Attaching a nasal airway to a breathing circuit as a tool to assist or control ventilation is a very helpful trick to have in challenging airway management situations.
Many years ago I was taking care of a 40 y.o. man had Ludwig’s Angina, a serious, potentially life-threatening cellulitis infection of the tissues of the floor of the mouth, often occurring in an adult with a dental infection. Ludwig’s Angina has nothing to do with cardiac angina. “Angina” is a word that comes from the Greek and means strangling — in this case strangling from airway obstruction. This gentleman had swelling so bad that it was hard to tell where his chin ended and his neck began. He was a big man anyway, over 6 ft tall and 110 kg (240 lbs.).
After 5 mg of valium and 50 mcg of fentanyl (both very small doses for a man his size) and an aerosolized lidocaine/pontocaine mixture he was ready. We did not perform injected nerve blocks because of concern of injecting into infected tissue. We needed to be gentle to avoid rupturing any abscesses in the oropharynx.
The nasal fiberoptic intubation went gratifyingly easily. The patient cooperatively took deep breaths on command as I pulled his tongue outward with a gauze pad. My resident expertly intubated him in less than 2 minutes.
We taped the tube. With the airway secure and the anesthetic proceeding uneventfully I left OR 3 and went to the adjacent OR 4 to see how my other resident was doing with his case. As I walked out, the surgeons were just starting to position the patient for surgery.
It wasn’t three minutes before the door burst open and an RN yelled that they needed me stat in OR 3. Upon arrival I saw my resident mask ventilating our Ludwig’s Angina patient, the ETT, on the ground. The surgeon had tripped over the anesthesia breathing circuit while turning the table and pulled the tube out.
Normally we could have awakened him and redone the awake intubation, but my resident had just paralyzed him with a long acting agent. Instead, I inserted a lubricated nasal airway with an endotracheal tube adaptor into the left nostril to which we attached our breathing circuit. My resident ventilated, closing the patient’s mouth with his left hand while squeezing the bag with his right.
In the meantime I inserted a new endotracheal tube into the right nostril and repeated the fiberoptic visualization. With the mouth tightly closed there was a fortuitous fold in the swollen tongue forming an open channel in the midline leading straight to the larynx. I followed it down and reintubated the patient. We retaped the tube and this time we turned the table for the surgeon, while holding the tube securely. The rest of the case was uneventful.
Use of the Nasal Airway To Ventilate
The trick we used to ventilate during this repeat fiberoptic intubation was one I was taught when I was a resident. It is useful for maintaining deep inhalation anesthesia in either an apneic or spontaneously ventilating anesthetized patient if you don’t have an endoscopic face mask.
First, insert an endotracheal tube adapter into the nasal airway. Place this nasal airway into the opposite nostril and attach it to your ventilation apparatus. Insert your nasotracheal tube using the other nostril and listening to breath sounds, guide the tube to the trachea.
This technique is particularly helpful during blind nasal intubation or fiberoptic intubation in young children after induction of general anesthesia for surgery, although in our example our patient was an adult. When using this technique, once the patient is anesthetized, connect the endotracheal tube adapter as described above to the anesthesia machine. Maintain depth of anesthesia through the nasal airway while nasal intubation is performed through the other nostril while the patient continues to breath spontaneously. Note that the breathing circuit is open and will allow waste anesthetic gas to escape into the room.
As you can see in our example, you can also use the same nasal airway to assist or control ventilation during the blind nasal or fiberoptic intubation. To do this you must close the mouth and occlude the other nostril until you place your nasotracheal tube into it and ventilate. You will need an assistant. When the assistant ventilates, the lungs inflate. If you are performing blind nasal intubation you can hear breath sounds out of the end of the endotracheal tube between breathes as the patient exhales, guiding your placement.
Be aware that the tip of the nasal airway can deflect the tip of the nasotracheal tube away from the larynx if it’s long enough. The nasal airway must occasionally be withdrawn slightly if it’s deflecting the nasal endotracheal tube in the posterior pharynx. Then withdraw the endotracheal tube slightly and try again if this occurs.
Nowadays we have intubating LMAs and that also might have been an option, although the distortion of the posterior pharynx and the potential for abscess rupture would have made this risky.
- Watch your feet. Every room is different. An outlet can be on the left in one room and on the right in another. Take note of the arrangement of equipment before you begin.
- Make sure you get everything ready for a table turn before you start to move. This often means disconnecting your breathing circuit and monitor cords. Make sure the IV tubing will not get pulled.
- Always tape your endotracheal tubes as though your patient’s life depends on it, because it does.
- Hold onto the tube where it exits the mouth when moving the patient.
- Always be ready for accidental extubation, not just with healthy patients, but also ones in poor health.
- Verify tube placement after every move.
May The Force Be With You
Christine Whitten MD