Anesth Analg 2004;99:1352-1354
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000134801.87404.3F
PEDIATRIC ANESTHESIA
A Secure Method of Nasotracheal Tube Fixation Using an Infant Feeding Tube
V. Ravindra Bhat, MD DA, DNB(Anesth), and
G. Venkateshwaran, DA
Department of Plastic Surgery, Hand Surgery and Reconstructive Microsurgery, Ganga Hospital, Coimbatore, India
Address correspondence and reprint requests to V. Ravindra Bhat MD, DA, DNB(Anesth), Department of Plastic Surgery, Hand Surgery and Reconstructive Microsurgery, Ganga Hospital, Swarnambika Layout, Ramnagar, Coimbatore, India 641 009. Address email to chitravi{at}vsnl.com
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Abstract
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A well secured endotracheal tube is very essential for the safe conduct of anesthesia. In maxillofacial surgeries, providing secure fixation of the nasotracheal tube has always been a problem. We have used an infant feeding tube that goes around the nasal septum for the fixation of the nasal endotracheal tube. This method of securing the nasotracheal tube does not hinder the surgical access, is well tolerated by patients, and is safe.
IMPLICATIONS: This article describes a method of fixing the nasotracheal tube for anesthesia for maxillofacial surgeries using an infant feeding tube.
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Introduction
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Fixation of the endotracheal tube is of vital importance in any general anesthetic procedure and in the intensive care unit (ICU) where an endotracheal tube is used to secure the airway. When the surgical field is away from the head and neck this can easily be achieved. In maxillofacial surgeries, anesthesiologists have to provide the operating team with maximum range of motion near the head of the patient without jeopardizing the security of the endotracheal tube. In surgeries requiring intraoperative assessment of proper mouth occlusion or performing intermaxillary fixation, nasotracheal intubation is preferable to oral intubation. Various methods of fixation of the nasotracheal tube have been described (1–3). We have described a technique of fixing the nasotracheal tube using an infant feeding tube (4).
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Methods
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After obtaining permission from the IRB and informed consent from the patients, seven patients with maxillofacial injuries were included for the study of this method of fixation of the nasotracheal tube. We used polyvinylchloride tubes for nasotracheal intubation in 3 patients and North Pole preformed RAE tubes for 4 patients (7 mm for female patients and 8 mm for male patients). While performing nasotracheal intubation the gloved little finger of the anesthesiologist was lubricated with 2% lidocaine jelly and introduced gently into the nostril selected for passing the nasotracheal tube. This cleared the nasal passage of any debris, provided lubrication, and provided the anesthesiologist with information regarding any deviation of the nasal septum. The nasotracheal tube was put in warm water to soften it so as to minimize the trauma to the nasal mucosa during insertion. This tube was passed through the nostril, and when the tube was in the oropharynx it was examined for any debris occluding the lumen of the endotracheal tube. The nasotracheal tube was then guided into the larynx under direct laryngoscopic guidance using a Magill’s intubating forceps. After confirming the position of the nasotracheal tube it was secured in the following way.
- A 6 F infant feeding tube was passed through the same nostril as the endotracheal tube and taken out through the mouth (Fig. 1).
- A 10F suction cannula was passed through the opposite nostril and brought out through the mouth with a Magill’s forceps (Fig. 2).
- The infant feeding tube was threaded into the suction cannula (Fig. 3).
- The suction cannula along with the infant feeding tube was pulled out through the nostril. The infant feeding tube was then encircling the nasal septum (Fig. 4).
- A loose knot was tied in front of the columella (Fig. 5). Care was taken that the knot was not tight, which could have caused damage to the septal mucosa.
- The two ends of the infant tube were used to secure the nasotracheal tube (Fig. 6).
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Figure 1. A 6F infant feeding tube has been passed through the same nostril as the endotracheal tube and has been brought out through the mouth.
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Figure 2. A 12F suction tube has been passed through the opposite nostril and brought out through the mouth.
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Figure 4. The suction tube has been pulled out of the nostril. The infant feeding tube has come out through the opposite nostril along with the suction tube.
