Nasotracheal Intubation in Children for Outpatient Dental Surgery: Is Fiberoptic Bronchoscopy Useful?
Phase: NA
Conditions: Nasotracheal Intubation
Sponsor: Inonu University

1 
 
22.02.2018 
Nasotracheal Intubation in Children for Outpatient Dental Surgery: Is Fiberoptic 
Bronchoscopy useful? 
Ahmet Selim Ozkan1, Sedat Akbas1 
1 Inonu University Faculty of Medicine, Malatya, Turkey 
 
Correspondening author 
Ahmet Selim Ozkan, Asst. Prof., Inonu University Faculty of Medicine, Turgut Ozal Medicine 
Center, 44216, Malatya, Turkey 
Mobile phone: +90 505 7729060 
Fax number: +90 422 341 06 60 
Email: asozkan61@yahoo.com 
 
Nasal Intubation in Children (Short title) 
 
Key words: Nasotracheal intubation, children, fiberoptic intubation, dental surgery 
 
Conflicts of interests:  
None 
Financial Disclosures:  
None 

2 
 
22.02.2018 
Study Protocol 
We obtained confirmation from the Inonu University Medical Faculty Hospital Ethics 
Committee (2015/101) and written informed consent from the guardians of all 80 children. 
These children, who had a ASA physical status of I-II, had a Mallampati Score of 1-2, were 
aged 5-15 years, were scheduled to undergo outpatient dental surgery under general anesthesia, 
and required NTI were included in this prospective and randomized study. Exclusion criteria 
included the following: the patient’s refusal for study consent, active upper respiratory 
infection, airway abnormalities, nasal mass or nasal injury, bleeding disorders, allergies to 
anesthetics, uncontrolled hypertension, morbid obesity, hepatic or renal failure, cardiovascular 
diseases, a history of nasopharyngeal surgery and those who were difficult to intubate. Children 
were randomly assigned into the DLS group (n = 40) or the FOB group (n = 40) according to a 
computer-randomized table. General anesthesia was administered to children due to the 
learning difficulties. The number of models was decided by a statistical power analysis after 
the conclusions from the pretest were obtained. The general data of the children in the two 
groups are shown in Table 1. 
All children fasted at least for 6 h before surgery, and the oral intake of clear fluids was 
restricted for 2-3 h. Premedication of midazolam (0.5 mg/kg) was orally administered in apple 
juice (0.5 mL/kg of body weight) 1 h prior to anesthesia. After being admitted to the operating 
room, the patient’s systolic blood pressure (SBP) and heart rate (HR) were continually 
monitored with a multichannel physiologic monitor (Dateks Ohmeda F-CU8, Datex 
Instrumentarium, Helsinki, Finland), and the baseline values for SBP and HR were recorded. 
Thirty min before the intubation attempt, the nasal mucosa of both nostrils were anesthetized 
with a topical vasoconstrictor (0.05% xylometazoline spray, and 2% lidocaine 1 mL two times 
in each nostril) (9) to attenuate cardiovascular responses and adverse events in all children. 
Anesthesia was induced with 8% sevoflurane with eight deep breaths via a face mask, and the 

3 
 
22.02.2018 
patient was maintained on 4% end-tidal sevoflurane, fentanyl 2 µr/kg and rocuronium 0.6 
mg/kg. NTI was achieved 2 min after rocuronium injection. The more patent nostril was 
selected for intubation. An experienced anesthetist performed all intubations in the study and 
an assistant applied the maneuvers (jaw trust) and evaluated the patient during the postoperative 
visits. All NTIs, both DLS and FOB, were conducted by the same experienced anesthetist (the 
anesthetist had performed DLS and the FOB nasal intubation in more than 150 patients, 
including in at least 100 children before the study). A study nurse documented the anesthetic 
data and timing. In the DLS group, the spiral tube was inserted into the nose and intubated with 
a Macintosh laryngoscope (Timesco, England) according to conventional procedures using 
Magill forceps. In the FOB group, NTI was conducted using an FOB with an outer diameter of 
3.1 mm (Olympus LF-DP, Tokyo, Japan) through the selected clear nasal passage with a spiral 
tracheal tube. The appropriate size of the tracheal tube for a child was determined with the 
following formula (10): ID (mm) = age/3 + 3.5 in both groups. The same type of tube was used 
in each group. Before intubation, enough lidocaine gel was placed on the tracheal tube, and the 
FOB was guided into patients with a suitable spiral tracheal tube. All tracheal tubes were cuffed 
and thermosoftened in warm normal saline and lubricated to reduce mechanic stimuli to airway 
structures. During the intubation, the head of the patient was the in supine position, and an 
assistant applied a jaw thrust for opening the nasopharyngeal passage and improved the image 
in all patients in the FOB group. If indicated (a suboptimal laryngeal view or resistance in 
passing of the tracheal tube), anterior laryngeal pressure and tongue withdrawal by digital 
traction was performed to improve the laryngeal field of view, and this procedure was recorded 
(11). When the glottis was clearly visible, the FOB was advanced through the vocal cords, and 
jaw thrust movement was released. To prevent the stimulation of the carina, the tube was placed 
4 cm below the glottis, sliding over the FOB. Intubation was verified with the FOB, and end-
tidal CO2 concentrations at 35-40 mmHg were monitored. A throat pack was inserted by the 

4 
 
22.02.2018 
anesthetist after the measurements were taken. Anesthesia was maintained with 2% sevoflurane 
and 50% N20 in oxygen with 1.5 l min-1 fresh gas flow and 35-40 mmHg end-tidal CO2 
concentrations. Isolyte-P was administered at rate of 15 mL/kg/h IV, and acetaminophen (15 
mg kg-1) was infused for postoperative analgesia in all children.   
SBP and HR were recorded at baseline, after induction of anesthesia, at the time of intubation, 
and 1, 3 and 5 min after intubation. The intubation time (the time from when manual ventilation 
with a facemask stopped to restarting ventilation via the nasotracheal tube and when carbon 
dioxide (CO2) was detected by capnography) was recorded by another anesthetist with a digital 
stopwatch. Nose bleeding after intubation (epistaxis), laryngospasms, bradycardia (HR<65 beat 
min-1), hypoxic episodes (SpO2<90%) and the surgery type were also recorded. Adverse 
events (hoarseness, sore throat) were assessed 24 h after surgery. If a sore throat developed, 
additional analgesics were not administered. If bradycardia or desaturation (SpO2<90%) 
occurred for more than 2 min, the intubation was interrupted, and patients were ventilated with 
100% oxygen and were administered IV atropine (5-10 µg / kg). 
 
 
 
 
 
 
 
 

5 
 
22.02.2018 
Statistical Analysis 
The data were expressed as the mean (standard deviation, SD) or frequencies with percentages, 
depending on the overall variable distribution. Normality was assessed using the Shapiro Wilk 
test. Normally distributed data were analyzed by the independent samples t-test. Qualitative 
data were analyzed using the Pearson chi-square test, Yates corrected chi-square test, and Fisher 
exact test, as appropriate. P<0.05 values were considered statistically significant. IBM SPSS 
statistics version 23.0 for Windows was used for statistical analyses. The number of models 
was decided by a statistical power analysis after the pretest conclusions were obtained. Power 
analysis was used to define the minimal clinically important difference in SBP to be 20 mmHg, 
and the a standard deviation of residuals was anticipated to be 12.5 mmHg. Therefore, a sample 
size of 26 children in each group was required for an α of 0.05 and a β of 0.2. To define a 30% 
difference in the incidence of side effects, 40 children in each group were for an α of 0.05 and 
a β of 0.2.