ORIGINAL CONTRIBUTION

Blind Nasotracheal Intubation

Kenneth V. Iserson, MD Temple, Texas

One hundred fifty successive nonapneic patients requiring tracheal intubation had blind nasotracheal intubation performed. The primary indications for intu- bation were: drug overdose, 54 (36%); head injury, 36 (24%); COPD, 18 (12%); cerebrovascular accident, 15 (10%); congestive heart failure, 11 (7%); and other, 16 (11%). One hundred thirty-eight patients (92%) were successfully in- tubated using this technique. Iserson KV: Blind nasotracheal intubation. Ann Emerg Med 10:468-471, September 1981. intubation, nasotracheal, blind; nasotracheal intubation, blind

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

"blind" nasotracheal intubation for operating3.7 room use by anesthesiologists. 1'2 In subsequent years, Magill and others attempted to popularize the technique. However, since the introduction of muscle re laxants and rapid induction methods, most anesthesiologists use this technique sparingly, if at all. 8

Although little has been written concerning the use of this technique out- side of the operating room, a new interest has recently been shown in its ap- plication by emergency physicians. 9'1°

The patients most likely to benefit are those with spontaneous respirations who are in need of intubation for stabilization. Included are severe head injuries with and without possible spinal cord involvement, overdoses, primary respira- tory distress, cerebrovascular accidents, and many less Commonly encountered problems.

While the indications for the procedure are multiple, our experience indi- cates that the only absolute contraindication is apnea. Relative contraindica- tions from the literature include upper airway foreign bodies, bleeding diath- esis, epiglottitis, CSF rhinorrhea, bilateral large nasal polyps or abscesses, and severe facial fracture (Table 1). 5'6 However, the latter two situations have not prevented the use of blind nasotracheal intubation in the author's experience.

This study was conducted to determine the overall success rate of blind nasotracheal intubation, and to determine the success of novices in performing the procedure.

METHOD All patients seen by the author who met the criteria for blind nasotracheal

intubation, ie, the need for intubation in a spontaneously breathing patient, were included in this study. Resident and staff physicians who had not previous- ly performed this technique were verbally instructed while performing the pro- cedure.

The standard for a successful intubation was that generally employed, ie, placing the tube in the trachea using this technique and without intercurrent morbidity. Specific time for performing the technique was considered a factor only if it contributed to morbidity.

From the Department of Emergency Medicine, Scott and White Clinic, Texas A&M University College of Medicine, Temple, Texas 76508. Presented at the American College of Emergency Physicians Scientific Assembly in Las Vegas, Nevada, September 1980. Address for reprints: K. V. Iserson, MD, Scott and White Clinic, 2401 South Thirty-First Street, Temple, Texas 76508.

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Follow-up of patients was done through observation in the emergen- cy department and intensive care unit and, when possible, through specific inspection on post-mortem examinations. Complications noted were those that would be specific to, or complicated by, this method of in- tubation. No attempt was made to assess frequency of sore throats.

RESULTS Intubation was attempted on 150

successive patients using the blind nasotracheal technique. The patients ranged in age from 14 to 87. There was a marked (68%) predominance of male patients. Fifty-four (36%) of the patients were victims of drug over- doses. Many of these were intubated in conjunction with gastric lavage and were extubated prior to admis- sion. Head injuries were present in 36 (24%) of the patients; COPD, in 18 (12%); cerebrovascular accidents, in 15 (10%); congestive heart failure, in 11 (7%); adult respiratory distress syndrome, in four (3%); pneumonias, in three (2%); hypothermia, in three (2%); as thma, in one (<1%); and multiple or undetermined etiologies, in five (3%) (Table 2).

