# Anyone Nasally intubate anymore?



## MasterIntubator (Sep 8, 2010)

Just curious if anyone still have this skill in the practice?  Its been a number of years... but I still itch for one.  We still have the proceedure available, but its been about 6 years on one.


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## Shishkabob (Sep 8, 2010)

We have it, and carry the BAM as well to facilitate it.

Could have done it back in June but... well, didn't.


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## abckidsmom (Sep 8, 2010)

Linuss said:


> We have it, and carry the BAM as well to facilitate it.
> 
> Could have done it back in June but... well, didn't.



BAM?  I don't know that one.  What is it?

For the record, I haven't nasally intubated since like 2001.  CPAP really changed how that goes.  Most of the NTIs I was a part of were for pulmonary edema.


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## Akulahawk (Sep 8, 2010)

Sacramento still has NTI in the local scope of practice. I believe the BAM is used to assist with it. The BAM is basically a whistle device that fits over the 15/22 adapter of the ETT and the idea is that when the distal end of the ETT is pointed at the larynx/trachea, you get the whistling. I think (it's been a while) CPAP has been added locally too.


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## Hockey (Sep 8, 2010)

Available here, but never seen/heard it done


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## EMTinNEPA (Sep 8, 2010)

I have seen it attempted twice, both times due to trismus, both times unsuccessful.  First one resulted in the patient aspirating.  Yet another reason RSI/DAI should be available to pre-hospital medical professionals.


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## Smash (Sep 8, 2010)

No, never done it.  CPAP staves off a tube for most (best thing ever!) and otherwise there is RSI/DAI.


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## reaper (Sep 8, 2010)

Still have it and still preform them. I get about 1 every 2 months. Not many newer medics here have done them or have success with them. It is an art form that gets lost in training. once you learn how to preform one correctly, then they are easy to be successful.

CPAP has cut them out a lot, but I still use them when needed.


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## 8jimi8 (Sep 8, 2010)

No one really ever went in depth on how to do it.  i understand the function of the BAM, but I never understood how anyone would be able to aim?  using a bougie? or a stylette?


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## Ridryder911 (Sep 8, 2010)

I would like to know what Paramedic schools are teaching sometimes?.. Apperantly not airway methods. It's an alternative way to intubate and should be taught just like any other method.. 

I've nasally intubated several times on patients with burns, CVA, spinal patients.. no need of special equipment, ellaborate techniques, etc... Vet's have been doing it for decades... 

R/r 911


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## LucidResq (Sep 8, 2010)

I know of a particular service out here that has a reputation for using NTI all the time. Not in a bad way, but definitely a frequently used tool in their box.


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## reaper (Sep 8, 2010)

8jimi8 said:


> No one really ever went in depth on how to do it.  i understand the function of the BAM, but I never understood how anyone would be able to aim?  using a bougie? or a stylette?



It is harder if you are using a normal ET Tube. It then comes to technique. Any good services that have NTI will have the tubes designed for it. Those tubes have a wire that runs to the tip and has a ring up by the top. When you pull on the ring, it moves the tip of the tube, so it allows you to "steer" the tube.

http://www.nellcor.com/prod/product.aspx?id=133


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## 8jimi8 (Sep 8, 2010)

oh excellent.   When I was shadowing down in our Trauma 1 ICU, i saw a dude nasally intubated with an 8!


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## MrBrown (Sep 8, 2010)

The consultant anaesthetist who intubated Brown shoved a bloody great tube up (down) his nose and it hurt with much of the painful and pharyngeal swelling for a week

At least good drugs were got out of it tho ....


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## Epi-do (Sep 8, 2010)

I recently had the opportunity to attempt it.  We had a pt that wasn't a candidate for CPAP, so it was our only option.  Unfortunately, I was unsuccessful and ended up with a respiratory arrest.  We don't have RSI here, but we still tried an oral intubation.  That was no good either.

Once we got to the hospital, they RSI'ed her, and it still took multiple attempts for them with the flouroscope.  The RT came out and talked to me for a minute and said that she had an anatomical anomaly that made her one of the more difficult intubations that he has seen in quite a while.


