Securing a patient’s airway is typically achieved through intubation. Nasotracheal intubation (NTI) is a specific method used to place an artificial breathing tube, known as an endotracheal tube, into the trachea or windpipe. This technique is distinguished by its route of entry, utilizing the nose as the conduit rather than the mouth. While the oral route remains the standard for emergency settings, NTI serves as a specialized alternative when certain clinical conditions are present. It provides a means of mechanical ventilation and airway protection tailored to specific patient needs or surgical requirements.
What is Nasotracheal Intubation?
Nasotracheal intubation involves inserting a specialized, flexible tube through one of the patient’s nostrils, guiding it past the nasopharynx and larynx, and finally into the trachea. The tube’s final position is identical to that of an orotracheal tube, which enters through the mouth. The primary anatomical difference between NTI and the more common orotracheal intubation (OTI) is the initial entry point into the upper airway.
The nasal route offers several distinct benefits, particularly for patients requiring prolonged airway management. A tube secured through the nasal passage tends to be more stable, decreasing the chance of accidental displacement or unplanned extubation. This stability is due to the natural confinement provided by the nasal anatomy. Furthermore, the nasal tube avoids interference with the mouth, which simplifies oral hygiene and nursing care for individuals on long-term ventilation.
Situations Requiring the Nasal Route
The decision to use the nasal route is often driven by the need to completely clear the oral cavity for medical or surgical access. This makes NTI the preferred method for many dental and intraoral procedures, such as complex mandibular reconstruction or other surgeries within the mouth and throat. By running the breathing circuit through the nose, the surgical team gains an unobstructed field of vision and access to the entire oral area.
The technique is also utilized when a patient cannot safely undergo orotracheal intubation due to limited mouth opening, a condition known as trismus. This restricted access can be caused by severe facial trauma, certain infections, or structural abnormalities. In cases of severe jaw or facial trauma, such as a fractured mandible, the oral cavity may be inaccessible or manipulating it could cause further injury, making the nasal passage the safer entry point.
NTI is commonly employed in awake intubations, where the patient is breathing spontaneously but needs a secure airway, particularly when a difficult airway is anticipated. Since the nasal route generally causes less gagging and is better tolerated by a patient who is not fully anesthetized, it facilitates the use of a fiberoptic scope for visualization. This controlled approach is sometimes used in patients with suspected cervical spine instability, as it allows the airway to be secured while maintaining neutral neck alignment.
Steps for Insertion
The procedure requires careful preparation to minimize trauma and bleeding within the nasal passages. A decongestant and a topical anesthetic are typically applied to the chosen nostril to shrink the blood vessels and numb the tissue, which helps prevent epistaxis, or nosebleeds. The medical provider then selects an appropriately sized endotracheal tube, which is usually smaller than an oral tube, and lubricates its tip.
The tube is gently advanced along the floor of the nasal cavity, a path that runs parallel to the hard palate, to avoid damaging the internal structures, particularly the turbinates. Resistance may be encountered as the tube passes the nasopharynx, which sometimes requires a gentle rotational maneuver to navigate the turn into the throat. Once the tube tip is positioned in the pharynx, a laryngoscope is used to visualize the vocal cords.
The provider then uses a specialized instrument, such as Magill forceps, to guide the tip through the vocal cords and into the trachea under direct vision. Successful placement is confirmed immediately by listening for equal breath sounds in both lungs and observing the rise and fall of the chest cavity. The tube is then secured firmly to the face, and its position is verified with a chest X-ray to ensure it is correctly situated above the carina.
Conditions Preventing Nasotracheal Intubation
Specific patient conditions act as contraindications, making the nasal route unsafe. The most serious involves trauma or injury that compromises the integrity of the skull base, the bony structure separating the brain from the nasal cavity. A known or suspected basal skull fracture presents a severe risk, as the intubation tube could inadvertently pass into the cranial vault instead of the trachea.
Severe facial trauma or midface instability is another reason to avoid NTI, as the procedure itself could dislodge bone fragments or cause catastrophic bleeding. Furthermore, any patient with a known coagulopathy or severe bleeding disorder is at a high risk of life-threatening epistaxis from the trauma of tube insertion. The rich blood supply of the nasal mucosa makes even minor injury potentially serious in these circumstances.
Obstruction of the nasal passage also prevents the procedure, including conditions like large nasal polyps, abscesses, or foreign bodies that block the pathway. Suspected acute epiglottitis, a severe swelling of the tissue covering the windpipe, is also a contraindication because manipulating the area could cause the airway to close completely.