Complicated Nasal Intubation Made Easy

An alternative anesthetic technique can be employed when conventional nasal intubation methods do not work, according to an article in Anesthesia Progress.

The method involves a gum elastic bougie (GEB) device, which is useful for difficult airway management but seldom has been used for nasotracheal intubation.

While insertion of a tracheal tube followed by layrngoscopy are commonly used in conventional nasal intubation, complications may arise that may cause the patient’s head to be extended during the procedures. This results when the “glottis cannot be visualized or the tube does not enter the glottis,” the authors write.

The authors report how this application of GEB for nasal endotracheal intubation was performed in 16 patients whose tracheas could not be intubated by conventional techniques because of anatomical problems or misdirection of the tip of the tracheal tube. These patients were among 632 people undergoing dental procedures or oral surgery.

The authors explain how to place and connect the nasal tube for optimal use. They describe part of the process, once the GEB is inserted, as follows, “After the correct position of a GEB has been visualized, the tracheal tube is gently threaded down into the trachea over the GEB. Finally, the GEB is withdrawn, and the correct position of the tracheal tube is confirmed.”

They note that the use of several other mechanical aids including suction catheters, nasogastric tubes, stylets, and nasal flexible laryngeal masks has been reported previously for nasal intubation.

The go on to explain that “With this technique, the crucial point is that the tip of the GEB has to protrude approximately 4 to 5 cm beyond the tip of the tube, which makes it easy to maneuver the GEB.” Once this is taken into consideration, “The GEB and the nasal tube are then inserted into the trachea with a single movement.”

In instances when mouth opening is limited or prohibited, the authors note that fiber-optic intubation can be an effective approach to intubation, although they have found it to be time-consuming. Because of this, they suggest application of GEB as a good alternative.

"In our experience with use of these methods, this GEB technique is very quick, safe, inexpensive, and easy to perform," the authors write. "Thus, we recommend the use of GEB from the first attempt for nasal endotracheal intubation in patients with difficult airways."

Included in the article are diagrams that visualize the process and highlight key steps.

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What are your thoughts on incorporating GEB into nasal intubation procedures?