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## abckidsmom (Sep 8, 2010)

8jimi8 said:


> oh excellent.   When I was shadowing down in our Trauma 1 ICU, i saw a dude nasally intubated with an 8!



There was a physician at a tiny urban hospital who liked to brag about the time he tubed a little old guy with a 10!!!  Insanity!  I don't think there are any other patients I ever saw intubated with a 10.


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## Veneficus (Sep 8, 2010)

leanred how to in paramedic school. Never actually performed NTI on a person.

In my memory, which is not always working perfectly.


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## Akulahawk (Sep 8, 2010)

Veneficus said:


> learned how to in paramedic school. Never actually performed NTI on a person.


Ditto.

I've seen a few done though... by flight crews.


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## Ridryder911 (Sep 9, 2010)

I wrote an article for _JEMS _ back when it first started from _Paramedics International_ to the rag it is today about alternative intubation techniques. I had not found any material about nasal or digital intubation, from even emergency medicine and definitely not pre-hospital care at that time. What I did find was a 1965 article from anesthesia journal about "ring" triger ETT. 

Wow! How come we have not used these? Well, short and simple ... no one was used to them and the costs..(you know $$ had to come in there somewhere!) We actually shared the costs with OR, ER, ICU, and so forth so we could carry some. Yes, they do facilitate nasal intubation(s) and patients with high grade scores such as those with anterior anatomy. 

There are as well flex stylet guides that mimick the same type of manuever of the trigger tube. 

There are several "tricks of the trade" to help facilitate intubation, such as ambient noisy area the end of a cheap stethescope dropped into the ET itself to hear respirations, use of Lidocaine topical to decrease pain and possibly use of Neo-Synephrine to reduce bleeding and swelling. 

I personally clip or shortened the end of the ETT to reduce movement after proper placement (auscultation and EtCo2 wave form). Of course, most practitioners prefer to remove as soon as possible and have patient orally intubated for several reasons. 

R/r 911


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## Dominion (Sep 9, 2010)

Ridryder911 said:


> I wrote an article for _JEMS _ back when it first started from _Paramedics International_ to the rag it is today about alternative intubation techniques. I had not found any material about nasal or digital intubation, from even emergency medicine and definitely not pre-hospital care at that time. What I did find was a 1965 article from anesthesia journal about "ring" triger ETT.
> 
> Wow! How come we have not used these? Well, short and simple ... no one was used to them and the costs..(you know $$ had to come in there somewhere!) We actually shared the costs with OR, ER, ICU, and so forth so we could carry some. Yes, they do facilitate nasal intubation(s) and patients with high grade scores such as those with anterior anatomy.
> 
> ...



It's in our protocols, I've been taught it, and I've used it twice.  Once in the hospital during OR rotations and once in the field for polypharmic OD.  Our methods if unable to orally intubate for reasons of trauma, trismus, gag reflex intact, etc.  RSI/DAI (only available to helicopters), then Nasal, then Blind, then Digital, then Surgical (if available) then finally Needle.  If I remember correctly that is.  It's heavily used locally as only one service nearby of 5 have CPAP.


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## Shishkabob (Sep 9, 2010)

Why is blind before digital?


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## 8jimi8 (Sep 9, 2010)

Linuss said:


> Why is blind before digital?



So you don't get bit??  They don't have RSI/DAI


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## reaper (Sep 9, 2010)

Digital is a form of ETI. If they bite you, then they are to alert for that procedure.


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## Shishkabob (Sep 9, 2010)

reaper said:


> Digital is a form of ETI. If they bite you, then they are to alert for that procedure.



If they bite the ET tube during blind insertion, they're just as alert...


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## 8jimi8 (Sep 9, 2010)

Linuss said:


> If they bite the ET tube during blind insertion, they're just as alert...



So that must be why blind before digital... No?


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## Veneficus (Sep 9, 2010)

8jimi8 said:


> So that must be why blind before digital... No?



Doesn't anyone test for gag with an OPA before trying to intubate anymore?


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## sirkhctiw (Sep 9, 2010)

We just finished airway in my medic class. I've done it on the dummy recently.


