Anyone Nasally intubate anymore?

[MasterIntubator]

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.

 

[Shishkabob]

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

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

 

[abckidsmom]

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.

 

[Akulahawk]

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.

 

[Hockey]

Available here, but never seen/heard it done

 

[EMTinNEPA]

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.

 

[Smash]

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

 

[reaper]

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.

 

[8jimi8]

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?

 

[Ridryder911]

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

 

[LucidResq]

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.

 

[reaper]

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

 

[8jimi8]

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

 

[MrBrown]

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 ....

 

[Epi-do]

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.

 

[abckidsmom]

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.

 

[Veneficus]

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

In my memory, which is not always working perfectly.

 

[Akulahawk]

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

Ditto.

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

 

[Ridryder911]

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

 

[Dominion]

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

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.