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Fibre optic Intubation -Better Choice
- Basavaraj C Lakkundi, Joshi VK (9 November 2005)
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Safety during nasotracheal intubation in facio-maxillary injuries
- M Sudhakar, Chethan DB, Patil A (24 October 2005)
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Nasal intubation: An alternative approach
- Pramod P. Bapat (5 June 2005)
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Basavaraj C Lakkundi, Consultant ISA hubli Branch, Joshi VK
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Dear Dr.Sudhakar, For maxillofacial injuries, the best is to go for tracheal intubation using fibreoptic aid. Yours Dr LakkundiBC Conflict of Interest:None declared |
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M Sudhakar, Consultant Anaesthetist Prince Charles Hospital, Merthyr Tydfil, Chethan DB, Patil A
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Editor - We read with interest the case report by Piepho et al(1) suggesting an algorithm for nasotracheal intubation. Although this algorithm could be useful in elective Oro-Maxillo-Facial surgery, we would like to highlight the challenges facing nasotracheal intubation during anaesthesia for patients with recent maxillo-facial injuries. Midfacial fractures (Le Fort fractures of maxilla) often present difficult anaesthetic problems. They may cause maxilla to float with complete separation of maxilla from the craniofacial skeleton. Although emergency management of such airway involves orotracheal intubation, for reduction and fixation of fractured maxilla, surgeons usually prefer a nasotracheal tube as this allows free surgical access and the wiring together of maxilla. Nasotracheal intubation involves a three-stage process(2). Firstly, nasopharyngeal intubation. Secondly, direct laryngoscopy to visualise the vocal cords and thirdly, passage of the tracheal tube into the trachea. Attempting the initial nasopharyngeal intubation in these groups of patients may cause profuse bleeding. This may make visualisation of the larynx difficult during direct laryngoscopy. The case described by Piepho et al confirms such difficulty, despite being an elective situation. Furthermore, flooding of the tracheo-bronchial tree with blood and debris may lead to hypoxia. Nasotracheal intubation may also lead to creation of false passage, misplacement and further damage(3). In addition, associated nasal bone fracture may make the initial nasopharyngeal intubation even more difficult and traumatic. We would like to highlight the advantages of a nasotracheal intubation technique(4) which can add to the safety of such patients. After induction of anaesthesia, face mask ventilation and muscle relaxation, the airway is first secured with a cuffed oro-endotracheal tube following direct laryngoscopy. The advantages of such initial oral intubation are three fold. Firstly, it allows a secure airway while nasopharyngeal intubation is performed. Anaesthesia can be continued via this orotracheal tube whilst the nasopharyngeal intubation is being performed. Secondly, if the facial anatomy is grossly deformed, the maxillo-facial surgeon can perform the initial nasopharyngeal part of the nasotracheal intubation. This allows stabilisation of the mobile maxilla with one hand inside the mouth and the other hand gently guiding the nasal tube through the nostril into the nasopharynx. An experienced surgeon will be able to identify the anatomy with his one hand inside the mouth and fingers in the posterior nares. This could be extremely helpful in minimising the risk of creating a false passage. During all this time the airway is secured with the cuffed oro-endotracheal tube and the nasotracheal intubation can be performed unhurriedly. Thirdly, it allows suctioning the blood and debris from the oropharynx following the nasopharyngeal intubation. Once the tip of the tube is beyond the nasopharynx, direct laryngoscopy and thorough suctioning is performed to remove any blood and debris that may have been caused during the nasopharyngeal intubation. In addition, the tamponading effect of the tube in the nose may prevent further bleeding into the oropharynx. At this stage any suspected damage to the cuff of the nasotracheal tube can be checked. Having ensured that the airway is dry and clear of blood and other debris, under direct vision, the oro-endotracheal tube is withdrawn and the naso-endotracheal tube advanced into the trachea with or without the help of a magill forceps and the cuff inflated. Anaesthesia is continued as thought to be appropriate. We feel that by this technique of initially securing the airway with oro-endotracheal tube, the safety of patients with maxillo-facial injuries during nasotracheal intubation is improved. We would like to stress the importance of an experienced maxillo-facial surgeon performing the initial nasopharyngeal intubation. We would be interested in what other readers think. References: 1 T.Piepho,A.Thierbach, and C.Werner. Nasotracheal intubation:look before you leap. British Journal of Anaesthesia 2005;94:859-860 2 S. Singh and J. E. Smith. Cardiovascular changes after the three stages of nasotracheal intubation British Journal of Anaesthesia 2003; 91: 667-671 3 C. E. J. Hall, L. E. Shutt. Nasotracheal intubation for head and neck surgery. Anaesthesia 2003; 58: 249-256 4 Why KS. A technique of nasotracheal intubation in patients with recent facio-maxillary injury. Anaesthesia and Intensive Care 1975; 3(2): 152-3 Conflict of Interest:None declared |
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Pramod P. Bapat, Consultant anaesthetist Wirral Hospital, Wirral. UK
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Editor- I read with interest the case report by Piepho, Thierbach and Werner [1] and would like to make a few comments. First of all I would like to know the rationale behind using thiopentone for minor ambulatory surgery. Were there any contraindications to propofol? Thiopentone increases airway irritability, and along with the blood in the laryngopharynx, could have caused laryngospasm and contributed to the difficult facemask as well as laryngeal mask ventilation. A dose of 45 mg of atracurium in an obese patient may not be sufficient to abolish laryngeal reflexes under such circumstances. For several years I have been doing blind nasal intubations without using muscle relaxants in ASA I/II patients undergoing oral surgery. My practice is to use i.v. midazolam 1-3 mg followed about 2 minutes later by alfentanil 0.5 to 1.0 mg and up to 3.0 mg kg-1 propofol. Facemask ventilation with oxygen and 4-5% of sevoflurane may be used to further deepen the anaesthetic. Phenylephrine and lidocaine spray is used after induction in both nostrils. Blind nasal intubation is attempted with the patient’s head on a pillow and well extended by pulling the chin firmly. Close observation of the neck is done to detect the position of the tip of the tube and if it is not in the midline then corrected by rotating the tube appropriately. Intubation can be achieved in up to 70-75% patients during first attempt. If needed, direct laryngoscopy can also be used to guide the tube into the trachea. A few patients may have coughing and moderate tachycardia, but it is short lasting and is not a problem in ASA I/II patients. I believe that avoiding the use of muscle relaxant makes this technique safer if there is unanticipated airway problem. Piepho and colleagues1 removed the nasal tube on noticing the grade IV view on laryngoscopy but I believe that using a fibrescope immediately through the tube might have given them a better chance to intubate the patient. If a fibrescope was not available at a moments notice then blind nasal intubation should have been attempted. In my experience blind nasal intubation is easy to achieve in previously documented grade III laryngoscopy patients. When blind nasal intubation could not be done, the laryngoscopic view was almost always grade I/II. I wonder if there is an inverse relationship between these two. I would like to know if other readers have had similar experiences. Unfortunately blind nasal intubation is not considered an essential skill to learn during training and is not even mentioned in courses on airway management. However, it is easy to learn and is a very useful option to think of in a difficult airway situation. The risk of troublesome haemorrhage is low and can further be reduced by using tubes of size 6.0-6.5. P Bapat Wirral, UK E-mail: pbapat@hotmail.com Reference 1. Piepho T, Thierbach A, Werner C. Nasotracheal intubation: look before you leap. Br J anaesth 2005; 94: 859-60. Conflict of Interest:None declared |
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