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## abckidsmom (Sep 9, 2010)

Veneficus said:


> Doesn't anyone test for gag with an OPA before trying to intubate anymore?



No, not ever.  Why would we waste any time with BLS airway maneuvers while planning or prepping for intubation?

I don't really consider placing an OPA as testing for gag, more like just placing an OPA to manage the airway, however temporarily.


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## reaper (Sep 9, 2010)

I just tell them to suck it up, it will be over in a minute!


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## 8jimi8 (Sep 9, 2010)

When we are talking about being so far down the list of interventions tried and failed that we are going for digital intubation, i don 't know if i'd stop to keep repeatedly putting the OPA back in, is that what you meant?  Is that something i should consider?

If I made a 30 second attempt to intubate and failed, how long should I preoxygenate before attempting again?  Long enough that I should throw the OPA back in?


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## Veneficus (Sep 9, 2010)

abckidsmom said:


> No, not ever.  Why would we waste any time with BLS airway maneuvers while planning or prepping for intubation?
> 
> I don't really consider placing an OPA as testing for gag, more like just placing an OPA to manage the airway, however temporarily.



testing for gag can be done with a tongue depressor.

It was this dual role I was trying without success to point out. While you are setting up your intubation gear, somebody is bagging, a perfect time to "place an adjunct" which in addition to being helpful to maintain the airway also has a diagnostic property of testing for gag.


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## Dominion (Sep 9, 2010)

Veneficus said:


> testing for gag can be done with a tongue depressor.
> 
> It was this dual role I was trying without success to point out. While you are setting up your intubation gear, somebody is bagging, a perfect time to "place an adjunct" which in addition to being helpful to maintain the airway also has a diagnostic property of testing for gag.



I'll be honest I don't know why blind before digital but I would assume it'd be due to possibly getting bit.  Any time I've heard of the airway priority being challenged usually the medic in question skipped blind and digital and called for orders to needle chric.  It doesn't come up that often really.


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## 8jimi8 (Sep 9, 2010)

I know that repeated attempts can cause someone to vagal down, but could it cause a spontaneous return of consciousness?


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## MasterIntubator (Sep 9, 2010)

8jimi8 said:


> When we are talking about being so far down the list of interventions tried and failed that we are going for digital intubation, i don 't know if i'd stop to keep repeatedly putting the OPA back in, is that what you meant?  Is that something i should consider?
> 
> If I made a 30 second attempt to intubate and failed, how long should I preoxygenate before attempting again?  Long enough that I should throw the OPA back in?



OPA has taken a back step for me, its NPA for everything airway needing... or diagnostically reducing dopehead siezure fakers, etc.  NPA for all my basic needs. 
Although... OPAs make a great bite stick tube protector next to the ETT. 

Digital.... was popular in the 80s in my area, as it was considered a coordination skill for small hand folks, and a mad trick for big hand people.  Had one incident where it worked in a MVC with entrapment, window access, fingers in mouth to the palm and tube in and confirmed ( I used a cork screw bend in the tube with a lightly lubed stylus ).  When the pt is flacid, it is easier... and oral secretions do make it a bit easier.  That was 15 some years ago.... and that novelty of me putting my valuable digits in a mouth has worn off.  The person would have to be dead before I attempt that.  One siezure... one wrong muscle spasm... one neurological fubar... and fingers will be injured.  We have much better tools to shove in the mouth at any angle, any position to get a tube in ( fiberoptics and such ).  Loosing a non-attached instrument will hurt me less.  Buuuuuuuuut.... it is a knowledge skill in the tool bag for that one special moment.... and I just might slide a bite stick between the molars before I go fingering someone.  But that is just me..... 

Now... if you were not able to intubate in 30 sec, do just what the class taught you. If they did not teach you... try it without the OPA.  If you shove a NPA in, you won't have to worry about an OPA.  If you have a relatively uncomplicated airway without an OPA, why not just BVM the pt without the OPA?  Does is work well?  Many have for me.  Just remember, BVM skills are not taught very good, lack lots of hands on and can be improved, we need to strive to be BVM experts.  If it does not work well, shove a NPA in ( or OPA ).

