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Year : 2012  |  Volume : 56  |  Issue : 1  |  Page : 81-83  

A rare, potentially hazardous, malposition of the nasotracheal tube

Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bangalore, Karnataka, India

Date of Web Publication29-Feb-2012

Correspondence Address:
Murali Chakravarthy
Chief Consultant Anesthesiologist, Wockhardt Heart Institute, Bangalore, Karnataka 560 076
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5049.93353

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How to cite this article:
Chakravarthy M, Holla S, Gowda N, Anand A, Mattur K, Reddy K, Kumar S, Simha R. A rare, potentially hazardous, malposition of the nasotracheal tube. Indian J Anaesth 2012;56:81-3

How to cite this URL:
Chakravarthy M, Holla S, Gowda N, Anand A, Mattur K, Reddy K, Kumar S, Simha R. A rare, potentially hazardous, malposition of the nasotracheal tube. Indian J Anaesth [serial online] 2012 [cited 2021 Feb 28];56:81-3. Available from: https://www.ijaweb.org/text.asp?2012/56/1/81/93353

   Introduction Top

Difficult intubation is a patient related problem that anesthesiologists need to address in their practice. Although various visual aids are now available for facilitating insertion of endotracheal tube (ETT), human errors do occur. A few unwritten guidelines about the process of intubation using fiberoptic bronchoscope (FOB) exist, but none are standardized. At times, it may not be possible to follow the guidelines for reasons beyond the control of anesthesiologists. The authors report in here a case of failed endotracheal intubation attempted using the FOB aid. The failure was masked by ability to ventilate the patient, observing normal end tidal carbon dioxide curves, and return of ventilated tidal volume. This brief communication is being published to highlight the errors that may creep if the standard procedure is not followed. The authors wish to reiterate that visualization of the carina and tracheal rings must be the end point for a successful endotracheal intubation.

   Case Report Top

A 42-year-old, 140-kg male patient was scheduled for right hip arthroplasty. The patient smoked 20 cigarettes daily for the past 20 years. He was using continuous positive airway pressure mask during nights for the past 5 years as he had been diagnosed to be suffering from obstructive sleep apnea. The laboratory tests were unremarkable, except for haemoglobin concentration of 19 G/dl. Only the soft palate and the base of the uvula were visible on oral examination (Mallampati grade 3). He also had short neck and limited extension of the neck. It was decided to electively intubate the patient's trachea via the nasal route using fiberoptic bronchoscopy guide in view of the above-described problems. The patient was explained about the procedure and an informed consent to the same effect was obtained from him. The patient was administered 0.2 mg of glycopyrrolate injection intravenously prior to commencement of endoscopy. As per the institutional protocol, the nasal passage was topically anaesthetized using xylometazoline nasal drops, 3 ml of 4% topical xylocaine in both nostrils, 10% aerosol spray of xylocaine and intermittent spray of the nasopharyngeal cavity with xylocaine with 1:200,000 adrenaline during the bronchoscopy. Additionally, local anaesthetic solution was sprayed on to the vocal cord and into the trachea through the bronchoscope. Before insertion of the bronchoscope, it was decided to examine the nasopharyngeal cavity because of the presence of deviated nasal septum. Examination of the nasopharynx using a 6-mm bronchoscope revealed significantly narrowed nasal passage. It was estimated that a 7-mm ETT could be atraumatically inserted on the left side and it was decided to use a 7-mm flexometalic ETT (Portex Ltd. CT21 6JL, UK). Accordingly, the 3-mm bronchoscope (KARL STORZ GmbH and Co. KG, Mittelstr. 8, 78532 Tuttlingen, Postfach 230, 78503 Tuttlingen, Germany) was threaded into the 7-mm-reinforced ETT, because threading the 6-mm FOB through the ETT was not successful.

