Suction catheter as a guide for nasotracheal intubation under general anesthesia: randomized clinical trial of efficacy.
Description
The aim of this study was to evaluate the efficacy of the suction catheter-guided ETT during NTI under general anesthesia. It was hypothesized that suction catheter guided method would reduce the injuries to nasal passage and improve the navigability. The study was designed as a single-site, randomized clinical trial with equal randomization (1:1), double-blinded (participants and primary outcome assessor) and parallel design. The primary outcomes were the incidence and extent of bleeding. Records from the videolaryngoscope (GlideScope®) during intubation were reviewed. Only bleeding observed at posterior pharyngeal area, originating from trauma during the attempt to pass the ETT through the nasal passage, was accounted for. Bleeding was scored at its most severe state observed from the insertion to the removal of the videolaryngoscope after successful intubation, using a 4-point scale: 0 (no bleeding); 1 (blood-stained tube and/or cuff); 2 (blood-stained posterior pharyngeal wall; 3 (blood pooling at the posterior pharyngeal wall). Secondary outcomes included ease of navigation through the nasal passage, first-pass success rate, number of attempts, and nasal passage time. Ease of navigation was graded as follows: smooth (no resistance, no adjustments needed); slight resistance (resistance encountered, requiring manipulation more than once); and impinged (unable to pass through, requiring a change of nostril). The first-pass success rate was defined as the rate of successful nasal pass without changing nostrils. The number of attempts referred to the times the ETT needed to be withdrawn completely in order to find a new angulation, change nostrils or decrease the tube size before successful intubation. Nasal passage time was measured from when the ETT or suction catheter entered the anterior nares until the ETT passed into the pharynx or the suction catheter was completely withdrawn from the ETT.
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Steps to reproduce
Anesthesia was standardized for all patients. General anesthesia was induced, the more patent nostril, predetermined by patient self-evaluation and the nasal occlusion test, was selected for starting intubation. If undecided, the right nostril was used. All intubations were performed by the same anesthesiologist. Nasal reinforced cuffed ETT with 7.5- and 7.0-mm ID was used for male and female patients, respectively. All tubes were lubricated with water-soluble lubricating gel before insertion. In the control group, the ETT was gently advanced through the selected nostril along the nasal floor. If resistance was encountered, gentle rotation and tilting of the tube were performed. If the tube failed to enter the pharynx, the other nostril was used. If that also failed, the tube size was reduced to 7.0-mm ID for males and 6.5-mm ID for females, and the procedure was repeated. The smallest acceptable tube sizes for inclusion in the study were 6.5-mm ID for males and 6.0-mm ID for females. The force used, tube manipulation, and decision to change nostril or ETT size were decided by the anesthesiologist. Once the tube tip reached the pharynx, tracheal intubation was completed using videolaryngoscope (with or without using Magill forceps. Video recordings during tracheal intubation were made for later review and labelled with a unique randomization code. In the guided group, a well-lubricated 14-French suction catheter was first inserted through the ETT, with about 10 cm of the catheter protruding from the distal end. The catheter tip was gently inserted through the selected nostril. The ETT was then advanced over the catheter while holding the catheter to prevent it from moving forward and avoid kinking. If resistance encountered during tube advancement, the same protocol as the control group was followed. Once the tube tip reached the pharynx, the suction catheter was withdrawn from the ETT, and the control group protocol was resumed. No additional appointments were required for data collection.
Institutions
- Mahidol University Faculty of DentistryBangkok