Desaturation.... another thing not taught very well.  If you have someone that has been properly ventilated, for... lets say 2 minutes, and the SaO2 is phenominal... banging 99% and stuff... you have 2-3 MINUTES ( or more depending how balsy the doc is... ) before the pt desaturates and the body starts thinking about anoxia probs. 
But... then if 3 minutes is up and you are still screwing around... you'll be behind the ball and playing catch up with oxygenation... right?   That can be debated, studies have shown that healthy folks desaturate somewhere around 5 minutes. Ventilate the pt, and try again or think of another tool. 
Maybe they choose not to teach this in field... but the point is, don't get too pressured into rushing to beat a clock.  30 seconds is a safe cutoff for all critical patients who may desaturate faster than the average non-complicated pt.  Most of this relates to elective intubations, most our pts are already behind the ball and traumatized, soooooo speed is of the essence, but once you have them well oxygenated... game on. Question is.... can you get them oxygenated without a secured airway of some kind?
You also have to follow your own protocols on it, cause in the end... that is what they QI.   Outside of that... have a sound and reasonable reason why you deviated.

Good lord... I think I rambled on wayyy too much...


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## MasterIntubator (Sep 9, 2010)

reaper said:


> Still have it and still preform them. I get about 1 every 2 months.



Nice!!!


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## Akulahawk (Sep 10, 2010)

Veneficus said:


> Doesn't anyone test for gag with an OPA before trying to intubate anymore?


I used to. If/when I get back out on the bus again, I'd continue doing precisely that. Why? A couple reasons. One: I can grab an OPA and get to using the BVM faster than I can set up my ETI stuff. Two: in the process, it lets me know the patient has a gag reflex, and if present, I might then consider an NPA and just using a BVM while considering OTI or NTI. Three, if the patient has been intubated orally, the OPA makes a great bite block (or chew toy) and it's right there for me to place as such.

This discussion makes me think back to the days of the oral screw... something I've never had to use.


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## phildo (Sep 10, 2010)

*nti*

We used to do it here alot, before we got RSI 10 years ago.  I still remember the last one I did. A man in his 80's, consolidated.  He was getting fatigued, but didn't want to be RSI'd. I explained NTI to him, did it in just a few seconds.  We would keep a couple of tubes curled around on themselves, with the tip inside the 15mm fitting, along with a small tube of fun jelly and a BAM in a small ziplock bag.  I got 'talked to' about it.  "we have a kinder and gentler intervention now"  It stayed in the protocols until just recently.  I think they realized that nobody teaches it anymore (around here). That and we have a really high intubation success rate. Higher than in Seattle (I forgot the name of that service).


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## JeffDHMC (Oct 6, 2010)

LucidResq said:


> I know of a particular service out here that has a reputation for using NTI all the time. Not in a bad way, but definitely a frequently used tool in their box.



I'll wager you are referring to us, if so that is indeed a rumor. If you're not, I am dying to hear who has gained a rep for doing it more than we did. Yes, we still do it but since the advent of CPAP it is used far less than it used to be. I can't tell you the numbers off the top of my head, but the procedure has decreased in use dramatically. For the most part the only ones doing it are those that were around when it was the only tool we had to manage the tired, profoundly dyspneic pt. that was not responding to pharmacology. Sure, it was great back in the proverbial day (my record is 3 in a 10hr shift, all legit) but I am glad we have gotten away from it. Though I still see a use for it in a system that does not RSI, I am glad it's not the only tool in our toolbox.

Jeff


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## TransportJockey (Oct 6, 2010)

JeffDHMC said:


> I'll wager you are referring to us, if so that is indeed a rumor. If you're not, I am dying to hear who has gained a rep for doing it more than we did. Yes, we still do it but since the advent of CPAP it is used far less than it used to be. I can't tell you the numbers off the top of my head, but the procedure has decreased in use dramatically. For the most part the only ones doing it are those that were around when it was the only tool we had to manage the tired, profoundly dyspneic pt. that was not responding to pharmacology. Sure, it was great back in the proverbial day (my record is 3 in a 10hr shift, all legit) but I am glad we have gotten away from it. Though I still see a use for it in a system that does not RSI, I am glad it's not the only tool in our toolbox.
> 
> Jeff



My short stint with ACA had me thinking you guys do it all the time, but it was some older medics talking about it.

