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COMMENTARY
Year : 2019  |  Volume : 12  |  Issue : 4  |  Page : 345-346  

Cuff inflation can do the trick for nasotracheal intubation using video laryngoscopy


1 Department of Onco-Anesthesiology and Palliative Medicine, Dr. BRA-IRCH, AIIMS, New Delhi, India
2 Department of Anesthesiology and Intensive Care, VMMC and Safdarjung Hospital, New Delhi, India

Date of Web Publication8-Jul-2019

Correspondence Address:
Nishkarsh Gupta
Department of Onco-Anesthesiology and Palliative Medicine, Dr. BRA-IRCH, AIIMS, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_261_18

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How to cite this article:
Gupta N, Gupta A. Cuff inflation can do the trick for nasotracheal intubation using video laryngoscopy. Med J DY Patil Vidyapeeth 2019;12:345-6

How to cite this URL:
Gupta N, Gupta A. Cuff inflation can do the trick for nasotracheal intubation using video laryngoscopy. Med J DY Patil Vidyapeeth [serial online] 2019 [cited 2019 Dec 10];12:345-6. Available from: http://www.mjdrdypv.org/text.asp?2019/12/4/345/262238



Nasotracheal intubation (NTI) is the favored method for securing the airway in oropharyngeal cancer surgeries. However, it is often difficult due to swelling, decreased mouth opening, submucosal fibrosis, and deformities.[1] NTI can be done blind, laryngoscope guided, or using a fiberoptic bronchoscope (FOB).[2],[3] All the described techniques have their own advantages and disadvantages. The FOB is considered the “gold standard” technique for intubation in such cases, but its usefulness is limited by a prolonged learning curve and limited availability in many centers. Blind intubation techniques are not ideal for oral cancer patients because it may lead to cause injury to the growth and cause excessive bleeding. A direct laryngoscope (DL) can be used for NTI provided the mouth opening of the patient is sufficient to allow for DL. The tip of DL is placed on the hyoepiglottic ligament to elevate the epiglottis for the optimal glottic view. This tends to misalign the glottic inlet from the nasally inserted endotracheal tube (ET) in the pharynx.[3],[4] One may require aids like Magill's forceps to align the tube to the glottic inlet.[4] This may damage the ET cuff and also may cause oropharyngeal mucosal injury (leading to bleeding).

Cuff inflation technique is a novel technique for NTI; it was first suggested by Gorback for blind nasal intubation in spontaneously breathing patients and was not found to be very successful.[2] “Cuff Inflation” lifts the ET tip off the posterior pharyngeal wall and helps the operator to direct the ET tube into the laryngeal inlet. Chung et al. showed that cuff inflation technique significantly increased the correct alignment of the ET with glottis and resulted in successful blind NTI in 84% of patients and FOB was required in only two patients.[5]

During DL-guided NTI “cuff inflation,” the operator has to insert the ETT through the nostril first till it lies in the pharynx. Then, the DL is inserted to get an optimum view of the larynx and the ETT cuff is then inflated with 15–20 mL air to lift its tip off the posterior pharyngeal wall and guided into glottis under vision. Thereafter, the ET cuff is deflated, and it is gently pushed into trachea under vision.

In oral cancer patients, the disease/growth may make it difficult to align the three axes (the tracheal, pharyngeal, and oral) during laryngoscopy to visualize the glottis. Recently, video laryngoscopes (VL) have been increasingly used for airway management in a potential difficult airway. Studies have shown that in DL s like VL are better than DL for orotracheal intubation as they do not need the line of sight view to visualize the glottis and may also be preferred for NTI.[3] VLs reduce the force required to lift the glottis during DL and reduce misalignment between the glottis and ET tip. A VL reduces the need for ET manipulation, and requirement of adjuncts like Magill's forceps for NTI. In addition, a VL-guided NTI may lead to a lesser hemodynamic response. Jones et al. have reported that Glidescope VL provided better conditions, did not require Magill's to guide NTI, and reduced postoperative sore throat.[6]

Glidescope VL has been used to assist NTI using cuff inflation technique in the head-and-neck cancer patients.[7] C-Mac D-blade has also been found to reduce the time to intubate, the number of attempts, and trauma when compared with DL for NTI in oral cancer patients.[8] TA-scope needs only 1.5 cm mouth opening for insertion into the oral cavity and may be an can be a feasible alternative in oral cancer patients with restricted mouth opening.

Another problem is that due to anterior deflection of the ET tube by cuff inflation, it often impinges the anterior tracheal wall after entering the glottis. One may need to rotate the ET tube or rotate the patient's head to further align the tip of ET and ensure smooth insertion.

In this issue, authors have described (Shah et al.) NTI with “cuff inflation technique” using anesthetist scope (indirect optical VL) in 50 patients posted for oral cancer surgery.[9] They could successfully align the ETT with glottis in 88% of cases by inflating the ET cuff with 15 mL of air.[9]

They have also reported that cuff inflation resulted in higher success of intubation in the first attempt and reduced the need of Magill's forceps. This cuff inflation technique may be considered if the mouth opening is sufficient to insert TA-Scope or any other VL. It should be part of our routine airway management plans for NTI in oral cancer patients in the absence of a functional FOB.



 
  References Top

1.
Hall CE, Shutt LE. Nasotracheal intubation for head and neck surgery. Anaesthesia 2003;58:249-56.  Back to cited text no. 1
    
2.
Gorback MS. Inflation of the endotracheal tube cuff as an aid to blind nasal endotracheal intubation. Anesth Analg 1987;66:916-7.  Back to cited text no. 2
    
3.
St Mont G, Biesler I, Pförtner R, Mohr C, Groeben H. Easy and difficult nasal intubation – A randomised comparison of macintosh vs. airtraq® laryngoscopes. Anaesthesia 2012;67:132-8.  Back to cited text no. 3
    
4.
Staar S, Biesler I, Müller D, Pförtner R, Mohr C, Groeben H, et al. Nasotracheal intubation with three indirect laryngoscopes assisted by standard or modified magill forceps. Anaesthesia 2013;68:467-71.  Back to cited text no. 4
    
5.
Chung YT, Sun MS, Wu HS. Blind nasotracheal intubation is facilitated by neutral head position and endotracheal tube cuff inflation in spontaneously breathing patients. Can J Anaesth 2003;50:511-3.  Back to cited text no. 5
    
6.
Jones PM, Armstrong KP, Armstrong PM, Cherry RA, Harle CC, Hoogstra J, et al. A comparison of glidescope videolaryngoscopy to direct laryngoscopy for nasotracheal intubation. Anesth Analg 2008;107:144-8.  Back to cited text no. 6
    
7.
Gupta N, Garg R, Saini S, Kumar V. GlideScope video laryngoscope-assisted nasotracheal intubation by cuff-inflation technique in head and neck cancer patients. Br J Anaesth 2016;116:559-60.  Back to cited text no. 7
    
8.
Hazarika H, Saxena A, Meshram P, Kumar Bhargava A. A randomized controlled trial comparing C mac D blade and macintosh laryngoscope for nasotracheal intubation in patients undergoing surgeries for head and neck cancer. Saudi J Anaesth 2018;12:35-41.  Back to cited text no. 8
    
9.
Shah KG, Shah BC, Mehul P. Effect of cuff inflation technique in video laryngoscopic assisted nasal intubation in oral cancer surgeries. Med J DY Patil Vidyapeeth 2019;12:340-4.  Back to cited text no. 9
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