli during the peri-NTI period were also recorded.

RESULTS

The incidence of epistaxis was 43.59% (17/39) in the 4% cocaine group and 50% (20/40) in the 6% cocaine group (p = 0.57). The severity of epistaxis did not differ between the two groups (p = 0.46). High resistance during NTI and epistaxis were closely correlated and the major bleeding sites were located at the nasopharynx. Compared with the 4% cocaine group, treatment with 6% cocaine resulted in a higher heart rate and mean arterial pressure (both p < 0.05). There was no statistically significance difference between the two groups with respect to the hemodynamic responses to NTI.

CONCLUSION

The spraying of either 4% or 6% topical cocaine into the nasal cavity gives comparable effects for intubation-related epistaxis. However, 6% cocaine may increase the hemodynamic responses while being sprayed. Therefore spraying with 4% topical cocaine had advantages with respect to 6% cocaine and is recommended for use prior to NTI.

Nasotracheal intubation for head and neck surgery

Nasotracheal intubation offers the head and neck surgeon more scope for surgical manoeuvre in operations of the mouth, pharynx, larynx and also the neck. Concern over the complications of using this route of intubation and lack of training may be limiting its use. A thorough knowledge of the anatomy, benefits of using nasal vasoconstrictors and attention to technique are prerequisites to maintaining the skill. This article reviews each of these topics and aims to encourage the appropriate use of nasotracheal intubation in current practice.

Thermosoftening treatment of the nasotracheal tube before intubation can reduce epistaxis and nasal damage

We evaluated whether a thermosoftening treatment with warm saline of a nasotracheal preformed tube can improve navigability through the nasal passageways and reduce epistaxis and nasal damage. A total of 150 patients were randomly allocated to three groups: Group I (untreated tube group, n = 50), Group II (35 degrees C treated tube group, n = 50), and Group III (45 degrees C treated tube group, n = 50). In Groups II and III, the tubes were softened at 35 +/- 2 degrees C and 45 +/- 2 degrees C with warm saline, respectively. In Group I the tube was prepared at room temperature (25 +/- 2 degrees C). The incidence of epistaxis and nasal damage in Groups II and III was significantly less than that of Group I (P: < 0.05). Despite the more frequent incidence of smooth passage in Group III, no statistical difference was found among the groups. Logistic regression analysis also confirmed that epistaxis was more likely to be reduced when the tube had been thermosoftened (odds ratio = 1.46, 95% confidence interval = 1.02, 2.11). We conclude that simple thermosoftening treatment of the nasotracheal tube with warm saline helps to reduce epistaxis and nasal damage.

IMPLICATIONS

Thermosoftening treatment of a nasotracheal tube with warm saline before intubation can effectively reduce epistaxis and nasal damage. This technique is safe, easy, and suitable for all types of tubes and does not require additional implements.