Strategies

• Routine Technique
  • Induce anesthesia as normal; reapply nasal vasoconstrictor if needed.
  • Insert smallest nasal trumpet first, increasing size as tolerated.
  • Advance ETT along the nasal floor, keeping bevel toward the septal floor — direct straight posteriorly, not downward.
  • Once posterior oropharynx reached, ensure patient in sniffing position for better alignment.
  • Use direct laryngoscopy to guide ETT through glottic opening; Magill forceps may be used cautiously to grasp proximal to the cuff only.
  • Grasping the cuff can rupture it — replace if damaged.

Alternative Aids

• Red Rubber Catheter Technique:
  • Attach 18 Fr red rubber catheter to ETT tip and guide through nare into oropharynx.
  • Advance ETT over catheter, then remove catheter.
  • Inflating cuff can lift the tip off posterior pharyngeal wall to improve trajectory.
• Fiberoptic Assistance:
  • Load ETT on scope prior to insertion through nare.
  • Can be used awake or under anesthesia, alone or combined with video laryngoscopy.
• Balloon-Advance Technique:
  • After entering oropharynx, lower head to neutral and inflate cuff to direct tip anteriorly.
  • Once at glottis, deflate cuff and advance into trachea.

Complications

• Submucosal dissection: if ETT tip not visible in oropharynx, suspect misplacement.
• Epistaxis: common — usually from anterior nasal septal vessels (Kiesselbach’s plexus).
• Nare necrosis: prolonged pressure from fixed ETT — pad and secure properly.

Securing the Tube

• Circuit typically exits over patient’s forehead; pad connector with foam to prevent facial compression.
• Tape securely with towel support or suture to nare if needed.

Clinical Optimization

• Pre-procedure assessment and choice of nare and tube size are key to success.
• Troubleshooting:
  • Tube movement or loss of seal may occur if head repositioned by surgeon; confirm secure depth and fixation.
  • If epistaxis occurs, suction gently — ETT may tamponade bleeding.

Pearls

• Plan thoroughly before proceeding — have backup and suction ready.
• Insert with bevel facing the floor of nasal cavity.
• Advance slightly caudad along the palate toward the posterior pharynx.
• Never grasp the ETT cuff with Magill forceps.