EditorWe read with interest Piepho and colleagues' description of a traumatic nasotracheal intubation (NTI) in a patient with an unanticipated difficult airway.1 We would like to suggest an addendum to Piepho's algorithm for NTI.
Any algorithm for NTI should include anticipated difficult airways. We feel this is pertinent as the nasal route is often used in cases with inadequate mouth opening and for oral and maxillofacial surgery. We have previously described the airway management with NTI in patients with anticipated difficult airways.2
In the NTI in anticipated difficult airway algorithm, we too like to look before we leap! First, we assess the airway under anaesthesia. When NTI is used for potentially difficult airways, it is important to maintain spontaneous ventilation.3 A preliminary laryngoscopic view under anaesthesia is useful for patients with adequate mouth opening.2 In Piepho's algorithm, direct laryngoscopy could be renamed preliminary laryngoscopy. If the view is CormackLehane (CL) 1 or 2, the plane of anaesthesia is further deepened using i.v. or volatile anaesthetic agents. Intubating laryngoscopy and tracheal intubation follows. NTI has been successfully performed without neuromuscular blockade.4 If the view is CL 3 or 4 or if laryngoscopy cannot be performed, the alternatives suggested by Piepho can be adopted.
The nasal cavity evaluation can also be carried out under anaesthesia; best immediately after the preliminary laryngoscopy. The apparently more patent nostril would have been already selected preoperatively by the airway patency test5 and suitable vasoconstrictors applied. If the nasal passage seems unsuitable for tracheal tube passage then the oral route or submental route may be used. Smith and Reid6 found a high incidence of intranasal pathologies (68% of their patients) that would make nasotracheal intubation difficult and have suggested fiberoptic intubation to select the best nostril. However, they add that despite major abnormalities, these patients do not sustain serious injury more frequently during intubation. We agree with their opinion that with experience, anaesthetists develop an acute sense of how much pressure they can apply on the tracheal tube before they abandon it for the other nostril.
Because of bleeding, Piepho and colleagues found themselves dealing with a dangerously difficult airway,7 possibly because they attempted NTI in a single step. Successful nasotracheal intubation, as described in their and other8 algorithms, consists of three important stepsadequate laryngoscopic views, atraumatic nasopharyngeal intubation, and passage of the tube into the trachea.
Padhar, Madhya Pradesh, India
References
1 Piepho T, Thierbach A, Werner C. Nasotracheal intubation: look before you leap. Br J Anaesth 2005; 94: 85960
2 Eipe N. The chewing of betel quid and oral submucous fibrosis and anesthesia. Anesth Analg 2005; 100: 121013
3 Elwood T, Stillions DM, Woo DW, Bradford HM, Ramamoorthy C. Nasotracheal intubation: a randomized trial of two methods. Anesthesiol 2002; 96: 513[CrossRef][ISI][Medline]
4 Alcock R, Peachey T, Lynch M, McEwan T. Comparison of alfentanil with suxamethonium in facilitating nasotracheal intubation in day-case anaesthesia. Br J Anaesth 1993; 70: 347[Abstract]
5 Smith JE, Reid AP. Identifying the more patent nostril before nasotracheal intubation. Anaesthesia 2001; 56: 25862[CrossRef][ISI][Medline]
6 Smith JE, Reid AP. Asymptomatic intranasal abnormalities influencing choice of nostril for nasotracheal intubation. Br J Anaesth 1999; 83; 8826
7 Eipe N, Pillai AD, Choudhrie R. Burns and tracheo-oesophageal-cutaneous fistula. Br J Anaesth 2005; 94: 1324
8 Singh S, Smith JE. Cardiovascular changes after the three stages of nasotracheal intubation. Br J Anaesth 2003; 91: 66771