Directional-tip endotracheal tubes for blind nasotracheal intubation

Blind nasal intubation as an alternative to difficult intubation approaches

Airway difficulties are a major concern for anesthesiologists. Even though fiberoptic intubation is the generally accepted method for management of difficult airways, it is not without disadvantages-requires patient cooperation, and cannot be performed on soiled airway or upper airways with pre-existing narrowing pathology. Additionally, fiberoptic bronchoscopy is not available at every medical institution. In this case, we encountered difficult airway management in a 71-year-old man with a high Mallampati grade and a thick neck who had undergone urologic surgery. Several attempts, including a bronchoscope-guided intubation, were unsuccessful. Finally, blind nasal intubation was successful while the patient's neck was flexed and the tracheal cartilage was gently pressed down. We suggest that blind nasal intubation is a helpful alternative in difficult airway management and it can be a lifesaving technique in emergencies. Additionally, its simplicity makes it a less expensive option when advanced airway technology (fiberoptic bronchoscopy) is unavailable.

Blind nasotracheal intubation is facilitated by neutral head position and endotracheal tube cuff inflation in spontaneously breathing patients

PURPOSE

To evaluate, using an endotracheal tube mounted on a flexible lighted stylet, how the patient's head-neck position and inflation of the endotracheal cuff affect correct alignment of the tube tip with the glottis.

METHODS

Eighty-two patients were enrolled. The course of the endotracheal tube in the pharynx was examined by observing the anterior neck for transillumination in each patient under four different intubating conditions. These were: patient's head on pad (8 cm) with the cuff deflated (HP-deflation group); patient's head on pad with the cuff inflated (HP-inflation group); patient's head on bed with the cuff deflated (HB-deflation group); and patient's head on bed with the cuff inflated (HB-inflation group).

RESULTS

Both a head on bed (neutral) position or endotracheal tube cuff inflation (15 mL of air) significantly increased the frequency of correct alignment of the tip of the endotracheal tube with the glottis. Blind nasotracheal intubation (BNTI) was successful in 69 patients (84%). Lightwand-assisted nasotracheal intubation was required in 11 of the remaining 13 patients (13%) and fibreoptic bronchoscopy-assisted intubation was performed in the last two patients.

CONCLUSION

A neutral position of the head combined with endotracheal tube cuff inflation is recommended for BNTI.

Paramedic success rate for blind nasotracheal intubation is improved with the use of an endotracheal tube with directional tip control

STUDY OBJECTIVES

Blind nasotracheal intubation (BNTI) is used to secure the airway in patients who are spontaneously breathing. The success rate for BNTI is often lower than for orotracheal intubation. We conducted this study to determine whether the use of an endotracheal tube (ETT) capable of directional tip control can improve the BNTI success rate.

METHODS

This prospective, experimental study was conducted by a state emergency medical services agency during 1997, 1998, and 1999. Consecutive patients undergoing attempted BNTI or orotracheal intubation were included. Five paramedic units were trained to use an ETT with triggeractivated distal tip directional control for BNTIs (intervention group). Ten units used conventional ETTs for BNTIs and served as concurrent controls (control group). Subjects in the 2 groups were enrolled concurrently with nonrandomized allocation based on the agency providing service. An intubation attempt was defined by tube passage, and success was defined as confirmed endotracheal placement.

RESULTS

A total of 219 BNTIs were studied (141 in the control group and 78 in the intervention group). BNTI was successful in 82 (58%) of 141 cases using conventional ETTs, and in 56 (72%) of 78 cases using directional tip control (P =.04). The overall success rate was 63%.

CONCLUSION

Use of ETTs with distal directional control is associated with a higher success rate for BNTI than conventional ETTs. Use of ETTs with directional tip control significantly improves the success rates for BNTIs.