Which nostril should be used for nasotracheal intubation with Airtraq NT?: the right or left? A randomized clinical trial

Abstract

Background and aim: Nasotracheal Airtraq, is specifically designed to improve the glottis view and ease the nasotracheal intubation process in normal and difficult cases. Materials and methods: After Ethics committee approval, we decided to enroll 40 patients with an ASA physical status of I or II, between 18-70 years of age undergoing elective maxillofascial, oral and double chin surgery to determine which nostril is more suitable for nasotracheal intubation with nasotracheal Airtraq. Patients were randomised into the right and left nostril groups. Results: Demographic and airway characteristics were similar among the groups. Nasotracheal intubation through the right nostril was shorter than that of the left nostril during nasotracheal intubation with the Airtraq NT (p<0.001). 90 anti-clockwise rotation of the tip of the tube was needed for directing the tube into the vocal cords in both right and left nostril groups (72% vs 88%). External laryngeal pressure and head flexion maneuvers can ease the intubation from the left nostril (p<0.001 vs p=0.03). Cuff inflation maneuver also can be helpful in some cases. We did not need any operator change or Magill forceps for any of the patients. Conclusion: Nasotracheal intubation via the right nostril can be safely and quickly performed with the Airtraq NT without the need of Magill forceps. We recommend the use of the 90 anti-clockwise rotation, external laryngeal pressure and head flexion maneuvers to direct the tube into the vocal cords first. On the other hand; cuff inflation maneuver also must be kept in mind. Keywords: Airtraq, nasotracheal, right nostril, 90 degree anticlockwise, cricoid pressure, head flexion

Comment on: “Which nostril should be used for nasotracheal intubation with Airtraq NT®: the right or left?”

“…In the discussion section, the statement that studies and case reports are available that had successfully performed all nasal intubations through the right nostril with Airtraq NT totally mismatches with regard to one of the three references cited for it. The study by Xue FS et al (cited as Ref # 7 in the current study [1]) was an observational study that had only analyzed the feasibility of Airtraq NT for orotracheal intubations (not for nasal intubations as mentioned in the article) and found that it was successful in all the 42 patients [4]. Another statement that the Airtraq NT would be produced with a left channel in the coming days to make it easier for nasal intubations through the left nostril also does not match with the three references cited for it.…”

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

“…1. The search of the databases yielded 113 citations, 7 RCTs 3,5,6,8,9,18,19 were included after 106 citations were excluded based on their title or abstract, improper intervention/control, duplicate studies and nonrelevant topic. Three additional RCTs 7,20,21 were identified from references within manuscripts, thus 10 RCTs met the inclusion criteria and were included in the present meta-analysis 3,5–9,18–21 …”

“…All 10 studies reported the incidence of epistaxis, 3,5–9,18–21 and five studies reported the severity of epistaxis 3,6,19–21 . Two studies reported the time to pass the tube through the nasal passage, 6,9 and three studies reported the total intubation time 5,6,9 …”

“…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 3,5–9 . Some textbooks advocated that the left nostril be used for nasotracheal intubation because of less damage to the turbinate from the sharp tube tip, 10,11 some recommend the right nostril because of less epistaxis and shorter intubation times, 3,5,6 and some studies showed no difference in the incidence of epistaxis between the nostrils.…”

Does really selection of nostril affect performance of nasotracheal intubation with nasotracheal Airtraq®?

“…In the recent article by Arslan and Türkyılmaz [1], comparing the performance of nasotracheal intubation (NTI) with the nasotracheal Airtraq® (Airtraq NT) between the right and left nostrils, they showed that NTI could be completed in a shorter time through the right nostril than through the left. Furthermore, both external laryngeal pressure and head flexion eased the NTI from the left nostril.…”