Nasal Intubation (Exam 4)

Question 1

Nasal Intubation Indications

Answer 1

Oral route not possible
-Wired Jaw
-Swelling (tongue)
Surgical Impedance
-Dental/Oral
Tolerated better than tracheostomy for extended periods

Question 2

Nasal Intubation Contraindications

Answer 2

Hx of basal skull fx
-Any neurological procedure which involved access via skull base
Recent sinus procedures

Question 3

Prolonged Nasal Intubation Issues

Answer 3

Nasal Damage
Local Abscesses
Otitis Media
Sinusitis

Question 4

Nasal Intubation Complicaitons

Answer 4

Epistaxis (Nose Bleed)
Damaged Turbinates
Avulsed Nasal Polyps (torn off)
Septal Abscess
Avulsed Adenoids

Question 5

Nasal Rae Sizing (A rae is a bent ETT designed for nasal intubation)

Answer 5

Sizing is based on height
-Diameter is limiting factor (only so big of a tube can fit inside a nare)
-Larger diameter tubes can be advanced further
Have multiple sizes ready as one may be too large or too short

Question 6

Nasal Intubation Process (first half)

Answer 6

1. Prewarm the Rae ETT (500ml bottle of sterile water and put in fluid warmer)
2. Equipment List
   –Lube
   –28,30, 32, 34Fr Nasal Airway (for dilation) or Red Rubber
   –Magil Forceps
   –Laryngoscope with blade (for DL)
3. Find which nare is more patent
4. Vasoconstrict both nares (preferably before heading back to OR)
   –1% Phenylephrine Spray (Most Common)
   –Afrin/Oxymetazoline Spray (Most Common)
   –4% Cocaine Pledget
   –Epinephrine Pledget
5. Patient Education (post op nosebleeds)

Question 7

Nasal Intubation Process (Nasal Airway Method)

Answer 7

6. Pt wheeled to OR
7. Vasoconstrict nares again
8. Induce
9. Dilate nares 28Fr to 34Fr (bevel lateral)
10. Lubricate Rae
    –Insert perpendicular to face
    –Bevel lateral
11. Advance until it has entered larynx
12. Perform DL
13. Try advancing into the glottic opening
    –No stylet
14. If facing issues, use Magil’s to advance
    –do not grasp the cuff, will tear

Question 8

Nasal Intubation Process (Red Robinson)

Answer 8

6. Pt wheeled to OR
7. Vasoconstrict nares again
8. Induce
9. Place Red Rubber over tip or Rae (covering murphy eye)
10. Lubricate Red Rubber
    –Insert perpendicular to face
    –Once seen in oropharynx pull out of mouth
11. Once removed from Rae, retract the Rae back into oropharynx
    –Advance Rae into larynx
12. Perform DL
13. Try advancing into the glottic opening
    –No stylet
14. If facing issues, use Magil’s to advance
    –do not grasp the cuff, will tear

Question 9

Securing Nasal Rae

Answer 9

Pad the connector (rolled towel or foam)
Do not fishhook nare (can cause necrosis)
Tape circumferentially
A few specialties will do this for you

Question 10

Retrograde Intubation

Answer 10

Takes Time
Needs proper mechanical ventilation
100% need pre-oxygenation

Question 11

Jet Ventilation Indications

Answer 11

Removal of foreign bodies
Evaluation of airway dynamics
Lesion removal

Question 12

Jet Ventilation Limitaions

Answer 12

Airway Pollution (Smoke inhalation [HPV lesions])
Lack of EtCO2
Possible loss of airway
One hand must continually supply ventilation via trigger/lever

Question 13

Types of Jet Ventilation

Answer 13

Supraglottic
–Rigid Bronchoscope via accessory port
Subglottic (upper airway obstructions)
–Transtracheal approach via the cricothyroid via a small catheter

Question 14

Jet Ventilation Process

Answer 14

1. Equipment
   –Jet Vent working and O2 supply
   –Double check surgical team has ridged scope
2. Induce
3. Place LMA/iGel and confirm ventilation
4. Proceed with TIVA (Paralyze too)
5. Prepare for LMA removal and ridged scope insertion
6. Scope inserted and in place, hook up ventilation
7. Squeeze Handle for O2 deliver
   –8 per min
   –less than 1 second per squeeze
   –PSI: 15 (as high as 25-50)
   –Look for chest rise
8. Oxygenation is well tolerated
9. Ventilation is usually adequate
10. Maintain Paralysis throughout
11. Once over, reinsert LMA
12. Confirm spontaneous ventilation
13. Wake up
14. Coughing likely as airway was irritated