What are the contraindications and considerations for nasotracheal (nasal tracheal) intubation?

Nasotracheal Intubation: Contraindications and Considerations

Nasotracheal intubation is NOT contraindicated for suspected cervical spine injury but is contraindicated for apneic patients, has moderate first-attempt success rates, and is less tolerated by patients compared to endotracheal intubation.

Contraindications for Nasotracheal Intubation

Absolute Contraindications:

• Apneic patients: Nasotracheal intubation requires spontaneous breathing to guide tube placement 1
• Severe coagulopathy or bleeding disorders
• Suspected basilar skull fractures
• Severe facial trauma involving the nasopharynx
• Patient refusal (in awake techniques) 2

Relative Contraindications:

• Nasal polyps or tumors
• History of frequent epistaxis
• Anticoagulant therapy
• Nasal foreign bodies

Cervical Spine Injury Considerations

Despite common misconception, nasotracheal intubation is not contraindicated in patients with suspected cervical spine injury 2. In fact:

• The risk of secondary neurological injury attributable to airway management is extremely low 2
• Orotracheal intubation with manual in-line stabilization is safe and effective in patients with unstable cervical fractures 3
• For patients with cervical spine injury who are breathing spontaneously, awake techniques (including nasotracheal intubation) are a viable option 2

Success Rates and Tolerance

Success Rates:

• Nasotracheal intubation has a reported success rate of 90-92% overall 1
• However, first-attempt success is lower, with studies showing approximately 70% first-attempt success rates 4
• Success can be improved using adjunctive techniques such as endotracheal tube cuff inflation in the pharynx 4

Patient Tolerance:

• Nasotracheal intubation is generally less tolerated by patients than orotracheal intubation 2
• It causes more stimulation of the airway reflexes, leading to:
  • Increased cardiovascular responses (hypertension, tachycardia)
  • Greater discomfort during placement
  • Higher risk of laryngospasm if performed under inadequate anesthesia

Common Complications

1. Epistaxis (most common complication):

   • Occurs due to damage to Kiesselbach's plexus in the anterior nasal septum 5
   • Can be minimized by proper technique and vasoconstrictors

2. Sinusitis:

   • Risk increases with prolonged intubation
   • Can lead to mucosal edema and middle ear problems 5

3. Nasal alar necrosis:

   • Results from pressure on nasal tissues 5
   • More common with prolonged intubation

4. Bacteremia:

   • Due to abrasion of nasal mucosa 5
   • Can lead to contamination of the lower airway

Best Practices for Nasotracheal Intubation

1. Patient Selection:

   • Use orotracheal rather than nasotracheal intubation when possible 2
   • Reserve nasotracheal intubation for specific indications (e.g., oral surgery, maxillofacial trauma)

2. Preparation:

   • Apply vasoconstrictor to nasal passages
   • Consider topical anesthesia for awake techniques
   • Select appropriate tube size (smaller than for oral intubation)

3. Technique:

   • Insert tube with bevel facing laterally to avoid septal damage 5
   • Use gentle, steady pressure following the natural curvature of the nasopharynx
   • Consider tube warming to increase pliability

4. Post-Procedure:

   • Secure tube carefully to avoid pressure on nasal ala
   • Monitor for bleeding or signs of sinusitis
   • Consider prophylactic measures for prolonged intubation

Nasotracheal intubation remains a valuable technique in specific clinical scenarios, particularly when oral access is limited or compromised, but requires careful consideration of its risks, benefits, and proper technique to minimize complications.