The FOB with the ETT threaded on it was inserted via the left nasal passage. After negotiating an extremely tortuous nasal passage, the vocal cords were visualized. Topical xylocaine was sprayed on the vocal cords and into the tracheal lumen via the port in the bronchoscope, which resulted in violent coughing. After repeating this procedure, when coughing abated, the ETT was threaded towards the vocal cords and positioned above the vocal cords. Despite repeated topical anaesthetic spray, the patient continued to cough violently. The ETT was "rail roaded" on the bronchoscope. Visualization of neither the tracheal rings nor the carina was possible. The ETT was connected to the breathing circuit of the anaesthesia machine, and satisfactory respiratory and ETCO 2 waveforms, movement of chest and exhaled tidal volume measurements (although 20% leak) were noted on the monitor. The respiration could be satisfactorily assisted using the re-breathing bag. Although the final confirmation of the appropriate tube position was not made, it was decided to anaesthetize the patient because he seemed to be uncomfortable because of the presence of the ETT. General anaesthesia was induced by intravenous administration of 150 mg of propofol and mechanical ventilation was facilitated by intravenous administration of 100 mg of rocuronium. Mechanical ventilation was initiated with tidal volume of 900 ml and frequency of 15/min. A mixture of oxygen in nitrous oxide (50:50) was used as inspiratory gas along with 2% of sevoflurane. Haemodynamic parameters, pulse oxymetry (SpO 2 ), ETCO 2 waveform, respiratory waveforms (peak pressure, plateau pressure), volume and flow loops and exhaled tidal volume appeared satisfactory after institution of mechanical ventilation, except for ongoing 20% leak of inspired gases (which was presumed to be due to a possible trauma that the cuff of the ETT may have suffered during its passage through the tortuous nasal passage). Despite these findings, it was decided to confirm correct position of the ETT by visualization of the tracheal lumen and the carina (as required by the institutional protocol prior to commencement of surgery in FOB-guided awake intubations) and change the ETT to abolish the leak in the cuff. Passage of the FOB through the ETT was difficult; it was lessened by the application of lubricant jelly. At the distal tip of the ETT, the tracheal rings and carina could not be visualized; instead, two globular masses at the 4 O'clock and 7 O'clock positions were seen. Abdominal distension was noted, presumably caused by swallowing of air due to anxiety during awake intubation and a nasogastric tube was passed through it to relieve the same. While the stomach was being deflated, the attempts at checking the correct position of the ETT continued and the nasogastric tube was seen coursing the visual field of the FOB. It was assumed that either the ETT was wrongly located at the oesophageal orifice or the nasogastric tube was in the trachea. In order to obtain clarity about this issue, the oropharynx was inspected using a laryngoscope, which revealed that the ETT had undergone a complete loop such that the body of the ETT was in the oropharynx while its tip was abutting the pharyngeal inlet [Figure 1]. The nasogastric tube was posteriorly entering the oesophageal orifice. The cuff of the ETT was grossly distended and was providing an airtight seal in the pharyngeal inlet. The ETT was withdrawn to eliminate the loop and, under visual control with FOB, reinserted into the trachea. The globular masses located earlier were the patient's tonsils. The rest of the anaesthesia and surgery was uneventful.
Figure 1: Disposition of the nasally inserted endotracheal tube

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   Discussion Top

Use of FOB to intubate the trachea in anticipated difficulty in intubation has been shown to be superior. In the described patient, ideally, a 6-mm FOB would have been suitable. Thinner FOB was used, because of severe nasal obstruction due to deviated nasal septum. If a 6-mm FOB was used for intubating the trachea, looping the ETT may not have occurred. In the described case, the looping of the ETT and FOB may have occurred while the bronchoscope was withdrawn when the ETT was advanced distally into the trachea. In the described case, the violent cough may have prevented the ETT from entering the trachea and attempts to "rail road" the ETT may have resulted in the loop formation. Visualization of tracheal rings and carina confirms the proper position of the endoscopically introduced ETT [1],[2] and, after such a confirmation, there is no requirement of direct visualization using the laryngoscope. In the described case, the authors were misled to accept the existing position of the ETT by the absence of other evidences suggestive of malposition of the ETT. Repeated inflation of the ETT cuff to overcome the "leak" of the ETT cuff may have promoted the outward shift while providing airway seal in a fashion similar to pharyngeal cuff of the oesophageal tracheal double-lumen airway. Although it may not be required to check the oral position of the ETT routinely, it may be advisable to check the position of the ETT by laryngoscopy if confirmation of the desired position was not carried out by FOB for whatever reasons. It became obvious that the tip of the tube was actually in the pharynx and not in the trachea. The "globular masses" seen on the bronchoscope were the tonsils. If the authors had not persisted with checking the final position of the ETT, slipping of the ETT (in the patient with known difficulty in intubation may have resulted in catastrophic intraoperative outcome). The authors suggest that direct visualization of the intraoral course of ETT using laryngoscopy may be performed if fiberoptic visualization of the correct position of the ETT is not done or possible. It may be relevant to note that in cases of difficult endotracheal intubation, oral FOB guided intubation, use of supraglottic airway devices such as laryngeal mask airway may be a safer alternative.

   Conclusion Top

If intratracheal placement of the ETT is not confirmed, induction of general anaesthesia should be delayed. In difficult nasotracheal intubations, the oral route may be tried.

   References Top

1.Stackhouse RA. Fiberoptic airway management. Anesthesiol Clin North America 2002;20:933-51.  Back to cited text no. 1
2.Salem MR. Verification of endotracheal tube position. Anesthesiol Clin North America 2001;19:813-39.  Back to cited text no. 2


  [Figure 1]

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1 A rare, potentially hazardous malposition of the nasotracheal tube
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2 An unusual potentially hazardous malposition of naostracheal tube
Chakravarthy, M. and Holla, S. and Gowda, N. and Anand, A. and Mattur, K. and Reddy, K. and Kumar, S. and Simha, R.
Indian Journal of Anaesthesia. 2012; 56(6): 595-596


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