Validation of Simple Methods to Select a Suitable Nostril for Nasotracheal Intubation

Thongrong, Cattleya; Thaisiam, Pattramon; Kasemsiri, Pornthep

doi:10.1155/2018/4910653

Cited by 7 publications

(7 citation statements)

References 21 publications

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“…During a preoperative visit, we asked patients to occlude the contralateral nostril in the sitting position to self-assess nasal airflow. This method has been verified as useful and accurate for assessing nostril selection for nasotracheal intubation [ 10 ]. Patients who were able to breathe clearly and equally through both nostrils were invited to participate in the study.…”

Section: Methodsmentioning

confidence: 99%

Impact of choice of nostril on nasotracheal intubation when using video rigid stylet: a randomized clinical trial

et al. 2022

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Background Patients undergoing oral and maxillofacial surgeries under general anesthesia usually require nasotracheal intubation. When presented with patients with equally patent nostrils, selection of the nostril to use for intubation is an important decision for facilitating intubation. The objective of this trial is to determine whether choice of nostril impacts nasotracheal intubation when using a video rigid stylet in patients undergoing oral and maxillofacial surgery. Methods Fifty patients scheduled for elective oral and maxillofacial surgery requiring nasotracheal intubation were randomly allocated into two groups to undergo nasotracheal intubation through the left nostril (Group L, n = 25) or the right nostril (Group R, n = 25). Intubation was performed by experienced anesthesiologists using a video rigid stylet. The primary endpoint was time to successful intubation, which was defined as the duration from when the tip of the stylet-tube assembly entered the selected nostril to when the tube entered the trachea. Secondary outcomes included: length of time for device insertion; length of time for tube insertion; total success rate; first-attempt success rate; number of intubation attempts; requirement of airway assisted maneuvers; incidence and severity of epistaxis. Intubation-related adverse events were monitored for up to postoperative 24 h. Results Median time (interquartile range) to tracheal intubation was 25.3 seconds (20.7 to 27.6) in Group L and 26.8 seconds (22.5 to 30.0) in Group R (median difference (MD) = 1.9; 95% confidence interval (CI) –1.8 to 5.7, P = 0.248). Nasotracheal intubation was successful in all patients in both groups and the first-attempt success rates in both groups were similar (Group L: 96% (24/25); Group R: 96% (24/25); relative risk (RR) 1.0; 95% CI 0.9 to 1.1; P > 0.999). No significant difference of requirement of assisted maneuvers was noted between the two groups (Group L: 36% (9/25); Group R: 28% (7/25); RR 0.8; 95% CI 0.3–1.8; P = 0.544). Furthermore, all patients showed a high quality of visualization of the glottis (Cormack and Lehane Grade I). For safety outcomes, the incidence and severity of epistaxis during intubation was comparable between the two groups. There were no significant differences between the selection of nostrils and intubation-related adverse events up to 24 h after surgery. Conclusions When considering which nostril to use for intubation with video rigid stylet, either nostril can be used similarly. Trial registration Clinicaltrials.gov. Identifier: NCT05218590.

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Section: Methodsmentioning

confidence: 99%

Impact of choice of nostril on nasotracheal intubation when using video rigid stylet: a randomized clinical trial

et al. 2022

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“…The side where the area of fogging due to condensation of the moisture in the expired breath is 1 cm more in diameter than the other side is considered to be more patent. [ 22 ] Interincisor gap (IIG)[ 23 ] – With head in the neutral position, the patient is asked to open his mouth as wide as possible. A scale is held between the central incisors or the corresponding alveolar margins (in an edentulous patient) so that its length matches the length of the patient's face.…”

Section: Figurementioning

confidence: 99%

“…The side where the area of fogging due to condensation of the moisture in the expired breath is 1 cm more in diameter than the other side is considered to be more patent. [ 22 ]…”

Section: Figurementioning

confidence: 99%

A new approach to airway assessment— “Line of Sight” and more. Recommendations of the Task Force of Airway Management Foundation (AMF)