Out here, it's still pretty common to for services to have protocols for NTI. I've attempted it twice in medic school internship and got one of them. Most trucks carry a bam, neosynephrine and lido-jelly, along with some services actually carry endotrols.


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## JeffDHMC (Oct 6, 2010)

Yeah, I can see that. Trust me, I'm one of the older medics and it just doesn't happen like it used to.

Jeff


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## TacoMEDIC (Oct 22, 2010)

I just started working in a rural system that includes NT intubation in the protocol. Having worked in a system that did not include it, I have learned that there is very rarely a need to use it. I could see when it may be useful in cases where positioning is a factor during extrication or when a patient has a clenched jaw...


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## TransportJockey (Oct 22, 2010)

Just found out my new service has ETI and NTI in protocol for EMT-Is and EMT-Ps. RSI in scope for EMT-Ps


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## TacoMEDIC (Oct 22, 2010)

jtpaintball70 said:


> Just found out my new service has ETI and NTI in protocol for EMT-Is and EMT-Ps. RSI in scope for EMT-Ps



Awesome! I really wish that my system utilized EMT-Is.


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## TransportJockey (Oct 22, 2010)

THis system doesn't have a choice. Counting me as the newbie ALS provider, we have a total of 4 FT ALS


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## TacoMEDIC (Oct 22, 2010)

jtpaintball70 said:


> THis system doesn't have a choice. Counting me as the newbie ALS provider, we have a total of 4 FT ALS



Understood. I dont know what youre resources, ETAs, etc are, but I think its extremely beneficial to have EMTs that are allowed to perform a few advanced procedures in any smaller or rural system.


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## TransportJockey (Oct 22, 2010)

TacoMEDIC said:


> Understood. I dont know what youre resources, ETAs, etc are, but I think its extremely beneficial to have EMTs that are allowed to perform a few advanced procedures in any smaller or rural system.



3000 sq mile county  1 lvl 4 trauma in the county, nearest large hospital is a lvl 2 at least 75 miles away. Nearest lvl 1s are 200 miles or so. It's my idea of heaven


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## TacoMEDIC (Oct 22, 2010)

jtpaintball70 said:


> 3000 sq mile county  1 lvl 4 trauma in the county, nearest large hospital is a lvl 2 at least 75 miles away. Nearest lvl 1s are 200 miles or so. It's my idea of heaven



Nice! Mine is 7000 sq. mile area with a small local ER that might as well be a clinic. We have a Level 1 Trauma, STEMI, etc 100 miles away in Las Vegas. Nearest additional ALS resource is 65 miles out.


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## swissmedic (Oct 29, 2010)

I do some nasal intubations, but only in the op-room/hospital. I didn't like it need many experience and is difficult too
In my opinion it is not an prehospital skill for untrained medics...
Matt


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## 8jimi8 (Oct 30, 2010)

swissmedic said:


> I do some nasal intubations, but only in the op-room/hospital. I didn't like it need many experience and is difficult too
> In my opinion it is not an prehospital skill for untrained medics...
> Matt



what is your definition of untrained? or did you mean, uneducated?


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## reaper (Oct 30, 2010)

Yes, NTI is not a difficult airway. If you are trained and educated, it is an excellent pre-hospital airway. 

The hesitation and uneasiness comes from lack of experience with them. Once you have done quit a few, you will see that it is an excellent alternative airway.


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## swissmedic (Oct 30, 2010)

8jimi8 said:


> what is your definition of untrained? or did you mean, uneducated?



Hello
I am still working between the 911calls in our anesthetixs dept.  We have not many real ALS calls in our aera. So I am untrained in outside hospital NTI :wacko:
So once a week there are dental operations and you do NTI, but i didn't like nasal intubation.
 In my opinion you must train often you can ETI/NTI in OP and not only at the simulator. ETI is high risk skill, so train it in real situations...
Matt


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## Fox800 (Nov 15, 2010)

My system does not have RSI, but we do have NTI as an option. Seems a little nerve-wracking, as I have yet to attempt one (or need to).


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