P079: NASOTRACHEAL INTUBATION FACILITATED BY INFLATION OF THE ENDOTRACHEAL CUFF: A CASE SERIES
Jacquelin Peck, MD; Chris Bauer, MD; Heather Barkin, MD; S. Howard Wittels, MD; Gerald Rosen, MD; Mount Sinai Medical Center
Introduction: Endotracheal tube (ETT) cuff inflation during nasotracheal intubation anteriorizes and aligns the tip of the endotracheal tube with the vocal cords and facilitates intubation. Cuff inflation remains an under-used technique despite high published success rates.
Methods: Nasotracheal intubation facilitated by cuff inflation was performed by resident physicians for five consecutive patients requiring nasotracheal intubation under the care of a single anesthesia provider. Confirmation of intubation was achieved using video laryngoscope visualization. Difficult intubation equipment and support staff were immediately available for each intubation. Written, informed consent was obtained prior to reporting of these findings.
Technique: After anesthesia time out, standard ASA monitoring, pre-oxygenation, induction, and neuromuscular blockade, the ability to manually ventilate the patient was confirmed and nasotracheal intubation was performed. A nasotracheal tube of predetermined size was inserted through the patient’s nare after sequential dilation with lubricated and phenylephrine-coated nasal airways to minimize trauma to the nasal mucosa. The ETT was advanced until the tip was visible within the pharynx by video laryngoscope. Once positioned, the ETT cuff was inflated with 10mL-20mL of air to anteriorize and align the tip with the vocal cords and the ETT was advanced until resistance was met. The cuff was then deflated, and the ETT was advanced under visualization into the trachea. The cuff was then re-inflated, breath sounds auscultated, and the tube secured.
Results: Of the included patients, one patient was female, the mean age was 37.2 years, mean ASA class was 2.4, and mean BMI was 29.8. Preoperative procedure codes included dental restoration, root planning, and scaling. All patients underwent successful nasotracheal intubation using inflation of the ETT cuff. One required two attempts at intubation (80% first-attempt-success). The mean time to intubation was 2.8 minutes including induction and neuromuscular blockade. One patient experienced nasotracheal intubation within 1 minute, which may reflect the imprecision of documenting in one-minute blocks in our electronic medical records. Future evaluation using a timer would enhance precision. No patient experienced a recorded period of desaturation, epistaxis, laryngospasm, or aspiration. One patient experienced a prolonged recovery period in the post anesthesia care unit related to management of pre-existing hypertension.
Discussion: Several existing studies describe successful nasotracheal intubation even among inexperienced providers1-2 and anticipated difficult endotracheal intubations3. Success rates range from 80% to 95%1-5 and improve with inflation of the endotracheal tube cuff.4 Furthermore, when compared to fiberoptic intubation, blind nasotracheal intubation using ETT cuff inflation is similarly effective (95% success vs 95% success) and results in lower mean time spent intubating (20.8 seconds vs 60.1 seconds).5
Limitations: Several factors limit the generalizability of this retrospective, observational case series. With only five patients, it is difficult to determine rates of successful nasotracheal intubation or time spent intubating with any degree of certainty. Included patients were also generally healthy, undergoing planned nasotracheal intubation for elective procedures in a controlled environment with readily available support staff and equipment.
Conclusion: Nasotracheal intubation performed using ETT cuff inflation was successfully performed on five consecutive patients under the care of a single provider.