Nasotracheal Intubation

Endotracheal intubation is indicated whenever direct access to the lower airway is required.

I. Technique of Introduction [1,2]

1. Open a sterile, 55 cm long, 7 to 10 mm Bivona® silastic endotracheal tube.
2. Inflate the cuff with a 5-20 ml syringe (depending on the size of the cuff) and make sure that the cuff does not leak.
3. Lubricate the cuff and the end of the tube (but not the lumen) with sterile K-Y jelly.
4. Gently pass the tube into the nasal cavity along the ventromedial side of the canal. Gently rotate the tube counterclockwise and clockwise as it is advanced.
5. If the tube meets an obstruction, withdraw it slightly, rotate it 180o and re-advance it. Do not try to force the tube past the obstruction.
6. If several attempts have failed to pass through the nasal cavity, either try the other nostril or a smaller endotracheal tube.
7. Once the endotracheal tube has passed into the nasopharynx (as determined by a reduced resistance to further introduction of the tube) extend the foal's head and, while gently rotating the tube, introduce the tube into the larynx.
8. Presence of the tube in the trachea can be confirmed by feeling or listening to large volumes of air moving out of the tube during exhalation.
9. If the tube passes instead into the esophagus, withdraw it into the nasopharynx, rotate it 180°, place pressure with fingers on proximal esophagus to prevent entry and re-advance it.
10. If the tube again does not pass into the larynx, withdraw it, change the foal's head and neck position and re-insert it.
11. If several positions and several attempts have failed, visualize the larynx with a long laryngoscope blade and attempt to introduce the tube under direct visualization.
12. If this technique is also unsuccessful, introduce a long, relatively stiff plastic stylet through the lumen of the tube and into the larynx. This stylet may then be used to guide the larger endotracheal tube into place.
13. If this technique also fails, grasp the end of the tube (which can be visualized in the oropharynx) with a long forceps (which has been introduced through the mouth) and direct the end of the tube into the larynx.
14. The tube should be introduced far enough so that the cuff is beyond the larynx and so that the tip of the tube is short of the thoracic inlet.
15. Apply tape to the tube, leave tag to allow suturing to the nostril.
16. Tubes should be changed daily because the lumen can accumulate material and plug airway.

II. Technique for Inflation of the Cuff [1,2]

1. The cuff may need to be inflated during positive pressure ventilation to prevent unwanted leakage. The cuff is inflated during application of positive pressure to the airways and while listening to the air leak.
2. The cuff should be inflated just to the point that it prevents the back-leak of air at the pressure being used. Any more pressure may cause damage to the tracheal wall which must, at all costs, be avoided.
3. The cuff should be inflated with a syringe and the volume used should be recorded. The proper level of cuff inflation should be re-evaluated periodically and changes in the volume of air required to provide the seal should be noted.