The Journal
of Emergency
Medune,
Vol 10. pp 729-734.
Prlnted in the USA t CopyrIght
1992
0 1992 Pergamon
Press Ltd
TECHNIQUES OF NASOTRACHEAL INTUBATION WITH THE FIBEROPTIC BRONCHOSCOPE Morito Nakayama, MD, Naoyuki Kataoka, MD, Yutaka Usui, MD, Naohiko Inase, MD, Shigemitsu Takayama, MD, and Hirotaro Miura, Reprint
Address:
Morito
Department Nakayama,
of Internal Medicine, Yokosuka Kyosai MD, Department of Internal Medicine,
0 Keywords - nasotracheal intubation; fiberoptic bronchoscopy; nasal obstruction; epistaxis; hoarseness
INTRODUCTION During nasotracheal intubation using a fiberoptic bronchoscope, passage of the endotracheal tube may be impeded, occasionally resulting in various complications, including epistaxis, nasal turbinate fracture, hoarseness, and tearing of the intubation cuff. The purpose of this study was to determine the sites and causes of obstruction and resultant complications, and to suggest the optimal technique of bronchoscopeassisted intubation to reduce these complications.
Yokosuka,
Japan
238
RESULTS The sites of endotracheal tube block were invariably either the nasal cavity or the larynx. In the nasal cavity, partial obstruction resulting in blocking of the tube was caused by 1) deviation of the nasal septum; 2) nasal septal spur; 3) mucosal thickening of inflamed turbinates; and 4) nasal polyp. In the larynx, the cause of obstruction was suboptimal positioning of the endotracheal tube resulting in block of the tube against the arytenoids. Each of these sources of obstruction will be discussed further. Obstruction in the nasal cavity is commonly due to a deviated nasal septum (Figures 1 and 2), but may also occur secondary to a cartilaginous spur of the nasal septum (Figure 3). In these instances, epistaxis may occur; additionally, the cuff of the endotracheal tube may be torn by the nasal spur, as occurred in
AND METHODS
Between 1981 and 1988 in the Department of Respiratory Medicine, we performed 180 nasotracheal intubations using fiberoptic bronchoscopy. Most patients had acute exacerbation of chronic obstructive pulmonary disease, but other patients had status asthmaticus, sequela of old tuberculosis, pulmonary fibrosis, bronchiectasis, pneumoconiosis, or lung =
Yokosuka, Japan Kyosai Hospital,
cancer. The patients required intubation because of acute respiratory failure or exacerbation of chronic respiratory failure. The nasal cavity, oropharynx, and larynx were observed prior to and after nasotracheal intubation. The various sites where the intubation tube was blocked were observed and complications associated with block at these sites were noted. The optimal method of endotracheal intubation using fiberoptic bronchoscopy was determined. This technique can be performed by pulmonologists, anesthesiologists, otolaryngologists, and emergency physicians.
0 Abstract-When nasotracheal intubation with a fiberoptic bronchoscope is performed, the tube may be blocked in the nasal cavity or larynx, resulting in several complications including epistaxis and hoarseness. We review the causesand complications of tube blockage and discussoptimal techniques for minimizing it.
MATERIALS
Hospital, Yokosuka
MD
Techniques and Procedures features practical, “how-to” articles of interest to all practicing emergency physicians.
=
This section is coordinated by George Sternbach, MD, Stanford University Medical Center. RECEIVED: 23 November 1990; FINAL SUBMISSION RECEIVED: 15 October 1991; 0736-4679/92 $5.00 + .OO ACCEPTED: 30 October 1991 729
M. Nakayama, N. Kataoka, Y. Usui, N. Inase, S. Takayama, H. Miura
730
3 Figure 1. The anterior part of the nasal septum projects prominently into one side of the nose, obstructing passage of the Intubation tube. Arrow 1 indicates the middle turbinate, arrow 2 the Inferior turblnate, and arrow 3 the nasal septum.
one of our patients. Other causes of partial obstruction in the nasal cavity include nasal polyps (Figure 4), mucosal thickening of inflamed turbinates (Figure 5), both of which may be associated with epistaxis and, as occurred in one of our patients, fracture of the middle turbinate. The latter complication occurred after intubation was performed through the upper part of the common nasal meatus because of an inflamed edematous inferior turbinate that had been pretreated with only 4% xylocaine. This emphasizes the optimal strategy for dealing with intubation in cases where partial nasal obstruction is due to in-
Figure 2. Photograph of structur& in Flgure 1. Ttie right nasal cavity Is shown. Arrow 1 indicates the inferior turbinate, and arrow 2 the nasal septum.
