# Idea for nasal intubation



## tchristifulli (Jul 11, 2013)




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## tchristifulli (Jul 11, 2013)

Tried this on a unresponsive patient who had his teeth clenched. Spo2 was 78%. Our protocols say we need 2 medics to RSI. I was running with a tech that day. Used a 5.0 tube and this trick worked perfect.


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## chaz90 (Jul 11, 2013)

I'm a bit unclear as to what exactly you did...


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## DesertMedic66 (Jul 11, 2013)

chaz90 said:


> I'm a bit unclear as to what exactly you did...



I'm assuming he/she connected the end of their steth to the tube and used it to intubate. The steth allowed them to hear air pass by to make sure they were in the right tube.


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## tchristifulli (Jul 11, 2013)

Exactly


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## tchristifulli (Jul 11, 2013)

We don't have the BAAM device where I work so you can't hear the whistle


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## DesertMedic66 (Jul 11, 2013)

I've heard about it being done during my EMT class but that's about it. I'm only an EMT so it's not in my scope and we don't have nasal intubation in our medic protocols either.


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## Clipper1 (Jul 11, 2013)

tchristifulli said:


> Tried this on a unresponsive patient who had his teeth clenched. Spo2 was 78%. Our protocols say we need 2 medics to RSI. I was running with a tech that day. Used a 5.0 tube and this trick worked perfect.



Was this for a pediatric patient?   A 5.0 tube is only about 24 cm in length which means if used nasally on an adult it is only a supraglottic device and would need to be changed quickly. There is also a risk of damage to the cords with an inappropriate sized device. Even a 6.0 might come up very short on an adult if done the nasal route. Usually these get secured at about 26 - 28 cm at the nare.


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## tchristifulli (Jul 11, 2013)

No just a small adult


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## Clipper1 (Jul 11, 2013)

Even small adults like a 4'11" Asian female would be taped at 20 - 21 cm oral.  The cuff is 2 - 3 cm in length at 1.5 cm above distal tip.  If this was a male, at least a 6 or 6.5 should be considered even nasally.  At least then the patient might last on a ventilator for a little while before changing the tube.


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## NomadicMedic (Jul 11, 2013)

I was always told the average tube size for adult nasal intubation is a 6.5. We carry enditrol tubes and BAAM whistles, but they never get used.


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## tchristifulli (Jul 11, 2013)

Yah I agree it was probably on the small side. I appreciate the advice though. It seemed to work just fine and the doc left it in for awhile. I'm sure a 6.5 would be about right. Just seems real big to be putting in this dudes nose lol.


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## Clipper1 (Jul 11, 2013)

The diameter is definitely small and will affect wob.  But the length is of most concern. It would be sad to have a good idea for facilitating NTI ruined by the pt's death due to aspiration from the cuff being mal positioned.


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## tchristifulli (Jul 11, 2013)

I think that's a little extreme. I didn't kill the guy man.


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## VFlutter (Jul 11, 2013)

tchristifulli said:


> I think that's a little extreme. I didn't kill the guy man.



Nope, but you didn't really secure the airway either. Aspiration is a serious and real concern.


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## Trashtruck (Jul 11, 2013)

I think it's a cool idea.
If I didn't have a BAAM and had a p.o.s. stethoscope, I'd do it.


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## NomadicMedic (Jul 11, 2013)

The OP never said anything about not fully securing the airway. He only said that he nasally intubated a patient. Clipper was the one who insinuated that he may not have fully secured the airway due to the length of the tube, which is mere speculation on her part.


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## Clipper1 (Jul 11, 2013)

Speculation?  No.  Any decent intubation class should teach you to be mindful about tube length and anatomical placement.  Securing an airway coorectly is important.  Look it up if you don't believe me about the length of the tube and the placement of the cuff.  Don't let your attitude get in the way of possibly learning something about tubes. You may not realize that some who work in hospitals measure the tube length for a few different reasons.  The complications from poorly positioned  tube can quickly undo all good efforts.


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## NomadicMedic (Jul 11, 2013)

Clipper1 said:


> Speculation?  No.  Any decent intubation class should teach you to be mindful about tube length and anatomical placement.  Securing an airway coorectly is important.  Look it up if you don't believe me about the length of the tube and the placement of the cuff.  Don't let your attitude get in the way of possibly learning something about tubes. You may not realize that some who work in hospitals measure the tube length for a few different reasons.  The complications from poorly positioned  tube can quickly undo all good efforts.



...and again, the OP simply related that he nasally intubated a patient. There was no mention of the tube not passing the glottis. YOU were the one who SPECULATED that the tube was placed incorrectly. (And I'll define it because you seem to have trouble understanding what I'm writing. *Speculation: to form a theory or conjecture about a subject without firm evidence.*) 

See what I did there? I called you out for being a doomsayer. 

I appreciate your passion for the subject, but don't let YOUR attitude, or your thinly veiled distaste for EMS providers get in the way of the message. Not every paramedic is a ham-fisted imbecile.


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## Tigger (Jul 12, 2013)

Not to play the whole "better than nothing card," but my partner nasally intubated a patient a few weeks ago with a 6.0 tube and she was a fairly large lady. She also had very small nostrils (we could only get a 18 or 20fr NPA I can't remember). The NPA wasn't cutting it and the 6.0 was as big as would fit. So would you rather see a patient with an unprotected airway being single person BVMed or  a possibly supraglottic airway in place?


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## ZootownMedic (Jul 12, 2013)

The BAAM isn't gonna work on an apneic patient anyways....neither will the stethescope trick, although its a cool one. I had a similar situation last week where a patient went unresponsive and apneic with the teeth clenched. No RSI so nasal intubation or cric would have been my only options. Fortunately I was 2 blocks from the hospital and was able to keep the sats up enough with an NPA. I think nasal intubation is a lost art and definitely a good skill to have. The more confirmation and assistance devices the better.


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## tchristifulli (Jul 12, 2013)

Right, the patient has to be breathing in order to use a baam or stethoscope. Does anybody here fill the cuff with water instead of air? We touched on it in CC school for flight purposes. One of my coworkers said he always uses saline instead of air because it holds the tube down better. It makes sense, but if the cuff breaks where does all that saline go.


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## Carlos Danger (Jul 12, 2013)

Tigger said:


> Not to play the whole "better than nothing card," but my partner nasally intubated a patient a few weeks ago with a 6.0 tube and she was a fairly large lady. She also had very small nostrils (we could only get a 18 or 20fr NPA I can't remember). The NPA wasn't cutting it and the 6.0 was as big as would fit. *So would you rather see a patient with an unprotected airway being single person BVMed or  a possibly supraglottic airway in place?*



Well, if you are talking about a true supraglottic airway, such as a King or LMA, then that's easily better than BVM ventilations.

But a misplaced ET tube is not an SGA. It might be forcing some air into the lungs, but is also may be forcing some into the gut, and is doing nothing at all to protect against aspiration. Unlike a real SGA, a supraglottic ETT is not secured in place in any way. It could easily move and damage airway structures or slip into the esophagus.




tchristifulli said:


> Right, the patient has to be breathing in order to use a baam or stethoscope. *Does anybody here fill the cuff with water instead of air?* We touched on it in CC school for flight purposes. One of my coworkers said he always uses saline instead of air because it holds the tube down better.



The necessity of that was debunked years ago.

At the altitude helicopters operate (~800-1500 AGL), pressure change inside the cuff is pretty small. And for the short duration of most helicopter transports (<1hr), you aren't looking at anything clinically significant, in terms of affecting tracheal capillary perfusion. 

In FW transport, cuff pressures definitely are a factor, both because of the much higher cabin altitudes and because of the typically longer transport duration. But in that case, you will have a cuff manometer to measure cuff pressures.

Plus, NS has been shown to degrade the PVC and cause cuff leaks surprisingly quickly. 

How would saline it "hold the the tube down better? Anyone who is having problem with their tube migrating needs to learn to secure it better. 

Just fill the cuff with just enough air to have a small leak (~5ml) and secure it really well. If you are transporting at an altitude much higher than that which the cuff was inflated at or for long distance, you really need a manometer. 




tchristifulli said:


> if the cuff breaks where does all that saline go.



Where _would_ it go?


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## Merck (Jul 12, 2013)

Here nasal intubation is never used and one would be thought a cowboy for even trying.  In the OPs case the sats were poor with trismus.  

It is dangerous to jump to 'advanced' airways when there are myriad other options available.  I commonly see cases where excellent BLS skills would be more than adequate and in many cases better than attempts to secure the advanced airway.  This has been a trend in training around here - trying to promote much improved BLS airway management skills.  Our ALS do not utilize paralytics and thus this approach is even more important.

When I worked on the street I didn't have RSI, only lido spray, MS, and midaz and we managed to intubate nearly everyone who required it.  Failing that simple procedures usually sufficed.

In this case the patient was clamped down with sats of 78.  While I'm sure the case ended well to be honest I'd just consider that a good time to cric rather than a blind intubation.


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## usalsfyre (Jul 12, 2013)

tchristifulli said:


> but if the cuff breaks where does all that saline go.


Do you ever use saline when you're suctioning a trach? Just a thought.....


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## usalsfyre (Jul 12, 2013)

Merck said:


> When I worked on the street I didn't have RSI, only lido spray, MS, and midaz and we managed to intubate nearly everyone who required it.


Not to be an ***....but how exactly is this less cowboy than nasal intubation?!?

Sedating the snot out of a patient (who already has respiratory compromise) without a NMB (a part of the procedure that has been shown to increase chances of success) vs being able to pass a tube without any sedation is playing cowboy? I guess I'm heading for Dodge City.


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## usalsfyre (Jul 12, 2013)

SmokeMedic said:


> The BAAM isn't gonna work on an apneic patient anyways....neither will the stethescope trick, although its a cool one. I had a similar situation last week where a patient went unresponsive and apneic with the teeth clenched. No RSI so nasal intubation or cric would have been my only options. Fortunately I was 2 blocks from the hospital and was able to keep the sats up enough with an NPA. I think nasal intubation is a lost art and definitely a good skill to have. The more confirmation and assistance devices the better.


Nasal intubation probably shouldn't have even have crossed your mind here. Generally, either you can keep the sats up and hope the patient isn't aspirating (please don't think I'm knocking this option) or can't in which case you cut. This isn't the patient to screw around trying to get an apenic nasal intubation on.


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## Handsome Robb (Jul 12, 2013)

Has anyone asked about ETCO2? Breath sounds? Absent epigrastric sounds? If the tube is confirmed by standard measures how can you not call it a good tube? I've never heard of an ETT work as a SGA...yes it's a temporizing measure but how many things do we do that are temporary until definitive care can be provided? Any NTI is going to pulled in the ER eventually and replaced with an oral tube provided there isn't a reason, such as angioedema that prevented it in the first place. 

I understand a 5.0 is a short tube and not all are cuffed so remember that as well. Our NTI kits are 6.0 tubes with a trigger, sorry can't remember the fancy name off the top of my head.


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## chaz90 (Jul 12, 2013)

Robb said:


> Our NTI kits are 6.0 tubes with a trigger, sorry can't remember the fancy name off the top of my head.



Endotrol


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## Clipper1 (Jul 12, 2013)

DEmedic said:


> ...and again, the OP simply related that he nasally intubated a patient. There was no mention of the tube not passing the glottis. YOU were the one who SPECULATED that the tube was placed incorrectly. (And I'll define it because you seem to have trouble understanding what I'm writing. *Speculation: to form a theory or conjecture about a subject without firm evidence.*)



For evidence, lay out all the ETTs you have in your box and look at how the lengths vary for each size.  The smaller the size, the shorter the length. You then need to notice where you normally would place an oral ETT.  Also notice how the cuffs vary by the brand if you have others available.  The size and shape are significant and do have a purpose.


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## Clipper1 (Jul 12, 2013)

Halothane said:


> The necessity of that was debunked years ago.
> 
> At the altitude helicopters operate (~800-1500 AGL), pressure change inside the cuff is pretty small. And for the short duration of most helicopter transports (<1hr), you aren't looking at anything clinically significant, in terms of affecting tracheal capillary perfusion.
> 
> ...



Normal Saline is not to be used in the cuffs of any tube. But, sterile water is routinely used especially for HBO treatments, for some special ETTs like those for neck surgeries which flaps need some extra caution and for many of the trach tubes used for children. The cuff of the Bivona is more porous and is specially designed to use sterile H2O.  Many long term trached pediatric will have a cuff with sterile water these days.  You do have to monitor the amount of water placed and use just enough for a seal.  Ask the parents of these kids or even the kids  and they will probably tell you the exact amount of water and why.

Tubes can also be made of nylon, Teflon or silicone rubber and not just PVC.


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## Clipper1 (Jul 12, 2013)

Robb said:


> Has anyone asked about ETCO2? Breath sounds? Absent epigrastric sounds? If the tube is confirmed by standard measures how can you not call it a good tube? I've never heard of an ETT work as a SGA...yes it's a temporizing measure but how many things do we do that are temporary until definitive care can be provided? Any NTI is going to pulled in the ER eventually and replaced with an oral tube provided there isn't a reason, such as angioedema that prevented it in the first place.
> 
> I understand a 5.0 is a short tube and not all are cuffed so remember that as well. Our NTI kits are 6.0 tubes with a trigger, sorry can't remember the fancy name off the top of my head.



The ETT does not work as a SGA.  But, some tubes migrate to a Supraglottic position.  Also, if the tube is to short, the cuff is trapped at or in the cords which can cause serious damage.  

Without the cuff, it is more like an NP tube and of little use in an adult which would need a decent VT and pressure. Even the infant 3.0 tubes now come with cuffs.


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## Merck (Jul 12, 2013)

usalsfyre:

No question that using vast amounts of sedatives is hazardous and not called for.  Things were done that way 10 years ago but much has changed with a shift of focus to improved BLS airway management and better understanding of the effects of the sedation.  Also, my point was more what you pointed out in your second post - not the time for a trial nasal intubation.  I've been called many things in my career, but cowboy has never been one of them.


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## NomadicMedic (Jul 13, 2013)

Clipper1 said:


> For evidence, lay out all the ETTs you have in your box and look at how the lengths vary for each size.  The smaller the size, the shorter the length. You then need to notice where you normally would place an oral ETT.  Also notice how the cuffs vary by the brand if you have others available.  The size and shape are significant and do have a purpose.



You again refuse to address the fact that at NO POINT did the OP make mention of the tube being placed incorrectly. You continue to blather on about tube size as if you're the only person who ever noticed that they come in (gasp) different lengths and diameter


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## Carlos Danger (Jul 13, 2013)

Clipper1 said:


> Normal Saline is not to be used in the cuffs of any tube. *But, sterile water is routinely used especially for HBO treatments, for some special ETTs like those for neck surgeries which flaps need some extra caution and for many of the trach tubes used for children*. The cuff of the Bivona is more porous and is specially designed to use sterile H2O.  Many long term trached pediatric will have a cuff with sterile water these days.  You do have to monitor the amount of water placed and use just enough for a seal.  Ask the parents of these kids or even the kids  and they will probably tell you the exact amount of water and why.
> 
> *Tubes can also be made of nylon, Teflon or silicone rubber and not just PVC.*



Yeah, and it's also used during laser procedures in the airway, and ETT's come in stainless steel and with copper coatings, as well.

But what does any of that have to do with the question of whether ETT's should routinely be filled with saline in the prehospital environment?


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## Clipper1 (Jul 13, 2013)

Halothane said:


> Yeah, and it's also used during laser procedures in the airway, and ETT's come in stainless steel and with copper coatings, as well.
> 
> But what does any of that have to do with the question of whether ETT's should routinely be filled with saline in the prehospital environment?




I was just responding to your comments. 

But, people with water ( not saline) filled trachs are  living in the communities either at home or in a facility.   In most states an EMT Basic can transport them.  Yes you might get 911 calls for a water filled cuffed reached patient.

I also believe when it comes to airways, having more info about the appropriateness of the type and size of a tube is important.  There are things which are very relevant and some things to consider so not to do harm.   When. It comes to learning about airways you really should not stop at just one sentence and not be open to other suggestions.


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## Carlos Danger (Jul 13, 2013)

Clipper1 said:


> When. It comes to learning about airways you really should not stop at just one sentence and not be open to other suggestions.



While I certainly don't claim to know everything there is to know about every different airway in existence, I assure you I am plenty familiar with artificial airways in general, so you can save the condescension for someone else

My comments were not intended to provide an exhaustive review of all the different types of airways that one may encounter or the situations where a cuff may be filled with fluid, but were rather in response to a question about whether it was appropriate to fill an ETT cuff with NS routinely in the prehospital setting.

Not every question or discussion requires some sort of lengthy diatribe about numerous things that are only tangentially related to the discussion. We aren't all out to prove in every post how much smarter we are than everyone else.


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## Clipper1 (Jul 13, 2013)

DEmedic said:


> You again refuse to address the fact that at NO POINT did the OP make mention of the tube being placed incorrectly. You continue to blather on about tube size as if you're the only person who ever noticed that they come in (gasp) different lengths and diameter



A 5.0 tube was placed in an adult. I have absolutely no way of knowing if the OP was aware of the different lengths. I bet there are others here who may not consider length when nasally intubating.  This forum has many, many members and not just you.  So what if someone learned something or will think about the length next time they intubate. Is learning or reviewing something really that bad?  Airway is a very important part of patient care for those who need one.  




Halothane said:


> While I certainly don't claim to know everything there is to know about every different airway in existence, I assure you I am plenty familiar with artificial airways in general, so you can save the condescension for someone else
> 
> My comments were not intended to provide an exhaustive review of all the different types of airways that one may encounter or the situations where a cuff may be filled with fluid, but were rather in response to a question about whether it was appropriate to fill an ETT cuff with NS routinely in the prehospital setting.
> 
> Not every question or discussion requires some sort of lengthy diatribe about numerous things that are only tangentially related to the discussion. We aren't all out to prove in every post *how much smarter we are than everyone else*.



I only responded to your posts about saline. I did not start that discussion. However, I think some should be aware that tubes with water are out that and I do know EMTs who have transported them since they were patients in the hospital I work at. I also know that at sometime an EMT or Paramedic might have to add additional water (not saline) to a cuff to ventilate.

The OP had a decent idea but it could easily have been turned to trouble had anything happened to the patient. Before trialing something new which could be great or come under scrutiny, make sure the other stuff like correct ETT size, including length, are in place so you can reap the full benefits of your good idea. 

Even a 6.0 or 6.5 tube might come up short when used nasally on an adult male.  This is not speculation either. Be familiar with your equipment. Lay out the tubes and look at the lengths. Look at CXRs of intubated patients to see where the tip, cuff and larynx are. Note the placements of oral tubes for depth.  

I am not trying to prove anything. I would like to prevent someone from making a mistake which could cause embarrassment to him or injury to the patient.  It is very sad that some useful information can not be taken as just that on an EMS forum without the "smarter than us or you" mess.  

All the information I have provided can easily be looked up. But, if anyone would like additional material, you can PM me so I don't make Halothane or the moderators angrier with more educational tidbits.


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## Handsome Robb (Jul 14, 2013)

Clipper1 said:


> The ETT does not work as a SGA.  But, some tubes migrate to a Supraglottic position.  Also, if the tube is to short, the cuff is trapped at or in the cords which can cause serious damage.
> 
> Without the cuff, it is more like an NP tube and of little use in an adult which would need a decent VT and pressure. Even the infant 3.0 tubes now come with cuffs.



Ok that's what I thought you were getting at.

I'm really interested in this since NTI is one of the things I do not feel comfortable with but I'm required to be proficient in.


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## Christopher (Jul 15, 2013)

tchristifulli said:


> View attachment 1562



Just connect your waveform ETCO2 adapter and use that as a guide.

(If you don't use waveform ETCO2, find a way other than ETI to manage your patient)


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## Action942Jackson (Jul 15, 2013)

A 6-7.0 endotrol 
Some Neo (dilates nasal passages allowing easier placement) spray
Some lube
BAAM

Slide, pull, swoop, and secure.

We have no RSI on the streets as that is a CCEMT-P/FP-C skill only per our state protocol. 

Our best bet is a NTI with the methods above.  I have yet to miss a NTI.  I came from a land of RSI before my tenure in rural medicine.  After experiencing both.  I favor endotrols.


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