Kumar

Misra³

et al. 2020

J Anaesthesiol Clin Pharmacol

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Assessment of airway is recommended by every airway guideline to ensure safe airway management. Numerous unifactorial and multifactorial tests have been used for airway assessment over the years. However, there is none that can identify all the difficult airways. The reasons for the inadequacy of these methods of airway assessment might be their dependence on difficult to remember and apply mnemonics and scores, inability to identify all the variations from the “normal”, and their lack of stress on evaluating the non-patient factors. Airway Management Foundation (AMF) experts and members have been using a different approach, the AMF Approach, to overcome these problems inherent to most available models of airway assessment. This approach suggests a three-step model of airway assessment. The airway manager first makes the assessment of the patient through focused history, focused general examination, and focused airway assessment using the AMF “line of sight” method. The AMF “line of sight” method is a non-mnemonic, non-score-based method of airway assessment wherein the airway manager examines the airway along the line of sight as it moves over the airway and notes down all the variations from the normal. Assessment of non-patient factors follows next and finally there is assimilation of all the information to help identify the available, difficult, and impossible areas of the airway management. The AMF approach is not merely intubation centric but also focuses on all other methods of securing airway and maintaining oxygenation. Airway assessment in the presence of contagion like COVID-19 is also discussed.

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“…Epistaxis is the most common complication of the procedure with a reported incidence ranging from 9.6 to 70% without an endoscopic examination of the nasal passages 1,2 ; even if both nostrils are patent, as observed with a nasal endoscope, an incidence of up to 44.4% is observed 3 . Numerous methods have been proposed to reduce epistaxis, including the application of a mucosal vasoconstrictor, a smaller size of tube, a gastric tube or suction tube to guide the tracheal tube and heating the tube to soften it, but none of these methods completely prevents epistaxis 4 . It may be helpful to select the more patent nostril to resolve this issue.…”

Section: Introductionmentioning

confidence: 99%

“…3 Numerous methods have been proposed to reduce epistaxis, including the application of a mucosal vasoconstrictor, a smaller size of tube, a gastric tube or suction tube to guide the tracheal tube and heating the tube to soften it, but none of these methods completely prevents epistaxis. 4 It may be helpful to select the more patent nostril to resolve this issue. Several studies on the topic have been published recently but the evidence is still conflicting.…”

Section: Introductionmentioning

confidence: 99%

For nasotracheal intubation, which nostril results in less epistaxis: right or left?

Tan¹,

Wu²,

Zhao³

et al. 2021

European Journal of Anaesthesiology

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BACKGROUND Nasotracheal intubation is usually required in patients undergoing oromaxillofacial, otolaryngological or plastic surgery to prevent the airway encroaching into the operating field. Epistaxis is the most common complication, but which nostril is associated with a lower incidence and severity of epistaxis is still unclear. OBJECTIVE When both nostrils are patent, to determine the preferred nostril for nasotracheal intubation under general anaesthesia. DESIGN A systematic review and meta-analysis of randomised controlled trials (RCTs). The primary outcome was the incidence of epistaxis and the secondary outcomes included the incidence of severe epistaxis, the time required to pass the tube through the nasal passage and total intubation time. DATA SOURCES PubMed, Embase and the Cochrane Register of Controlled Trials were searched from database inception to 1 March 2020. ELIGIBILITY CRITERIA The only studies included were RCTs comparing epistaxis related to nasotracheal intubation via right or left nostril, in adult surgery patients undergoing general anaesthesia. RESULTS Ten RCTs with 1658 patients were included. Compared with the left nostril, intubation via the right nostril was associated with a significantly lower incidence of epistaxis: risk ratio (RR) and 95% confidence intervals (CI) were 0.78 (0.62 to 0.99), P = 0.04: a lower incidence of severe epistaxis (five studies, n=923), RR 0.40 (0.22 to 0.75), P = 0.004: and a shorter intubation time (three studies, n=345), mean difference −7.28 (−14.40 to −0.16) seconds, P = 0.05. In two studies (n=310), no significant difference between the right and left nostril was observed in the time to pass the tube through the nasal passages, mean difference −0.59 (−1.95 to 0.77) s, P = 0.40. CONCLUSION On the basis of the current available evidence, when both nostrils are patent, the right nostril is more appropriate for nasotracheal intubation, with a lower incidence and severity of epistaxis and faster intubation time. TRIAL REGISTRATION The study protocol has been registered in PROSPERO (CRD42020169949).

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Validation of Simple Methods to Select a Suitable Nostril for Nasotracheal Intubation

Cited by 7 publications

References 21 publications

Impact of choice of nostril on nasotracheal intubation when using video rigid stylet: a randomized clinical trial

Impact of choice of nostril on nasotracheal intubation when using video rigid stylet: a randomized clinical trial

A new approach to airway assessment— “Line of Sight” and more. Recommendations of the Task Force of Airway Management Foundation (AMF)

For nasotracheal intubation, which nostril results in less epistaxis: right or left?

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