Twelve patients (8%) were not successfully intubated using this technique (Table 3). The largest group (six patients) were those in whom structural or technical diffi- culties blocked intubation. These in- cluded nasogastric tubes catching the nasotracheal tube, tracheal ste- nosis (seen on subsequent radiogra- phy and bronchoscopic procedure) which did not permit passage of what seemed a reasonably sized tube, and an unsuspected glottic mass. Four patients had supervening apnea. Of these 10 patients, seven were intu- bated by use of Magill forceps and three via the orotracheal route.

One patient developed laryngo- spasm during the procedure, but was easily intubated via the orotracheal route without use of muscle relax- ants.

The potentially most serious mor- bidity was in a 23-year-old man in severe status asthmaticus. Intuba- tion was thought to be successful, but breath sounds were so poor that it could not be determined. A chest film showed possible esophageal in- tubation. The patient was then taken to the operating room and intubated under general anesthesia. The tube was removed prior to direct laryn- goscopy. The patient did well.

Minimal epistaxis was noted in

Table 1 BLIND NASOTRACHEAL INTUBATION

Contraindications To Procedure Apnea* Foreign bod ies- upper airway t Bleeding diathesis t Epiglottitist CSF rhinorrhea? t Severe facial fractures?* Bilateral large nasal polyps t Abscesses t

Indication For Procedure Need for intubation Spontaneously breathing patient

*Absolute contraindication. *Relative contraindication.

approximately 40% of all patients. However, in no case was the bleeding prolonged nor was it necessary to pack the n o s e - either around the tube or after extubation. Eleven pa- tients had their laryngeal structures inspected on autopsy. There were no findings other than those normally expected with nasotracheal intuba- tion for the amount of time appropri- ate to that patient. 11

For 80 of the 150 patients, physi- cians were attempting the procedure for the first time. Forty-four of these patients (55%) were successfully in- tubated by them in what was consid- e r e d a reasonable amount of time based on the patient's condition. This varied from one to four minutes.

A total of 138 (92%) of the 150 patients in this series were success- fully intubated via the blind naso- tracheal approach.

DISCUSSION

The results of this series are similar to those recorded in other series, both by anesthesiologists and emergency physiciansfi s1° The tech- nique described, however, differs in one area from that usually employed, ie, neither translaryngeal nor through- the-tube local anesthesia was given. As Magill stated, this leaves a pro- tective cough reflex intact. 3 In addi- tion, Cetacaine ® was used ra ther than the more standard 4% cocaine. Both are modifications which should be considered in light of the tech- niques used in the emergency de- partment. As none of these intuba- tions was elective, it was thought that the 10 minutes necessary for co- caine to take effect was too long. 12'13 In addition, we thought that trans-

Table 2 CASES REQUIRING

NASOTRACHEAL INTUBATION (N = 150)

Injury/Disease No. % Overdose 54 (36) Head injury 36 (24) COPD 18 (12) CVA 15 (10) CHF 11 (7 ) Multiple/

undetermined 5 (3 ) ARDS 4 (3 ) Pneumonia 3 (2 ) Asthma 1 (<1)

tracheal anesthesia carries its own risks, as well as e l iminat ing the cough reflex that is integral to the technique. 14 Only one patient in the series developed laryngospasm, a n d

this was easly managed. The signifi- cant difference between the need for local anesthesia in the operat ing room and its lack in the emergency department is that no patient in the series was awake and alert. A stan- dard lubricant jelly is used rather than lidocaine jelly because it aids passage through the nose and causes less cord irritation. 15

Several methods for aiding this technique of intubation are cited in the literature. They include passage

16 17 of a nasogastric tube, Fogarty, or suction is catheter through the naso- tracheal tube; administration of dox- apram, m propanidid, 2°'21 or C023 as respiratory stimulants; administra- tion of ketamine; 22 use of a hook 23'24 to guide the tube; use of an "S"

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Table 3 CAUSES OF UNSUCCESSFUL

BLIND NASOTRACHEAL INTUBATIONS

Cause No, Structural/technical 6 Apnea 4 Larnygospasm 1 Esophageal }ntubation 1

tube; 25 and use of a visual expira t ion indicator a t the d is ta l tube. 26 None of these t e c h n i q u e s was u sed in t h e series, a l though ut i l iza t ion of a naso- gastric tube was useful on a subse- quent pat ient .

