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From the Department of Dental Anesthesiology, Graduate School of Dentistry, Osaka University, Suita, Osaka, Japan.
Address correspondence to: Dr. Yoshinari Morimoto, Department of Dental Anesthesiology, Graduate School of Dentistry, Osaka University, 1-8, Yamadaoka, Suita, Osaka 565-0871, Japan. Phone: +81 6 6879 2972; Fax: +81 6 6879 2975; E-mail: ysn-mori{at}dent.osaka-u.ac.jp
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Abstract |
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Methods: Subjects comprised 131 adult patients who under-went NTI. Subjects were randomly divided into two groups: a) NTI under CTSC guidance (G[+] group). The CTSC (14 Fr) was first inserted through the tracheal tube, with the tip of the CTSC emerging from the distal end of the tube. The curved tip was directed ventrally. Both tracheal tube and CTSC were advanced together through the nasopharynx; b) NTI without CTSC guidance (G[–] group). The tracheal tube was advanced into the nasal cavity and passed into the pharynx without CTSC guidance. The time required to pass the endotracheal tube through the nasal cavity (nasal passage time), success rate of nasal passage with nasotracheal tube, and the incidence and severity of nasal bleeding were compared.
Results: Success rate for nasal passage was 100% in the G(+) group (62/62) and 82.6% in the G(–) group (57/69; P = 0.0006). Frequency of nasal bleeding was significantly lower in the G(+) group (21/62, 33.9%) than in the G(–) group (37/69, 53.6%; P = 0.023). Severity of nasal bleeding was also significantly lower in the G(+) group than in the G(–) group (P = 0.030).
Conclusions: Nasotracheal intubation under CTSC guidance increases the success rate of airway instrumentation, and also reduces the incidence and severity of epistaxis.
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Introduction |
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TOPAbstractIntroductionPatients and methodsResultsDiscussionReferences |
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The present study used a curve-tipped suction catheter (CTSC) to guide NTT advancement. The effectiveness of this technique for reducing nasal bleeding was evaluated.
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Patients and methods |
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TOPAbstractIntroductionPatients and methodsResultsDiscussionReferences |
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Subjects comprised 131 adult patients between the ages of 16 and 82-yr (American Society of Anesthesiologists class I or II) who required NTI for elective oral and maxillofacial surgery. Subjects had no history of nasal disease, including epistaxis, and were taking no medication likely to induce bleeding. Patients underwent premedication (atropine 0.01 mg·kg–1 im and pethidine 1 mg·kg–1 im, administered 40 min before intubation) on the ward. Probing with a swab was performed under conscious sedation with midazolam (0.05 mg·kg–1 iv) prior to induction of anesthesia, to examine which side of the nasal cavity was wider. Anesthesia was induced using thiamyral (5 mg·kg–1 iv) and tracheal intubation was facilitated by vecronium bromide (0.1 mg·kg–1 iv). Patients were mask-ventilated with 3% sevoflurane in 100% oxygen until onset of muscle relaxation.
Subjects were randomly divided into two groups according to a computer-generated random table, using sealed envelopes opened at the anesthesia induction. Study protocols for each group were as follows:
a) Nasotracheal intubation under CTSC guidance (G[+] group, n = 62):
The CTSC (Portex Suction Catheter-AngledTM; Smiths Medical, London, UK; 14 Fr) was first inserted through the tracheal tube (Phycon SwayTM; Fuji Systems, Tokyo, Japan), with the tip of the CTSC protruding from the distal end of the tube by about 10 cm. The curved tip was directed ventrally, with the control valve fixed at the proximal end of the tube by the anesthesiologist’s hand during advancement of the NTT through the nasopharynx (Figure
). The size of the NTT was determined (inner diameter, 7.0–8.0 mm) according to tracheal size on a chest radiography done preoperatively.
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b) Nasotracheal intubation without CTSC guidance (G[–] group, n = 69): the tracheal tube was advanced carefully into the nasal cavity and passed into the pharynx without CTSC guidance. The tracheal tube was inserted into the preferred naris and carefully advanced through the nasopharynx. Tracheal intubation was then performed using a standard laryngoscopic technique. If the NTT could not be advanced through the nasal passage without resistance, the same size NTT was reinserted into the same nostril under CTSC guidance.
McGill forceps were used to assist endotracheal intubation in both groups as necessary. No other techniques for facilitating NTI, including warming the tracheal tube, were employed. In both groups, NTI was performed by anesthesiologists with 
five years of experience, who had no prior information about the patient.
Patient number, gender, age, height, weight and size of tracheal tube, time required to pass the tracheal tube through the nasal cavity (nasal passage time), success rate of nasal passage with NTT, and incidence and severity of nasal bleeding were evaluated. Nasal passage time was defined as the interval between the start-point when the tip of the CTSC was just inserted into the anterior naris, and the endpoint when the tip of the tracheal tube was just passed through the posterior naris.
An independent anesthesiologist who did not watch the airway instrumentation procedure assessed the severity of nasal bleeding using a laryngoscope both immediately following and 15 min after the NTT was passed through the nasal cavity. Nasal bleeding was graded as follows: bleeding in the pharynx just after passing NTT through the nasal cavity, 2 points; bleeding only in the pharynx 15 min after NTT passage through the nasal cavity (no bleeding immediately after NTT passage through the nasal cavity), 1 point; or no apparent bleeding in the pharynx, 0 points.