Figure 3. This photograph shows the left nasal cavity. A sharp spur can be seen in the center of the nasal septum (arrow). Arrow 1 indicates the mlddle turbinate, arrow 2 the Inferior turbinate, and arrow 3 the nasal septum.
flamed mucosa or polyps. In these cases, 4% xyloCaine and 1300 epinephrine spray applied topically to the nasal mucosa just prior to intubation will promote contraction of these tissues. The effect of this is demonstrated in the photographs that show the inferior turbinate prior to (Figure 5) and after (Figure 6) application of xylocaine and epinephrine. We recommend intubation through the common nasal meatus (Figure 7) because it usually becomes the most patent meatus. In contrast to the effectiveness of this technique when used in cases of incomplete obstruction due to small nasal polyps, intubation is not facilitated when the nasal cavities are totally obstructed by polyps (Figure 4). We rely on oral intubation in these cases.
Figure 4. Nasal polyps. It Is difficult to lntubate in the presence of enlarged polyps (arrow 1). Arrow 2 indicates the inferior turbinate, arrow 3 the small polyps.
Nasotracheal
731
lntubation
3 Figure 5. Mucosal thickening of the inferfor turbinate before application of eplnephrine. Arrow 1 indicates the inferior turbinate and arrow 2 the inferior meatus.
At the larynx, block was observed to occur due to suboptimal positioning of the endotracheal tube as it passed the arytenoids (Figure 8). It became apparent that when the bevel of the tube was facing anteriorly, the tube would be blocked by the right or left arytenoid or interarytenoid (Figure 9). Although not encountered in our patients, attempts to pass the tube in such a case might result in permanent hoarseness from arytenoid injury. The optimal positions of the tube during intubation were determined and are shown in Figure 10. To ensure optimal positioning, the physician should place the blue line of the tube
Figure 6. Mucosal contraction of the inferlor turbinate after application of epinephrine. Arrow 1 indicates the inferior turbinate.
Figure 7. The intubation tube should be inserted in the common nasal meatus as far as possible (arrow). Arrow 1 lndicates the nasal septum, arrow 2 the middle turbinate, and arrow 3 the inferior turbinate.
to his right and make sure to intubate without rotating the tube (Figure 11).
DISCUSSION Nasotracheal intubation guided by fiberoptic bronchoscopy has become common since its first description by Taylor and Towey (1). Epistaxis related to
Flgure 6. The intubation tubs was blocked at the arytenoid during nasotracheal intubatlon. The bevel of the tube Is facing anteriorly. Attempts to pass the tuba further would result in blockage of the tube by the arytenolds and Intemrytenoid. Arrow 1 indicates the right arytenoid, arrow 2 the posterior wall of the hypopharynx, arrow 3 the intemrytenoid, and arrow 4 the beveled edge of the tube.
732
Figure bation facing arrow
M. Nakayama, N. Kataoka, Y. Usui, N. Inase, S. Takayama, H. Miura
9. This model picture shows the position of the Intutube tip In Figure 8. The beveled edge of the tuba is anteriorly. Arrow 1 indicates the right vocal cord, 2 the right atytenold, and arrow 3 the Interarytenold.
nasal trauma or obstruction is the most common complication of this procedure. Because of its vasoconstrictive effects, epinephrine is very helpful in minimizing this complication. However, textbooks Figure 11. After confirming the appropriate orientation of the blue line of the endotracheal tube (arrow), the physician inserts the tube straight. In this example, the beveled edge of the tube will face posteriorly when it passes the vocal cords (see Figure lo), and the blue line is on the right.
