Nasal versus Tracheal Intubation
Intubation is a common intervention for patients who have diminished respiratory function. Additionally, intubation can be used to deliver nutrition and medication, bypass blockages, or allow doctors to examine airways. Depending on the condition of the patient and other parameters, different methods of intubation can be indicated for different situations. This article will examine and compare nasal versus tracheal intubation.
Nasal intubation was pioneered in 1902, and was at first used primarily for oral and dental surgeries to enable a clear operating field.1 However, it is now preferred over oral intubation for a number of additional indications, including patients with compromised cervical spine stability, intraoral lesions, or inability to fully relax and open the jaw.1 There are two main intranasal routes:2 the first, and often preferred, is the lower route, which involves guiding the intranasal tubing along the floor of the cavity. The alternate “upper route,” on the other hand, lies below the highly vascular middle turbinate, which is at the base of the cranium.2 The optimal route often depends on which is more accessible at the time of the intubation.
Despite being common, there are distinct challenges to nasal intubation. For example, there is a high degree of variation in the nasal anatomy, depending on genetic differences or, quite commonly, past trauma to the cartilage of the nose and the nasal cavity. Many of these differences are not reported in a patient history and are therefore encountered unexpectedly during the intubation process. A common alteration in anatomy is a deviated nasal septum.3 There are also a number of absolute contraindications for nasal intubation, including suspected epiglottitis, midface instability, coagulopathy, suspected basilar skull fractures, apnea or impending respiratory arrest.1 Despite being more comfortable in the long term, nasal intubation is also associated with increased bleeding, retro-pharyngeal and turbinate bones injury, and incidence of sinusitis.4 For patients who are predisposed to these sorts of complications, tracheal intubation is the preferred intervention when deciding between nasal versus tracheal intubation.
Tracheal (oral) intubation, on the other hand, is often preferred in trauma patients as it tends to be quicker and more comfortable.4 In crisis situations, unconscious patients are able to receive blind oral intubation, whereas blind nasal intubation typically requires patient consciousness. Oral intubation is preferred for patients with complex or blocked nasal airways and reduces risk of bleeding as well as retro-pharyngeal and turbinate bones injury.4 The technique is achieved by adjusting the positioning of a supine patient so that the head is elevated while retaining neck stabilization. A laryngoscope is then used to visualize the epiglottis and guide tube insertion. As with nasal intubation, there are many potential complications to oral intubation which should be considered prior to intervention, including soft tissue damage, vomiting or choking during insertion, incorrect tube placement, and hypoxia.4
In conclusion, nasal and oral intubation are both commonly practiced respiratory interventions; however, this does not mean that they are without complications and unique considerations. Individual patient needs should always be taken into consideration when determining whether to select nasal versus tracheal intubation.
References
1 Chauhan, V., & Acharya, G. (2016). Nasal intubation: A comprehensive review. Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine, 20(11), 662–667. https://doi.org/10.4103/0972-5229.194013
2 Smith, J. E., & Reid, A. P. (1999). Asymptomatic intranasal abnormalities influencing the choice of nostril for nasotracheal intubation. British journal of anaesthesia, 83(6), 882–886. https://doi.org/10.1093/bja/83.6.882
3 Scott-Brown, W. G., Ballantyne, J. C., & Groves, J. (Eds.). (1965). Diseases of the ear, nose, and throat (Vol. 2). Butterworths.
4 Holzapfel L. (2003). Nasal vs oral intubation. Minerva anestesiologica, 69(5), 348–352.