Nasal Intubation Without That Nasty Bleeding

Campsite View in Tibet - photo by JoAnn Sturman

During training at Seattle Children's Medical Center all of the anesthesia attendings insisted upon the residents nasally intubating our patients using the following technique. The problem with nasal intubation, especially in children, is not only stirring up severe cases of epistaxis, but also inadvertently performing a partial adenoidectomy as evidenced on occasion by finding a chunk of adenoid in the end of the endotracheal tube. To avoid causing this mess, we followed these 6 steps. 

1) Afrin spray to bilateral nares about ten minutes prior to going into the OR.

2) Soak a suitably-sized nasal ETT in hot water for about ten minutes so it is nice and pliable.

3) Have a red robinson foley catheter size 14 or 16, as well as a Magill forceps on the clean intubation equipment area on your anesthesia machine ready to go.

4)Preoxygenate well, then induce general anesthesia and paralyze as per your routine. You might consider squirting some 2% Lidocaine jelly in both nares at the time of induction. 

5) Cinch the red robinson onto the end of your nasal ETT and pass through the nares. Place your finger in the back of the patient's throat, you will feel the tip of the catheter descending into the nasopharynx. Grasp the tip, gently tug it up and out of the mouth while simultaneously pushing the ETT into the nose. By keeping the ETT tip seated in the catheter as you simultaneously push and pull, this provides atraumatic guidance of the ETT "around the corner" and into the oropharynx.

6) When the tip of the ETT is visualized in the oropharynx, take the red robinson off of the tip of the ETT and intubate using Magills as usual.

I've never caused a nosebleed using this technique.

Cliff VanPutten, MD
Anesthesia Consultants of Fresno