(4
Figure 10. Optimal poeltlons of the endotracheal tube tip are shown in these pictures. A} The beveled edge of the tuba is facing posteriorly (arrow), 9) it is facing left laterally (right lateral orientation is sfao acceptable). Arrow 1 indicates the right vocal cord and arrow 2 the right arytenoid.
Figure 12. Nasotracheal intubation is being performed. We usually insert the fiberoptic bronchoacope through the IIntubation tube in advance.
Nasotracheal
lntubation
Figure 13. This picture shows the left nasal cavity. Arrow 1 indicates the common nasal meatus, arrow 2 the inferior turbinate, arrow 3 the Inferior meatus, arrow 4 the floor of the nose, and arrow 5 the nasal septum.
Figure 15. This shows the pharynx and larynx. Arrow 1 indicates the base of the tongue, arrow 2 the epiglottis, arrow 3 the arytenoids, and arrow 4 the posterior wall of the pharynx.
published in our country, particularly those dealing with fiberoptic bronchoscopy, do not commonly recommend the use of epinephrine. We apply a solution of equal amounts of 1:5000 epinephrine and 4% xylocaine spray (a total of 2 mL) on the nasal mucosa and obtain patency of the nasal cavity, particularly the common nasal meatus. In hypertensive patients and those 60 years or older, use of smaller amounts of epinephrine should be considered. Alternatively, nasal decongestants such as neosynephrine can be
used. To ensure ease of suctioning, we intubate with an 8.5- to 9.0-mm tube in males and an 8.0- to 8.5mm tube in females (Japanese nasal cavities are generally narrow). Of our 180 cases of nasotracheal intubation with fiberoptic bronchoscopy, only four instances of epistaxis occurred, one in a patient with end-stage leukemia. Two other complications were observed, one a fracture of the middle turbinate (which may cause meningitis from extension of infection through the cribriform plate), and the other a tear of the endotracheal tube cuff. Sekiya et al (2) reported a case of cuff perforation that they believed
Figure 14. This is the nasopharynx. Arrow 1 indicates the posterior end of the nasal septum, arrow 2 the right orifice of the eustachian tube, arrow 3 the posterlor wall of the nasopharynx, and arrow 4 the posterior tip of the inferlor turbinate.
Figure 16. This is the larynx. Arrow cords, arrow 2 the arytenoids.
1 indicates
the vocal
M. Nakayama,
Figure 17. This shows the trachea. Arrow 1 indicates the carina, arrow 2 the right main bronchus, and arrow 3 the left main bronchus.
occurred during rotation of the tube in the nasal cavity, pharynx, or larynx. The nasal cavity is the more likely site of cuff perforation because the pharynx and larynx are largely composed of soft tissues. Ripley reported cuff perforation on turbinate projections during intubation (3). A sharp spur on the nasal septum was thought to tear the cuff in our case. Because of these considerations, we perform nasotracheal intubation with the fiberoptic bronchoscope in the following manner: 1. The patient lies supine with the physician at the patient’s head. 2. The optimal nasal cavity for intubation is chosen by visualizing the cavities with a bronchoscope or, time permitting, a nasal speculum. 3. Epinephrine (1:5000) and xylocaine (4Vo) in equal amounts (total 1.5 to 2 mL) are applied to the nasal mucosa using Jackson spray. 4. The fiberoptic bronchoscope (we use an Olympus B3R, BF-10 or BF-20) is inserted (usually in advance) through the intubation tube (Figure 12) after lubricating the entire bronchoscope with sterile olive oil (1 to 2 mL) or xylocaine jelly. Xylocaine jelly is
N. Kataoka,
Y. Usui, N. Inase, S. Takayama,
H. Miura
also applied to the distal half of the intubation tube for lubrication. 5. The bronchoscope is inserted into the nasal fossa adjacent to the inferior turbinate (common nasal meatus) (Figure 13). 6. After visualization of the nasopharynx (Figure 14), 4% xylocaine (2 mL) is instilled through the bronchoscope by syringe. Then the tip of the bronchoscope is angled up and advanced approximately 1 to 2 centimeters. When the epiglottis and base of the tongue are observed (Figure 15), additional 4% xylocaine (2 mL) is instilled. The xylocaine is promptly aspirated by suction after instilling it in order to avoid xylocaine intoxication. Then the tip of the bronchoscope is angled down a little, and advanced through the epiglottis to the larynx. When the vocal cords are visualized (Figure 16), 2 to 3 mL of 4% xylocaine is instilled into the vocal cords and trachea. We promptly aspirate the xylocaine after instillation on the vocal cords but not from the trachea. 7. After advancing the bronchoscope past the vocal cords, 2 mL of 4% xylocaine is applied to the trachea, and the tip of the bronchoscope is advanced to the juncture of the middle and distal third of the trachea (Figure 17). Then the intubation tube is inserted straight without rotation over the bronchoscope into the middle third of the trachea. 8. The bronchoscope is withdrawn 2 to 3 centimeters to visualize the position of the tip of the intubation tube, then sputum is aspirated through the bronchoscope, and finally the bronchoscope is removed.
