Nasotracheal intubation is a nonsurgical technique used during emergencies to establish a definitive airway and deliver oxygenated air to a person experiencing breathing difficulties prior to his or her arrival at an emergency room. This technique may also be used when a person experiences an inability to maintain adequate blood oxygen levels or when a person needs to undergo dental, intraoral, or oropharyngeal procedures, such as mandibular reconstruction. Nasotracheal intubation is mostly used for people who are awake, spontaneously breathing, and seeking comfort.
To perform nasotracheal intubation, a local anesthetic, such as lidocaine, is first sprayed inside the nostril to minimize discomfort. The nasotracheal tube is then passed through the nostril to a position estimated to be above the larynx or vocal cords. Afterward, the patient is asked to take a deep breath in order to keep the trachea open or patent. The tube is then promptly inserted into the trachea while the patient is sitting because in this position the larynx does not fall toward the back of the throat. If the emergency physician or healthcare provider deems it necessary for the patient to undergo general anesthesia, it can be done while the patient is lying flat on his or her back.
Nasotracheal intubation may be used when preparing a patient for the management of upper gastrointestinal tract disorders. When a person has esophageal varices or friable blood vessels in the esophageal walls, for example, a Sengstaken-Blakemore tube may be inserted either through his or her mouth or nose. The tube may be accidentally inserted through the patient’s trachea, so the airway has to be secured beforehand through either nasotracheal or orotracheal intubation.
The use of nasotracheal intubation is avoided in cases of coagulopathy or blood clotting disorders such as hemophilia, epiglottitis or inflammation of the epiglottis, midface instability caused by facial trauma, suspected fractures in the base of the skull caused by head trauma, and impending respiratory arrest. Its use is also relatively avoided in the presence of big nasal polyps, infection in the upper neck, heart valve replacement surgery, and recent upper airway surgery. Nasotracheal intubation should not be used longer than needed because it is a common cause of nosebleeds due to damage to the nasal mucosa. It may also cause loss of consciousness due to vagal stimulation as well as damage to the vocal cords when improperly placed. The nasotracheal tube is essentially a foreign body that can be colonized by bacteria, thus it may also serve as a source of bacteremia and infection.