What is the likelihood of a patient experiencing epistaxis (nosebleed) and pharyngeal bleeding (throat bleeding) during intubation after sedation?

From the Guidelines

Bleeding from the nose and throat during intubation after sedation is relatively uncommon, occurring in approximately 1-5% of cases, with the risk increasing in traumatic or difficult intubations, particularly in patients with anatomical challenges, coagulopathies, or those on anticoagulant medications. The likelihood of epistaxis and pharyngeal bleeding during intubation is influenced by several factors, including multiple intubation attempts, use of larger endotracheal tubes, pre-existing nasal or pharyngeal pathology, and patients with bleeding disorders 1. To minimize this risk, proper technique is essential, including appropriate sedation combined with neuromuscular blockade for optimal intubating conditions. Using video laryngoscopy rather than direct laryngoscopy can reduce trauma, especially in difficult airways, as noted in studies on intubation and extubation in the ICU 1. For patients with known bleeding risks, having suction readily available and considering smaller endotracheal tubes may be beneficial. The bleeding is typically self-limiting and rarely requires specific intervention beyond gentle suctioning.

Key Factors Influencing Bleeding Risk

• Multiple intubation attempts
• Use of larger endotracheal tubes
• Pre-existing nasal or pharyngeal pathology
• Patients with bleeding disorders
• Traumatic or difficult intubations

Recommendations for Minimizing Bleeding Risk

• Proper technique, including appropriate sedation and neuromuscular blockade
• Use of video laryngoscopy instead of direct laryngoscopy
• Having suction readily available
• Considering smaller endotracheal tubes for patients with known bleeding risks
• Avoiding routine use of throat packs, as they have been associated with more harm than benefit 1

From the Research

Incidence of Epistaxis and Pharyngeal Bleeding

• The incidence of epistaxis after nasotracheal intubation (NTI) is higher in the blind insertion/direct laryngoscopy group (88%) compared to the fiberoptic group (51%) 2.
• The severity of bleeding is also greater in the blind tube insertion/direct laryngoscopy cohort 2.
• Epistaxis is one of the most common complications of nasotracheal intubation and can be life-threatening 3.
• Nasotracheal intubation may lead to certain complications, with epistaxis being the most common, generally occurring due to damage of the Kiesselbach's plexus in the anterior part of the nasal septum 4.

Pharyngeal Bleeding

• There is limited information available on the incidence of pharyngeal bleeding during intubation after sedation.
• However, it is mentioned that nasotracheal intubation can cause mucosal oedema in the nasopharynx, which can result in middle-ear problems 4.

Sedation and Intubation

• A combination of remifentanil and propofol can be used as a safe sedation regimen for fiberoptic intubation 5.
• The use of fiberoptic visualization and guidance rather than direct laryngoscopy may affect the incidence and severity of epistaxis during NTI 2.
• Nasal capnography can be used to monitor ventilation during bronchoscopy and intubation, and the onset of hypoventilation can be recognized and treated by adjusting the narcotic dose 5.

Complications and Countermeasures

• Nasotracheal intubation can lead to complications such as epistaxis, sinusitis, and superficial necrosis of the nasal ala 4.
• A simple countermeasure to avoid possible complications of nasotracheal intubation involves removing nasal dirt from the tip of the tracheal tube and cleaning the pharynx before advancing the tube into the larynx 4.