SUMMARY
The sites, causes, and complications of obstruction during bronchoscopy-directed nasotracheal intubation are presented. Techniques for minimizing obstruction and its complications are discussed. Acknowledgment-We Yokosuka Naval English language.
would like to thank Dr. Cook at Hospital for his advice concerning the
REFERENCES 1. Taylor PA, Towey RM. The broncho-fiberscope as an aid to endotracheal intubation. Br J Anaesth. 1972;44:611-12. 2. Sekiya S, Kuramitsu K, Kiuchi H, et al. Nasotracheal intubation with the flexible fiberoptic bronchoscope. J Jap Sot Bronchology. 1984;2:269-73.
3. Ripley JF, Mcanear JT, Tilson HB. Endotracheal tube obstruction due to impaction of the inferior turbinate. J Oral Maxillofat Surg. 1984;42:687-8.
of Emergency
Medune,
Vol 10. pp 729-734.
Prlnted in the USA t CopyrIght
1992
0 1992 Pergamon
Press Ltd
TECHNIQUES OF NASOTRACHEAL INTUBATION WITH THE FIBEROPTIC BRONCHOSCOPE Morito Nakayama, MD, Naoyuki Kataoka, MD, Yutaka Usui, MD, Naohiko Inase, MD, Shigemitsu Takayama, MD, and Hirotaro Miura, Reprint
Address:
Morito
Department Nakayama,
of Internal Medicine, Yokosuka Kyosai MD, Department of Internal Medicine,
0 Keywords - nasotracheal intubation; fiberoptic bronchoscopy; nasal obstruction; epistaxis; hoarseness
INTRODUCTION During nasotracheal intubation using a fiberoptic bronchoscope, passage of the endotracheal tube may be impeded, occasionally resulting in various complications, including epistaxis, nasal turbinate fracture, hoarseness, and tearing of the intubation cuff. The purpose of this study was to determine the sites and causes of obstruction and resultant complications, and to suggest the optimal technique of bronchoscopeassisted intubation to reduce these complications.
Yokosuka,
Japan
238
RESULTS The sites of endotracheal tube block were invariably either the nasal cavity or the larynx. In the nasal cavity, partial obstruction resulting in blocking of the tube was caused by 1) deviation of the nasal septum; 2) nasal septal spur; 3) mucosal thickening of inflamed turbinates; and 4) nasal polyp. In the larynx, the cause of obstruction was suboptimal positioning of the endotracheal tube resulting in block of the tube against the arytenoids. Each of these sources of obstruction will be discussed further. Obstruction in the nasal cavity is commonly due to a deviated nasal septum (Figures 1 and 2), but may also occur secondary to a cartilaginous spur of the nasal septum (Figure 3). In these instances, epistaxis may occur; additionally, the cuff of the endotracheal tube may be torn by the nasal spur, as occurred in
AND METHODS
Between 1981 and 1988 in the Department of Respiratory Medicine, we performed 180 nasotracheal intubations using fiberoptic bronchoscopy. Most patients had acute exacerbation of chronic obstructive pulmonary disease, but other patients had status asthmaticus, sequela of old tuberculosis, pulmonary fibrosis, bronchiectasis, pneumoconiosis, or lung =
Yokosuka, Japan Kyosai Hospital,
cancer. The patients required intubation because of acute respiratory failure or exacerbation of chronic respiratory failure. The nasal cavity, oropharynx, and larynx were observed prior to and after nasotracheal intubation. The various sites where the intubation tube was blocked were observed and complications associated with block at these sites were noted. The optimal method of endotracheal intubation using fiberoptic bronchoscopy was determined. This technique can be performed by pulmonologists, anesthesiologists, otolaryngologists, and emergency physicians.
