Nasotracheal Intubation: An Effective Forgotten Method In The Difficult Airway Management Of Acute Burns Patients

Abstract

Introduction: Inhalation injury has a significant impact on patient outcome, with a 30% increased mortality rate when present. Management of difficult airway and respiratory and hemodynamic stability is an important challenge during their treatment. Complications such as multiple intubation attempts, prolonged direct laryngoscopy, hypoxia, and cardiac arrest are more common in emergency orotracheal intubation outside (OI) the operating room. Blind Nasotracheal Intubation (BNI) is a technique in which a tracheal tube is passed through the nose into the trachea without the use of a laryngoscope (also anesthetic drugs) and with the help of the patient's breathing sound. We conducted a randomized clinical trial to investigate the efficacy of BNI and OI in difficult airway management of patients requiring immediate intubation.

Method: Thirty patients with inhalation injury and difficult airway (Mallampati Ⅲ-Ⅳ) who need to be intubated were randomly assigned in the orotracheal intubation Group (O) and the nasotracheal intubation (N) group. The outcome measures were speed and ease of intubation, respiratory and hemodynamic parameters in three time points, as well as complications.

Results:  One eligible patient was excluded from the nasotracheal intubation group because the tube did not pass through the nasal cavities (7.14%). The intubation time in the nasotracheal intubation group (58.50±28.54 S) is significantly shorter than the other group (112.40±60.88 S) (P=0.006). Intubation attempts in the nasotracheal group (1.14±0.36) are almost half of the attempts in the other group (2.27±0.79) (P=0.001). In terms of hemodynamics, there was no significant difference between the heart rate (HR) at three time points between the two groups. Despite of the comparable mean arterial pressure (MAP) in the 5 minutes before intubation, there was a significant difference in MAP between the two groups during the intubation (OI: median=84 mmHg VS BNI: median 63 mmHg, P=0.012) and the 5 minutes after the tube fixation (OI: median=83 mmHg VS BNI: median 70 mmHg, P=0.007. Respiratory rate (RR) had significant differences during intubation (OI: median=0 VS BNI: median 20/min, P=0.001) and the 5 minutes after the tube fixation (OTI: median=10 VS NTI: median 19/min, P=0.001). There were similar differences in blood oxygenation saturation (SpaO2) during (OI: median=60% VS BNI: median 87%, P=0.001) and 5 minutes after the tube fixation (OI: median=93% VS BNI: median 97%, P=0.001) between the two groups. in the orotracheal intubation group, seven patients had apnea (46.66%) and three patients suffered cardiac arrest (severe bradycardia) during intubation.

Conclusion: Data showed the superiority of nasotracheal intubation technique in difficult airway management of patients with inhalation injury requiring emergency intubation.