Determination of the site of tracheal tube impingement during nasotracheal fibreoptic intubation*

Abstract

Summary This study examines the incidence and site of tracheal tube impingement during nasotracheal fibreoptic intubation, and the efficacy of anticlockwise tube rotation to overcome the problem. Forty‐three patients underwent fibreoptic‐assisted nasotracheal intubation using a preformed nasal tube, and a second fibrescope was used to observe any obstruction to passage of the tracheal tube. Impingement occurred in 10 cases, with the most common site being the right arytenoid cartilage. Rotation resulted in successful intubation in all 10 cases, but proximal rotation did not always result in an equal degree of rotation at the tube tip. We conclude that the site of impingement for nasotracheal intubation with preformed nasal tubes is located at the posterior structures of the laryngeal inlet and that anticlockwise rotation is a simple and effective solution.

Basic airway management by junior doctors

“…We suggest that tracheal extubation be included in the initial test of competency and be given the same importance as intubation. Although not its intent, we found that Kidner and Laurence's study on basic airway management by junior doctors highlighted how Advanced Life Support (ALS) teaching of basic airway management can differ from our anaesthetic practice [1]. Whilst the authors seem to suggest that ALS may be beneficial, we believe this study exposes the limitations of ALS as much as it demonstrates its strength.…”

“…We read with interest the recent article on the determination of site of tracheal tube impingement during nasotracheal fibreoptic intubation [1]. The conclusion of the study was that the most common site of impingement is the right arytenoid cartilage, as shown for orotracheal fibreoptic intubation [2].…”

“…There is a greater incidence of complications such as desaturation, laryngospasm, airway obstruction and vomiting during tracheal extubation than intubation [1,2]. Despite this, competencies for tracheal extubation do not exist and trainees are not formally assessed.…”

Endotracheal Tubes: Old and NewDiscussion

“…This method has been associated with complications and challenges related to the design of the standard ETT, particularly tissue trauma and inability to redirect and pass by anatomic structures. 51,52 To help address this, the Parker Flex-Tip tube (Parker Medical, Englewood, Colorado) has a soft, flexible, hemispherical, curved tip pointing toward the center of the distal lumen of the tube, rather than the straight, stiff, right-sided tip of the standard ETT (Fig. 6).…”

Another use of Magill forceps to assist nasotracheal intubation

“…Other techniques include rotating the ETT counterclockwise before applying pressure to facilitate its advancement. 3 However, proximal rotation does not always result in an equal degree of rotation at the distal tip, 4 and the tip of the tracheal tube may repeatedly abut the laryngeal wall despite these above measures, and fail to pass into the trachea.…”