0 Abstract-When nasotracheal intubation with a fiberoptic bronchoscope is performed, the tube may be blocked in the nasal cavity or larynx, resulting in several complications including epistaxis and hoarseness. We review the causesand complications of tube blockage and discussoptimal techniques for minimizing it.
MATERIALS
Hospital, Yokosuka
MD
Techniques and Procedures features practical, “how-to” articles of interest to all practicing emergency physicians.
=
This section is coordinated by George Sternbach, MD, Stanford University Medical Center. RECEIVED: 23 November 1990; FINAL SUBMISSION RECEIVED: 15 October 1991; 0736-4679/92 $5.00 + .OO ACCEPTED: 30 October 1991 729
M. Nakayama, N. Kataoka, Y. Usui, N. Inase, S. Takayama, H. Miura
730
3 Figure 1. The anterior part of the nasal septum projects prominently into one side of the nose, obstructing passage of the Intubation tube. Arrow 1 indicates the middle turbinate, arrow 2 the Inferior turblnate, and arrow 3 the nasal septum.
one of our patients. Other causes of partial obstruction in the nasal cavity include nasal polyps (Figure 4), mucosal thickening of inflamed turbinates (Figure 5), both of which may be associated with epistaxis and, as occurred in one of our patients, fracture of the middle turbinate. The latter complication occurred after intubation was performed through the upper part of the common nasal meatus because of an inflamed edematous inferior turbinate that had been pretreated with only 4% xylocaine. This emphasizes the optimal strategy for dealing with intubation in cases where partial nasal obstruction is due to in-
Figure 2. Photograph of structur& in Flgure 1. Ttie right nasal cavity Is shown. Arrow 1 indicates the inferior turbinate, and arrow 2 the nasal septum.
Figure 3. This photograph shows the left nasal cavity. A sharp spur can be seen in the center of the nasal septum (arrow). Arrow 1 indicates the mlddle turbinate, arrow 2 the Inferior turbinate, and arrow 3 the nasal septum.
flamed mucosa or polyps. In these cases, 4% xyloCaine and 1300 epinephrine spray applied topically to the nasal mucosa just prior to intubation will promote contraction of these tissues. The effect of this is demonstrated in the photographs that show the inferior turbinate prior to (Figure 5) and after (Figure 6) application of xylocaine and epinephrine. We recommend intubation through the common nasal meatus (Figure 7) because it usually becomes the most patent meatus. In contrast to the effectiveness of this technique when used in cases of incomplete obstruction due to small nasal polyps, intubation is not facilitated when the nasal cavities are totally obstructed by polyps (Figure 4). We rely on oral intubation in these cases.
Figure 4. Nasal polyps. It Is difficult to lntubate in the presence of enlarged polyps (arrow 1). Arrow 2 indicates the inferior turbinate, arrow 3 the small polyps.
Nasotracheal
731
lntubation
3 Figure 5. Mucosal thickening of the inferfor turbinate before application of eplnephrine. Arrow 1 indicates the inferior turbinate and arrow 2 the inferior meatus.
