CONCEPTS, COMPONENTS & CONFIGURATIONS intubation, nasotracheal; nasotracheal intubation: teaching model, intubation

Blind Nasotracheal Intubation: A Model for Instruction

Described is a model for use in instruction and evaluation in the technique of blind nasotracheal intubation. The model is constructed of readily avail- able equipment that can be used for its primary purpose when the model is not needed. [Iserson KV: Blind nasotracheal intubation: A model .for in- struction. Ann Emerg Med August 1984;13:601-602.]

INTRODUCTION During World War I, Rowbotham and Magill developed a technique of

"blind" nasotracheal in tubat ion for operat ing room use by anesthe- siologistsA,2 In recent years the technique has gained wide acceptance as an excellent method of definitive airway control in emergency and critical care areas. 3-s One major limitation of this technique has been the need to have a live, spontaneously breathing patient to use for instruction. This has, of ne- cessity, greatly limited the opportunities to instruct students in this tech- nique in a controlled, nonthreatening, and repeatable environment.

An animal model would be optimal. A search for such a model, made in concert with academic veterinarians at two medical centers, was unsuc- cessful due to the expense or restrictions on using some proposed animals (ie, monkeys), the extremely small nasal passages in some (all common labo- ratory animals), or the animal's unwieldy size.

A mechanical model for use as an instructional tool was developed from readily available material.

MODEL The model is prepared from an adult intubation manikin (Laerdal Medical

Corporation, Armonk, NY). The left "lung" is removed in a procedure that is nondestructive and easily reversible. A rubber female-female adapter (Cou- pling, Filter, Main Flow #3443, Puritan-Bennett, Los Angeles) is attached, and the standard 15-mm (ID) end of a bag ventilator is inserted into the other end of the adapter to provide "ventilation" (Figure, inset). Silicone is sprayed both into the nasal passages of the manikin and on the nasotracheal tube. The model is then ready for use (Figure).

Respiration airflow through the manikin's mouth and nose is controlled by the instructor, using the bag ventilator. A screen to block the operator's view of the manual bag ventilations is often useful. Hyper- and hypoventilation, breath-holding, and supervening apnea can be simulated.

Intubations are found to be consistently easier in the model than in the human being. Using this model during the past four years, however, it has been possible to both give initial instruction in this intubation method and help to refine other trainees' technique.

DISCUSSION This simple model supplies a low-cost method, available at virtually all

hospitals, to give initial instruction in the technique of blind nasotracheal intubation.

Bag-mask ventilation equipment is required at every acute care facility, and adult intubation manikins are found at most. Neither need be commit- ted to this model, but could be used for their normal functions until the model is to be utilized. The cost of the model is only that of the female-

Kenneth V Iserson, MD, FACEP Tucson, Arizona

From the Section of Emergency Medicine, University of Arizona Health Sciences Center, Tucson, Arizona.

Received for publication October 21, 1983. Accepted for publication December 20, 1983.

Address for reprints: Kenneth V Iserson, MD, FACEE Section of Emergency Medicine, University of Arizona Health Sciences Center, 1501 North Campbell, Tucson, Arizona 85724.

13:8 August 1984 Annals of Emergency Medicine 601/47

BLIND NASOTRACHEAL INTUBATION Iserson

Fig. A s tandard adul t i n t u b a t i o n manikin modified as a blind nasotra- cheal teaching model. (Inset: Connec- tion to bag ventilator.)

female adapter (about $5.75). In addi t ion this low cost and the

ready availabili ty of a model suggest i t s i n c l u s i o n in s t a n d a r d a d v a n c e d medical support courses (ie, advanced cardiac life support and advanced trau- ma life support), as well as in emer- gency m e d i c i n e , c r i t i ca l care , and a n e s t h e s i a c u r r i c u l a - - as b o t h a teaching and a testing tool.

C O N C L U S I O N An eas i ly c o n s t r u c t e d m o d e l for

teaching and evaluating the technique of b l i n d n a s o t r a c h e a l i n t u b a t i o n s h o u l d m a k e th i s h i g h l y e f fec t ive m e t h o d of def in i t ive a i rway con t ro l available to, and usable by, more prac- titioners.

REFERENCES 1. Rowbotham ES, Magill IW: Anaes- thetics in the plastic surgery of the face and jaws. Proc R Soc Med 1921;14:17.

2. Magill IW: Blind nasal intubation. An- aesthesia 1975;30:476-479.

3. Iserson KV: Blind nasotracheal intuba- tion. Ann Emerg Med 1981;10:468-471.

4. Tintinalli J, Claffey J: Complications of nasotracheal intubation. Ann Emerg Med 1981;10:142-144.

5. Danzl D, Thomas DM: Nasotracheal intubation in the emergency department. Crit Care Med 1980;8:677-682.

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