Nasotracheal Intubation

Contraindicated when apnoeic, and when severe midface #s or suspicion of basilar skull # exists.

1. Leave a C-spine collar in place if # suspected.

2. Assure adequate ventilation, oxygenation.

3. Inflate/deflate cuff to check for leak.

4. Spray nasal pasage with anaesthetic and vasoconstrictor if conscious.
- if unconscious a vasoconstrictor will do.

5. Assistant performs manual immobilsiation of head/neck.

6. Lubricate nasotracheal tube with jelly and insert into nostril.

7. Guide slowly but firmly.
- go up from the nostril (avoids large inferior turbinate) then backward and down into the nasopharynx.
- the tube is curved to facilitate this passage.

8. As the tube passes through the nose and into the nasopharynx, it must turn downward to pass through pharynx.

9. One in pharynx, listen to airflow from the tube.
- advance until airflow noise is maximal, suggesting it is at the tracheal opening.
- determine a likely point of inhalation and advance quickly.
- if unsuccessful, retry with gentle thyroid cartilage pressure after reventilating.

10. Inflate to ensure adequate seal (do not overinflate).

11. Visually observe chest excursion with ventilation.

12. Auscultate with stethoscope for tube position (chest bilaterally and stomach).

13. Secure tube and recheck if pt moved.

14. If not accomplished in 30s, discontinue reventilate and reattempt.

15. CXR can help check position (but is not sure-fire).

16. Attach a CO2 calorimetric device.

17. Attach a pulse oximeter.

i) oesophageal intubation --> hypoxia.
ii) R bronchus intubation --> L lung collapse.
iii) inability to intubate
iv) induction of vomiting --> aspiration
v) trauma to airway --> bleeding aspiration
vi) damage of teeth
vii) rupture leak of ET cuff
viii) cervical cord injury