Several o ther tools for in tubat - ing have been used for some of the same types of p a t i e n t s seen in the series. The fiberoptic laryngoscope is the most useful, as i t can be ut i l ized in vir tual ly all cases in which bl ind n a s o t r a c h e a l i n t u b a t i o n is i nd i - cated. 27 This employs a f ibe rop t i c scope and l ight source over which an endotracheal tube is passed . How- ever, this is a r e l a t i v e l y expensive piece of equ ipmen t . In addi t ion , i t takes considerable exper t i se to ut i - lize this tool, especia l ly in noncon- trolled emergency conditions. Use of the e s ophagea l o b t u r a t o r a i r w a y ~ and esophageal gas t r ic tube a i rway ® (Surv iva l T e c h n o l o g y , B e t h e s d a , Maryland) h a s been a d v o c a t e d a t times for possible neck injur ies seen in the emergency depar tment . 2s This is l i m i t ed to a p n e i c p a t i e n t s . A n a d d i t i o n a l m e t h o d s u g g e s t e d for some of t h e s e p a t i e n t s , w h e t h e r apneic or not, is re t rograde in tuba- tion u t i l i z i n g a c a t h e t e r p a s s e d through the cr icothyroid membrane toward the mou th , w i th the endo- tracheal tube being passed back over it. 2s Th i s s e e m s to be s o m e w h a t cumbersome, but m a y have applica- tion in selected instances. 3°

Supervening apnea is a constant threat in pa t i en t s wi th r e sp i r a to ry distress. The ab i l i ty to v i sua l ly intu- bate is a n i m p o r t a n t s a f e g u a r d . Structural problems are sure to be encountered because of ana tomic and pathological var ia t ions . 31'32 To avoid some of these, we commonly will re- move a n a s o g a s t r i c t u b e p r i o r to a t t empt ing th i s t echn ique . Esoph- ageal in tubat ion is a common event; however, i t is usua l ly quickly recog-

: nized because of the cessat ion of res- p i ra tory sounds , and is cor rec ted . The e x p e r i e n c e o f u n r e c o g n i z e d

esophageal in tuba t ion in a very se- v e r e a s t h m a t i c , no m a t t e r h o w briefly, probably indicates this was a cand ida te for i n t u b a t i o n under the more c o n t r o l l e d c o n d i t i o n s of t he opera t ing room.

Compl i c a t i ons r e p o r t e d in the l i t e r a t u r e which were not seen in this series are r e t ropha ryngea l dis- section 3~ and severe epistaxis. 3a There is also the theoret ica l problem of cra- nial pene t ra t ion in bas i l a r skul l frac- tu res . This has not been r e p o r t e d w i t h n a s o t r a c h e a l i n t u b a t i o n , al- though it has been repor ted for naso- gastr ic tubes.

Compl i ca t ions seen wi th endo- t rachea l in tuba t ion which were not seen in th is series were broken tee th and those compl ica t ions assoc ia ted with use of muscle re laxants .

The long- te rm compl ica t ions of subglott ic stenosis, nasa l septa l per- foration, s t r ic ture of the nasa l vesti- bule sinus, and centra l nervous sys- tem infections in cases of local injury, and glott ic u lcera t ion and edema are t h o s e c o m m o n to l o n g - t e r m naso- t rachea l in tuba t ions 34 and are not in any way specific to th is technique.

CONCLUSION

Blind naso t rachea l in tuba t ion is shown to be a safe, re l iable method for defini t ive a i rway main tenance in the emergency depar tment . Ninety- two percent of pa t ien ts in th is s tudy were succes s fu l l y i n t u b a t e d u s i n g this technique.

REFERENCES

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