Nasotracheal intubation is a medical procedure involving the placement of a flexible breathing tube, called an endotracheal tube, through a patient’s nostril and into the trachea, or windpipe. This method secures an open airway, allowing for assisted breathing or the delivery of anesthetic gases during medical procedures. It is distinct from orotracheal intubation, where the tube is inserted through the mouth, by its specific route through the nasal passage. The procedure is commonly performed in an operating room, often after general anesthesia has been administered.
Medical Reasons for Nasotracheal Intubation
This intubation method is chosen when access to the patient’s mouth is needed for surgical procedures or when conditions prevent oral intubation. For instance, it is frequently used during major dental, oral, or maxillofacial surgeries, as it keeps the oral cavity clear for the surgical team, allowing unobstructed access.
Nasotracheal intubation is also preferred when a patient cannot open their mouth sufficiently. This can occur due to severe facial trauma, trismus (lockjaw), or jaw wiring that restricts mouth movement. Patients with cervical spine instability or those requiring neck immobilization may also benefit, as this method avoids excessive neck manipulation.
The Intubation Process
Before the procedure, medical staff prepare the patient by administering sedatives and general anesthesia if needed. The nasal passages are sprayed with a topical anesthetic and a vasoconstrictor to numb the area and minimize bleeding. The chosen nostril is often gently dilated with a nasal airway or trumpet to ease the tube’s passage.
A lubricated endotracheal tube is then carefully guided through the selected nostril, following the natural curve of the nasal cavity. The tube advances through the nasopharynx and into the oropharynx, moving towards the vocal cords. Medical professionals use a laryngoscope or a flexible fiberoptic scope to visualize the vocal cords and guide the tube into the trachea. In some cases, Magill forceps are used to help direct the tube through the vocal cords.
Once the tube is in place, its correct positioning within the trachea, rather than the esophagus, must be confirmed. This involves listening for equal breath sounds in both lungs and observing the rise and fall of the chest. An end-tidal carbon dioxide (CO2) detector measures CO2 in exhaled breath, indicating proper tracheal placement, and a chest X-ray provides final verification.
Associated Risks and Complications
Nasotracheal intubation, while effective, carries immediate risks during insertion. The most common complication is epistaxis, or nosebleeds, which can occur due to trauma to the delicate nasal mucosa. There is also potential for damage to nasal structures and the creation of a false passage if the tube is forced. Patients with clotting factor deficiencies or those on anticoagulants face an increased risk of severe bleeding.
Once the tube is in place, other complications can arise. Sinus infections are a concern because the tube can block the natural drainage pathways of the sinuses. Pressure sores or necrosis can develop inside the nostril from prolonged contact with the tube. The tube can also become kinked or obstructed, potentially compromising the patient’s breathing. There is also a risk of introducing bacteria from the nasal cavity into the trachea, leading to bacteremia.
Recovery and Tube Removal
While the nasotracheal tube is in place, patients are unable to speak because the tube passes through their vocal cords. They may also experience discomfort or a feeling of fullness in their nasal passages. Regular suctioning is performed to clear any secretions from the airway and maintain tube patency.
The decision to remove the tube is made once the patient demonstrates the ability to breathe independently and their underlying medical condition has improved. Before removal, the cuff that inflates inside the trachea to secure the tube and prevent air leakage is deflated. The tube is then gently and quickly slid out from the nostril. After removal, patients experience a sore throat, hoarseness, or some nasal discomfort for a short period. They may also require supplemental oxygen via a nasal cannula or mask as they fully recover their independent breathing.