At the larynx, block was observed to occur due to suboptimal positioning of the endotracheal tube as it passed the arytenoids (Figure 8). It became apparent that when the bevel of the tube was facing anteriorly, the tube would be blocked by the right or left arytenoid or interarytenoid (Figure 9). Although not encountered in our patients, attempts to pass the tube in such a case might result in permanent hoarseness from arytenoid injury. The optimal positions of the tube during intubation were determined and are shown in Figure 10. To ensure optimal positioning, the physician should place the blue line of the tube
Figure 6. Mucosal contraction of the inferlor turbinate after application of epinephrine. Arrow 1 indicates the inferior turbinate.
Figure 7. The intubation tube should be inserted in the common nasal meatus as far as possible (arrow). Arrow 1 lndicates the nasal septum, arrow 2 the middle turbinate, and arrow 3 the inferior turbinate.
to his right and make sure to intubate without rotating the tube (Figure 11).
DISCUSSION Nasotracheal intubation guided by fiberoptic bronchoscopy has become common since its first description by Taylor and Towey (1). Epistaxis related to
Flgure 6. The intubation tubs was blocked at the arytenoid during nasotracheal intubatlon. The bevel of the tube Is facing anteriorly. Attempts to pass the tuba further would result in blockage of the tube by the arytenolds and Intemrytenoid. Arrow 1 indicates the right arytenoid, arrow 2 the posterior wall of the hypopharynx, arrow 3 the intemrytenoid, and arrow 4 the beveled edge of the tube.
732
Figure bation facing arrow
M. Nakayama, N. Kataoka, Y. Usui, N. Inase, S. Takayama, H. Miura
9. This model picture shows the position of the Intutube tip In Figure 8. The beveled edge of the tuba is anteriorly. Arrow 1 indicates the right vocal cord, 2 the right atytenold, and arrow 3 the Interarytenold.
nasal trauma or obstruction is the most common complication of this procedure. Because of its vasoconstrictive effects, epinephrine is very helpful in minimizing this complication. However, textbooks Figure 11. After confirming the appropriate orientation of the blue line of the endotracheal tube (arrow), the physician inserts the tube straight. In this example, the beveled edge of the tube will face posteriorly when it passes the vocal cords (see Figure lo), and the blue line is on the right.
(4
Figure 10. Optimal poeltlons of the endotracheal tube tip are shown in these pictures. A} The beveled edge of the tuba is facing posteriorly (arrow), 9) it is facing left laterally (right lateral orientation is sfao acceptable). Arrow 1 indicates the right vocal cord and arrow 2 the right arytenoid.
Figure 12. Nasotracheal intubation is being performed. We usually insert the fiberoptic bronchoacope through the IIntubation tube in advance.
Nasotracheal
lntubation
Figure 13. This picture shows the left nasal cavity. Arrow 1 indicates the common nasal meatus, arrow 2 the inferior turbinate, arrow 3 the Inferior meatus, arrow 4 the floor of the nose, and arrow 5 the nasal septum.
Figure 15. This shows the pharynx and larynx. Arrow 1 indicates the base of the tongue, arrow 2 the epiglottis, arrow 3 the arytenoids, and arrow 4 the posterior wall of the pharynx.
published in our country, particularly those dealing with fiberoptic bronchoscopy, do not commonly recommend the use of epinephrine. We apply a solution of equal amounts of 1:5000 epinephrine and 4% xylocaine spray (a total of 2 mL) on the nasal mucosa and obtain patency of the nasal cavity, particularly the common nasal meatus. In hypertensive patients and those 60 years or older, use of smaller amounts of epinephrine should be considered. Alternatively, nasal decongestants such as neosynephrine can be
used. To ensure ease of suctioning, we intubate with an 8.5- to 9.0-mm tube in males and an 8.0- to 8.5mm tube in females (Japanese nasal cavities are generally narrow). Of our 180 cases of nasotracheal intubation with fiberoptic bronchoscopy, only four instances of epistaxis occurred, one in a patient with end-stage leukemia. Two other complications were observed, one a fracture of the middle turbinate (which may cause meningitis from extension of infection through the cribriform plate), and the other a tear of the endotracheal tube cuff. Sekiya et al (2) reported a case of cuff perforation that they believed
Figure 14. This is the nasopharynx. Arrow 1 indicates the posterior end of the nasal septum, arrow 2 the right orifice of the eustachian tube, arrow 3 the posterlor wall of the nasopharynx, and arrow 4 the posterior tip of the inferlor turbinate.