Age, height, weight and nasal passage time (mean ± standard deviation) were analyzed using Wilcoxon’s test. Gender, size of tracheal tube, success rate of NTI and incidence and severity of nasal bleeding were analyzed using Chi-square tests. Post hoc power analysis was performed where appropriate. Values of P < 0.05 were considered statistically significant.
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Results |
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TOPAbstractIntroductionPatients and methodsResultsDiscussionReferences |
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The incidence of nasal bleeding was significantly lower in the G(+) group (21/62, 33.9%) than in the G(–) group (37/69, 53.6%; P = 0.023). The severity of nasal bleeding was 0 points in 41 patients, 1 point in 12 patients, and 2 points in nine patients in the G(+) group, compared to 0 points in 32 patients, 1 point in 14 patients, and 2 points in 23 patients in the G(–) group, again representing a significant difference (P = 0.030), (Table II).
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Discussion |
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TOPAbstractIntroductionPatients and methodsResultsDiscussionReferences |
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Numerous reports have described methods of preventing nasal bleeding during NTI. Softening the endotracheal tube by heating in warm water,1,2 guidance using a gastric tube, a red-rubber catheter or a finger cot,1 use of a bubble-tip tracheal tube system (AirguideTMintroducer)3 and a lighted stylet (TrachlightTM)4 have been reported as interventions for the endotracheal tube. Moreover, mechanical dilation5 and application of epinephrine or phenylephrine6 have been used to prepare the nasopharyngeal passages and minimize epistaxis. However, these methods may not be available in all institutions, as the techniques require special apparatus and/or procedures, or may not be acceptable for some patients as application of catecholamines may induce adverse cardiovascular responses.
In the present study, nasal passage of the NTT was uniformly successful, and the frequency and severity of nasal bleeding were lower in the G(+) group compared to the G(–) group. Although a failure rate of 17% for NTI in the G(–) group may seem high, NTI was suspended if the NTT could not be advanced through the nasal passage without resistance, and NTI was then successfully reperformed under CTSC guidance. As resistance to nasal passage was not measured objectively, bias in technique was not completely excluded. However, anesthesiologists suspended advancement of the NTT through the nasal passage when they felt unusual resistance that suggested the nasal structures might be damaged if the NTT were forcibly advanced further. Whether NTT was passed through the nasal cavity depended on the judgment of well-trained anesthesiologists. Furthermore, if forced advancement of the NTT had been used to obtain high success rates, the frequency of nasal bleeding would have been higher in both groups. Anesthesiologists were thus considered to have performed NTT advancement adequately, and bias was considered minimal, and to have had no effect on these results.
Nasal passage time was about 3.1 sec longer in the G(+) group than in the G(–) group. This additional time was required for the soft and pliable tip of the CTSC to be introduced and advanced into the inferior nasal passage, prior to guiding the NTT through the naris. However, in our view, this increase in time does not represent a major drawback to the NTI procedure. Post hoc power analysis indicated sufficient statistical power to demonstrate significant differences in main outcomes of the success rate of nasal passage and epistaxis.
The CTSC was specifically designed for suctioning each bronchus separately, and is inexpensive and widely available. The tip is curved 45° from the axis of the catheter. The NTT advances through the inferior nasal passage following advancement of the CTSC tip without trauma to the nasal mucosa or soft palate. This technique thus facilitates advancement of the endotracheal tube. Although a vertical angle is formed between the posterior naris and pharynx, the tip of the CTSC readily passes through this area if the curved tip is directed ventrally, guiding the NTT into the pharynx. After withdrawing the CTSC from the tracheal tube, the usual laryngoscopic approach is used and tracheal intubation is performed. The CTSC ensures smooth transit of the tube through the nasal passageway, which is essential for reducing the frequency of epistaxis.8 In conclusion, NTI under CTSC guidance represents a simple and effective method for smoothly introducing a nasal endotracheal tube and reducing nasal bleeding during nasotracheal intubation.
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Footnotes |
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References |
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2 Kim YC, Lee SH, Noh GJ, et al. Thermosoftening treatment of the nasotracheal tube before intubation can reduce epistaxis and nasal damage. Anesth Analg 2000; 91: 698–701.
3 Watanabe S, Yaguchi Y, Suga A, Asakura N. A "Bubble-Tip"(Airguid®) tracheal tube system: its effects on incidence of epistaxis and ease of tube advancement in the subglottic region during nasotracheal intubation. Anesth Analg 1994; 78: 1140–3.
4 Favaro R, Tordiglione P, Di Lascio F, et al. Effective nasotracheal intubation using a modified transillumination technique. Can J Anesth 2002; 49: 91–5.
5 Adamson DN, Theisen FC, Barrett KC. Effect of mechanical dilation on nasotracheal intubation. J Oral Maxillofac Surg 1988; 46: 372–5.[Medline]
6 Gross JB, Hartigan ML, Schaffer DW. A suitable substitute for 4% cocaine before nasotracheal intubation: 3% lidocaine - 0.25% phenylephrine nasal spray. Anesth Analg 1984; 63: 915–8.
7 Hall CE, Shutt LE. Nasotracheal intubation for head and neck surgery. Anaesthesia 2003; 58: 249–56.[Medline]
8 Sim WS, Chung IS, Chin JU, et al. Risk factors for epistaxis during nasotracheal intubation. Anaesth Intensive Care 2002; 30: 449–52.[Medline]
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