NASOTRACHEAL INTUBATION (NTI)

INDICATIONS:

• Adult patients requiring definitive airway management for whom orotracheal intubation is impossible or contraindicated, due to patient presentation or condition:
• Conscious, spontaneously breathing patients with intact gag reflex (e.g. COPD, asthma, burns)
• Unconscious patients with GCS less than 8 due to trauma or medical conditions
• Patients with possible C-spine trauma whose injuries may be aggravated by neck movement

CONTRAINDICATIONS:

ABSOLUTE CONTRAINDICATIONS

• Apnea
• Age less than 13 years
• Severe midface congenital or traumatic deformity
• Nasal airway obstructions

RELATIVE CONTRAINDICATIONS

• Suspected basilar skull fracture (raccoon’s eyes, Battle’s sign, CSF leakage from ears or nose)
• Coagulopathy (e.g. hemophilia or liver disease)
• Anti-coagulants (e.g. aspirin, heparin Coumadin, Pradaxa®, Plavix®, etc.)
• Acute hypertension
• Suspected elevated intracranial pressure

EQUIPMENT:

• ET Tube 0.5 to 1 size smaller than that for oral intubation – or select a tube slightly smaller than the patient’s nostril
• Lidocaine jelly (or sterile lubricant): if time allows, apply lidocaine jelly to an NPA and insert several minutes prior to intubation
• BAAM® “whistle-tip” device
• 10 mL syringe
• Soft suction catheter
• ETCO2 detection device, preferably continuous waveform capnography
• Tape or commercial tube holder

PROCEDURE (Observe Body Substance Isolation Precautions):

1. Prepare the tube: wrap into a circular shape for 1 minute and attach the BAAM® device; lubricate with lidocaine jelly (or sterile lubricant).
1. If BAAM® device unavailable: remove stethoscope bell and insert tubing into the ETT for auscultation.
2. Place the patient in a “sniffing” position, IF CERVICAL SPINE TRAUMA IS NOT SUSPECTED.
3. Insert the tube straight back into the right nare, parallel to the floor, anterior to posterior:
1. Do not angle the tip upwards towards the skull, or downwards.
2. Insert with the tube bevel facing the nasal septum.
3. Use a slight back-and-forth rotation of the tube, if minor resistance is felt.
4. If significant resistance is encountered, remove the tube and insert into the left nare.
4. Once the tube tip reaches the pharynx, listen for breath sounds through the BAAM® device and observe for condensation in the tube.
5. Advance the tube:
1. Conscious patient: ask the patient to take a deep breath, and gently advance the tube during inhalation.
   1. Asking the patient to protrude the tongue during this step reduces risk of esophageal insertion.
2. Unconscious patient: advance the tube during inhalation.
6. Confirm tube placement:
1. Patient coughs; condensation appears in the tube; ETCO2 detection; conscious patient is unable to speak; auscultation of symmetrical, bilateral breath sounds; and stable/improving SpO2.
7. If tube placement is confirmed, advance the tube another 1-1½ inches and remove the BAAM® device.
8. Inflate the cuff and secure the tube.

COMPLICATIONS: