# Nasal intubation skill



## MedicPatriot (Jan 7, 2012)

Does anyone have some tips on actually being good at nasal intubation? I mean I know the basics of using the BAAM and whatnot but is it really all just blind luck most of the time? I've been finding it hard to do lately and in this state that doesn't let us do RSI its sometimes the only alternative.


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## NomadicMedic (Jan 7, 2012)

Redacted.


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## Veneficus (Jan 7, 2012)

*there are no secrets.*

practice, practice and more practice.


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## NomadicMedic (Jan 7, 2012)

Veneficus said:


> practice, practice and more practice.



That's what I said, but I thought I'd get slapped for being a wisea$$.


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## Veneficus (Jan 7, 2012)

n7lxi said:


> That's what I said, but I thought I'd get slapped for being a wisea$$.



I wasn't being a smartass,

experience counts.

Would you want your bypass done by a C/T surgeon who does 100 a year or one that does 1000 a year?


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## NomadicMedic (Jan 7, 2012)

Agreed. Putting a tube in Fred the Head does nothing for skill improvement. I wish I had opportunity to do more nasal tubes, but CPAP has placed the nose firmly out of reach for most of us.


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## Veneficus (Jan 7, 2012)

n7lxi said:


> Agreed. Putting a tube in Fred the Head does nothing for skill improvement. I wish I had opportunity to do more nasal tubes, but CPAP has placed the nose firmly out of reach for most of us.



Don't get me started on playing with dolls and calling that practice.

The only people who benefit from simulation is the manufacturer. (economically)


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## MSDeltaFlt (Jan 7, 2012)

MedicPatriot said:


> Does anyone have some tips on actually being good at nasal intubation? I mean I know the basics of using the BAAM and whatnot but is it really all just blind luck most of the time? I've been finding it hard to do lately and in this state that doesn't let us do RSI its sometimes the only alternative.



If you can keep from it try not sedating them to the point they lose their cough reflex.  You want them coughing to bring the trachea right in front of the tube so it'll pass easily.


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## JeffDHMC (Jan 7, 2012)

All above is true and just about the only way to get good; do as many as is medically acceptable. Before CPAP and such we did a lot of them (3 in one night is my record). Then BAAM is a gimmick that you really can do without. For your awake pt have them cough when the tube is near the cords, if they can that is. There's loads of stuff you can do to facilitate placement, just don't rough it in, an avulsed turbinate is something to be avoided. It has nothing to do with luck, it's more about finesse.


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## firetender (Jan 7, 2012)

*Practice the art*

Though a lot of the stuff we do is considered highly technical, there's still much to be said to the art. Nasal intubation requires more than proper positioning and timing, it also requires developing a "feel" for the right moment. 

Part of that means being able to sense with your fingers what is the proper position for that particular person so the tube will get past the vocal cords with the least resistance.

So practice can also include working with patients, conscious or not, and feeling what angle is best to position the head so that the airway is completely open. That is something you can hear. 

And you don't have to be doing an intubation to get the feel of it. Whenever you get a chance, without invading a patient, give your fingers experience!


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## CANMAN (Jan 7, 2012)

Also sitting up vs. supine IMO helps alot, obviously your CHF'ers etc that are tripoding it will not be an issue but I have seen people trying to nasally intubate a supine pt, it can be done but is more difficult. 

If you do have a supine patient a bougie is an excellent tool to utilize if you don't have access to trigger tubes as well. Most people tend to not think of utilizing a bougie during nasal intubation but it does work, rather well, and is taught in some difficult airway classes. 

Trigger tube and BAMM really makes it an easy skill IMO, gimmick or not it works excellent. I always tend to go on the smaller side for tube size, which will decrease the amount of trauma and increase your success. Chances are at most facilities they will have it swapped out to an oral tube at some point within the first 24 hours anyway...



As everyone has said the increase in rapid deployment of CPAP has greatly decreased the amount of times we get to go the nasal route.


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## Fish (Jan 7, 2012)

I have only done one...... it was on a Ped in the OR 4 years ago. Since then I have not worked for a system that allows it, nor have I seen it in the ER.


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## Commonsavage (Jan 8, 2012)

*Something more that anecdotal statements would be helpful...*

1) Put a bit of a curve in that sucker
2) As the bulb enters the nasopharynx, approaching the epiglottis, inflate with 3 to 5 cc's.  This will lift the tip into a postion to more easily engage the trachea/glottal opening...above the esophageal opening.
3) As you advance, and block the tracheal opening, your BAMM should start whistling.
4) Simultaneously deflate the bulb and advance the tube until proper depth.
5)  Inflate bulb and secure tube.

All skills require practice and the ability to mentally visualize the anatomy.

Hope that this helps.


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## the_negro_puppy (Jan 8, 2012)

What are the pre-hospital indications for naso-tracheal intubation?


In cases like patients approaching respiratory failure that are still conscious/ gag reflexes intact?


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## 18G (Jan 8, 2012)

I never done it before but what about attaching the EtCO2 filter line to the ETT and watching for the waveform as the tube enters the trachea?

I have heard this technique before. Not sure how well it actually works though.


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## NYMedic828 (Jan 8, 2012)

I have actually been wondering how nasal intubation is properly performed.

In New York, more specifically New York City, nasal intubation is not a practicable skill under standing orders.

We were taught in class to perform the skill briefly, but only to be in compliance with National Registry standards.

I was never able to get it to work on the Laerdal vital-sim manikins we had. Now that I think about it tho, as far as nasal intubation, the manikins anatomy does not function the same as a real person.

The manikins epiglottis is always closed and only opened with a laryngoscope blade or digitally, whereas a real body the epiglottis stays open unless an outside force or swallowing tells the body to close it.

Is this the reason most likely I could never get it to work? Is it really as simple as lubing up a slightly smaller tube, removing the stylet and hoping for the right hole?


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## d_miracle36 (Jan 9, 2012)

I done my first nasal intubation a few days ago and was suprised that it went in quite effortlessly on my part. The pt tolerated it very well.


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## 325Medic (Jan 10, 2012)

18G said:


> I never done it before but what about attaching the EtCO2 filter line to the ETT and watching for the waveform as the tube enters the trachea?
> 
> I have heard this technique before. Not sure how well it actually works though.



I have used this procedure that you stated once and it worked well. 

325.


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## Kwidmeier (Jan 24, 2012)

I have my medics practice nasal intubations. We take out a lung in a manikin and replace it with an inflated ETT. This allows them to hear the sounds, utilize a BAAM, and capnography.


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