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

Nasotracheal Intubation: Facts and Contraindications

Nasotracheal intubation is NOT contraindicated for suspected cervical spine injury, but it is contraindicated for apnoeic patients who require immediate airway management. 1, 2

Contraindications and Limitations

• Nasotracheal intubation requires a spontaneously breathing patient, making it contraindicated for apnoeic patients who need immediate airway intervention 3
• It is NOT contraindicated for suspected cervical spine injury; in fact, it can be used as an alternative technique in patients with cervical spine instability or cervical spine fixation 2, 4
• Success rates on first attempt are generally poor, especially among non-anesthesia specialists, with one study showing only 6 successful intubations in 90 attempts among Advanced Trauma Life Support graduates 5
• Patient tolerance is typically lower compared to orotracheal intubation due to the trauma and discomfort associated with passage through the nasal cavity 4

Cervical Spine Considerations

• For patients with suspected cervical spine injury, nasotracheal intubation remains a viable option when performed by experienced providers 1, 2
• Orotracheal intubation with manual in-line stabilization is often preferred for patients with cervical spine injury due to higher success rates 1
• Videolaryngoscopy is recommended for patients with cervical spine injury as it increases intubation success with minimal cervical movement 1
• A prospective study demonstrated that orotracheal intubation with manual cervical immobilization was safe in patients with unstable cervical spine fractures, with no patients experiencing neurological deterioration 2

Complications of Nasotracheal Intubation

• Epistaxis is the most common complication, typically occurring due to damage to Kiesselbach's plexus in the anterior part of the nasal septum 4
• Risk of sinusitis is increased with prolonged nasotracheal intubation 4
• Superficial necrosis of the nasal ala can occur, particularly with prolonged intubation 4
• Bacteremia may result from abrasion of the nasal mucosa during tube insertion 4
• Airway injury including vocal cord paralysis, granuloma formation, and arytenoid dislocation can occur 1

Clinical Recommendations

• For critically ill patients with cervical spine injury, rapid sequence induction (RSI) with manual in-line stabilization is generally recommended over blind nasotracheal intubation 1
• When nasotracheal intubation is performed, using endotracheal tube cuff inflation in the pharynx can improve success rates, with one study showing 95% success compared to fiberoptic bronchoscopy 6
• Orotracheal intubation is preferred over nasotracheal intubation for most emergency airway management scenarios due to higher first-pass success rates 1
• Guidelines recommend performing orotracheal rather than nasotracheal intubation unless specifically contraindicated by the patient's condition 1

Pitfalls and Caveats

• Blind nasotracheal intubation requires significant skill and experience to perform successfully 5
• The technique should not be recommended as first-line management for securing airways in patients with suspected cervical spine injury unless performed by highly experienced providers 5
• For patients requiring prolonged intubation, the increased risk of sinusitis with nasotracheal tubes must be considered against the benefits 4
• When nasotracheal intubation is performed, proper preparation with vasoconstrictors and topical anesthesia can reduce complication rates 3

In summary, nasotracheal intubation is not contraindicated for patients with suspected cervical spine injury but is contraindicated for apnoeic patients. It is typically less successful on first attempt and less tolerated by patients compared to orotracheal intubation.