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The oropharynx was examined for any bleeding. The nasal endotracheal tube was observed intraoperatively to look for any accidental extubation or advancement into the trachea. At the end of the procedure, in patients in whom extubation was planned on the operating table, the infant feeding tube was cut away from the knot so that when the endotracheal tube was removed the knot would come along with the tube. After extubation the nasal mucosa, the ala of the nose, and columella were observed for any pressure necrosis or ulcerations. All patients were asked to report any discomfort in the nose in the postoperative period. Four patients were electively ventilated in the postoperative ICU from 4 to 24 h. These patients received IV infusion of propofol with a syringe pump and intermittent IV injection of fentanyl 2 micrograms per kg body weight every second hour. They did not receive any muscle relaxants.
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Results
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No significant bleeding was observed from either nostril after securing the nasotracheal tube. There was minimal movement of the nasotracheal tube intraoperatively. None of the patients had any injury to the nasal mucosa, ala of the nose, or the columella. In the 4 patients in whom elective postoperative ventilation was chosen, the patients accepted the nasotracheal tube comfortably. None of the patients complained of any discomfort in the nose.
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Discussion
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Endotracheal tubes have to be secured effectively during surgery. Inadvertent extubation during surgery can be life-threatening. Movement of the endotracheal tube up and down can cause trauma to the laryngeal and tracheal mucosa. At the same time, techniques used to secure the tube should not interfere with the surgical field.
Many methods have been advocated to secure the nasotracheal tube. Adhesive tapes have been used alone and along with adhesives such as tincture benzoin on the tube and skin. Sutures taken through the nasal septum have been used to secure the nasotracheal tube (2). Umbilical tapes or discarded oxygen tubing have been used. A method using the RAE tube and use of the Mayo table to secure the endotracheal tube has been described (3). All these techniques have disadvantages, such as dislodgement of the tapes as a result of constant movement during the surgery, the development of allergy to the adhesive tapes, and injury to the nasal septum as a result of the sutures cutting through it. We have found that the technique using an infant feeding tube to be very secure during surgical manipulation. We have not encountered any problems such as inadvertent extubation, septal damage, or pressure necrosis. Most major maxillofacial reconstructions are electively ventilated postoperatively, and we have found that patients tolerate this technique of fixation well in the postoperative period in the postanesthesia care unit.
We have used this technique only for those patients who had maxillofacial surgeries and not in the ICUs as a routine. The safety of this method of fixation needs to be assessed in patients who need prolonged nasotracheal intubation. Popovich et al. (5) have safely used this nasal bridle for periods of more than 30 days in the ICU in critically ill patients for securing nasogastric tubes.
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Conclusion
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We have found this technique of fixation of the nasotracheal tube to be a very effective manner of stabilization of the nasal endotracheal tube with the least morbidity in the perioperative period. It rarely interferes with the surgical field and is well tolerated by the patient. The safety of this method for routine use in the ICU needs to be evaluated.
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References
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- Fenje N, Steward DJ. A study of tape adhesive strength on endotracheal tubes. Can J Anaesth 1988; 35: 198–202.[Abstract/Free Full Text]
- Ota Y, Karakida K, Aoki T, et al. A secure method of nasal endotracheal tube stabilization with suture and rubber tube. J Exp Clin Med 2001; 26: 119–22.
- Baek RM, Song YT. A practical method of surgical draping using the preformed RAE (Ring-Adair-Elwyn) nasotracheal tube and the Mayo table in maxillofacial surgery. Plast Reconstr Surg 2003; 112: 1484–5.[Medline]
- Woodsford PV. Nasotracheal tube security, airway management. In: Park GR, Sladen RN, eds. Top tips in critical care. London: Greenwich Medical Media, 2001: 11.
- Popovich MJ, Lockrem JD, Zivot JB. Nasal bridle revisited: an improvement in the technique to prevent unintentional removal of small bore nasotracheal feeding tubes. Crit Care Med 1996; 24: 429–31.[Medline]
Accepted for publication May 18, 2004.
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Abstract
Introduction
