Airway & Respiratory, Commentary, Exclusives, Patient Care

Nasotracheal Intubation: Should the Art Be Lost?

As a profession, paramedicine providers pride themselves on their ability to care for acutely ill and injured patients. Modern emergency medical services (EMS) systems in the United States have progressed substantially since first conceived in the 1960s and 1970s.

While the roots of ambulance transport trace to the time of Napoleon Bonaparte and later the Civil War – during which time the first dedicated vehicles were used to recover injured soldiers – EMS as we know them today began with the groundbreaking report Accidental Death and Disability: The Neglected Disease of Modern Society, better known simply as The White Paper. With the subsequent Highway Safety Act of 1966, therapies that existed only within the confines of hospitals were distributed to the field environment, hoping for significant improvements in patient outcomes in the prehospital setting.

Like any medical field, the available technology improved, outcomes guided the quality improvement of protocols, and strategies that were accepted as commonplace were gradually replaced.

A useful example is in spinal motion restriction via the long spine board (LSB). For years considered the standard for spinal protection, research has shown a diminished utility of securing patients to a rigid and often uncomfortable LSB. As such, guidelines have shifted away from the indiscriminate use of an LSB on every trauma patient.

Part of the core that is EMS is the ability to establish and maintain a patient’s airway: whether through noninvasive means, such as manual positioning, oral airways, and the bag-valve-mask, to more invasive measures such as endotracheal intubation and surgical cricothyrotomy.

Photo National Highway Traffic Safety Administration

These skills have been, and continue to be, a major portion of the National Highway Traffic Safety Administration EMS Scope of Practice, unchanged in the new iteration released in 2019.

This article will not make any comment on the controversial topic of field intubation and the future of EMS, as numerous journals and research articles continue to shape that discussion. Rather, this discussion will focus on a small piece of the larger picture: the role of nasotracheal intubation in the hands of a prehospital provider.

When compared to the traditional orotracheal route, nasotracheal intubation (NTI) was often preferred for the conscious patient in which there was concern for decompensation. This was especially true in patients in which sedation should be avoided, if possible, whether due to difficult airway and/or medical comorbidities.

NTI may also be preferred for patients with unfavorable spinal pathology or limited mouth opening (such as in trismus). However, with the advent of rapid-sequence intubation and new technology such as BiPAP/CPAP, the practice of NTI outside of the hospital has diminished in its utilization.

An examination comparing data from the 2008 and 2012 NEMSIS databanks reveals that, while the rates of endotracheal intubation are relatively stable across the population, rates of NTI more than halved during this period, with airway management methodology shifting more toward rapid sequence intubation (RSI) or supraglottic airways.

The data suggest that BiPAP and CPAP have become heavily favored for the management of patients in respiratory distress – rather than NTI.

In a 2018 survey of the Eagles Coalition (an international group of EMS physician medical directors of large urban centers), it was noted that, of 43 medical director respondents, only fifteen had protocols in place for NTI. Of those fifteen, only two reported common usage. Additionally, two others reported that they were discontinuing NTI from their protocols.

In terms of skills maintenance and training, only eight of the fifteen allowing NTI reported any separate formal curriculum for NTI training. Although a relatively small sample size, this “litmus test” of medical protocols from large urban centers is consistent with the 2012 NEMSIS data, which also showed that there is a shift away from using NTI in favor of other available strategies.

Thus, the question is raised: Should EMS training entities continue to teach the skill of NTI, and should the implementation of NTI continue to be authorized by EMS medical directors?

It is a challenge to maintain proficiency for all skills required of a prehospital provider, especially as it regards the recreation of the complexities and nuances of living patients. Invasive airway management can be a skill that is rarely practiced, depending on geographic location and the size of the patient population being served. 

An argument can therefore be made that training resources should be focused on those advanced skills more likely to be used, foregoing NTI in favor of other strategies such as CPAP/BiPAP or RSI.

Conversely, however, one must still consider if there exists a patient in which NTI would be the preferred, or perhaps the only advanced airway management strategy from all available techniques. Does such a patient exist: the patient with significant cervical spine pathology; the patient with trismus; or, the patient with grossly distorting airway anatomy? 

If such a patient does exist, could an EMS provider care for them without NTI? In such a case, with limited work-arounds to allow for successful airway management, would a medical director then be comfortable with opting for a more complex or invasive procedure to secure an airway (such as surgical cricothyrotomy)?

A recent comment made about EMS practice generally states, “when we eliminate something, we tend to find something more complicated to take its place.”

As with anything in the practice of medicine, no blanket statement applies to every situation.  Likewise, in advanced airway management there is no silver bullet, no ideal strategy, that can address every clinical condition. The overriding hope is that, when the time comes, the provider will be proficient in the skills demanded.