The call came in as a patient being unresponsive. You arrive on scene to find an elderly woman, hunched in her wheelchair, semiconscious, with labored breathing. She has a history of stroke, and by the drooping appearance of her left side, which her family states is not normal, it appears she has had another.
Your first concern is her airway. Her O2 saturation is 89 percent, so you place her on a non-rebreather mask at 15 liters. Intubation appears imminent. The problem is, she has a debilitating kyphosis, which means placing her supine for intubation is going to be impossible. Your second choice? Nasotracheal intubation.
Nasotracheal intubation is not a skill that is practiced with regularity. Because of that, many paramedics are hesitant to proceed. So, let's return to our patient and walk through the various do's and don'ts of nasotracheal intubation.
First, the advantages. Nasotracheal intubation provides a secure airway for patients who are breathing on their own, preventing aspiration of blood, vomit, or sputum. It is better tolerated than oral intubation in the patient who is semiconscious and is a good alternative if the patient is unable to open his or her mouth, is morbidly obese, or is unable to lay supine.
The disadvantages include possible damage to the delicate nasal tissues, the patient must be spontaneously breathing, and it is contraindicated in patients with possible basal skull fractures or facial trauma. Despite these disadvantages, it is a good alternative to oral intubation.
Before you decide on intubation, you must first assess your patient to determine if he or she meets the criteria. A useful technique is to distinguish whether your patient is in respiratory distress versus failure. Generally, a patient in distress may exhibit the following signs and symptoms:
The patient in respiratory failure, on the other hand, needs immediate intervention and will exhibit the following:
You've determined your patient is exhibiting impending respiratory failure and decide nasotracheal intubation is your best option. Prepare the patient and your equipment, just as you would before oral intubation¹:
As with oral intubation, you want to have suction at the ready. If the patient has an altered LOC, he or she cannot protect his or her airway, so stay alert for critical suction scenarios that may develop in the semiconscious patient. By incorporating your portable suction unit into your airway bag or storing it next to other ALS equipment, you will always have it on hand when needed. There's never time to run back to the truck to retrieve the suction. Arrive prepared!
Once you know the do's and don'ts of nasotracheal intubation, you can approach the procedure with confidence. Nasotracheal intubation is a great alternative to the oral route. Just be sure your patient meets the criteria, have your equipment ready, and keep the portable suction unit nearby, just in case.
Editor's note: This blog was originally posted in Nov 2017, it has since been updated with new content.
¹ 2013, Johnson, NJ and ET Dickinson
Swollen Tongue Necessitates Nasotracheal Intubation, JEMS online, http://www.jems.com/articles/print/volume-38/issue-10/departments-columns/case-of-the-month/swollen-tongue-necessitates-nasotrachael.html