Figure 16. This is the larynx. Arrow cords, arrow 2 the arytenoids.
1 indicates
the vocal
M. Nakayama,
Figure 17. This shows the trachea. Arrow 1 indicates the carina, arrow 2 the right main bronchus, and arrow 3 the left main bronchus.
occurred during rotation of the tube in the nasal cavity, pharynx, or larynx. The nasal cavity is the more likely site of cuff perforation because the pharynx and larynx are largely composed of soft tissues. Ripley reported cuff perforation on turbinate projections during intubation (3). A sharp spur on the nasal septum was thought to tear the cuff in our case. Because of these considerations, we perform nasotracheal intubation with the fiberoptic bronchoscope in the following manner: 1. The patient lies supine with the physician at the patient’s head. 2. The optimal nasal cavity for intubation is chosen by visualizing the cavities with a bronchoscope or, time permitting, a nasal speculum. 3. Epinephrine (1:5000) and xylocaine (4Vo) in equal amounts (total 1.5 to 2 mL) are applied to the nasal mucosa using Jackson spray. 4. The fiberoptic bronchoscope (we use an Olympus B3R, BF-10 or BF-20) is inserted (usually in advance) through the intubation tube (Figure 12) after lubricating the entire bronchoscope with sterile olive oil (1 to 2 mL) or xylocaine jelly. Xylocaine jelly is
N. Kataoka,
Y. Usui, N. Inase, S. Takayama,
H. Miura
also applied to the distal half of the intubation tube for lubrication. 5. The bronchoscope is inserted into the nasal fossa adjacent to the inferior turbinate (common nasal meatus) (Figure 13). 6. After visualization of the nasopharynx (Figure 14), 4% xylocaine (2 mL) is instilled through the bronchoscope by syringe. Then the tip of the bronchoscope is angled up and advanced approximately 1 to 2 centimeters. When the epiglottis and base of the tongue are observed (Figure 15), additional 4% xylocaine (2 mL) is instilled. The xylocaine is promptly aspirated by suction after instilling it in order to avoid xylocaine intoxication. Then the tip of the bronchoscope is angled down a little, and advanced through the epiglottis to the larynx. When the vocal cords are visualized (Figure 16), 2 to 3 mL of 4% xylocaine is instilled into the vocal cords and trachea. We promptly aspirate the xylocaine after instillation on the vocal cords but not from the trachea. 7. After advancing the bronchoscope past the vocal cords, 2 mL of 4% xylocaine is applied to the trachea, and the tip of the bronchoscope is advanced to the juncture of the middle and distal third of the trachea (Figure 17). Then the intubation tube is inserted straight without rotation over the bronchoscope into the middle third of the trachea. 8. The bronchoscope is withdrawn 2 to 3 centimeters to visualize the position of the tip of the intubation tube, then sputum is aspirated through the bronchoscope, and finally the bronchoscope is removed.
SUMMARY
The sites, causes, and complications of obstruction during bronchoscopy-directed nasotracheal intubation are presented. Techniques for minimizing obstruction and its complications are discussed. Acknowledgment-We Yokosuka Naval English language.
would like to thank Dr. Cook at Hospital for his advice concerning the
REFERENCES 1. Taylor PA, Towey RM. The broncho-fiberscope as an aid to endotracheal intubation. Br J Anaesth. 1972;44:611-12. 2. Sekiya S, Kuramitsu K, Kiuchi H, et al. Nasotracheal intubation with the flexible fiberoptic bronchoscope. J Jap Sot Bronchology. 1984;2:269-73.
3. Ripley JF, Mcanear JT, Tilson HB. Endotracheal tube obstruction due to impaction of the inferior turbinate. J Oral Maxillofat Surg. 1984;42:687-8.
