Nasotracheal Intubation in Children for Outpatient Dental Surgery
Condition: Nasotracheal Intubation
Study type: Interventional

Summary: 
      The aim of study was to compare the hemodynamic responses and adverse events associated with
      nasotracheal intubation (NTI) using a fiberoptic bronchoscope (FOB) and a direct laryngoscope
      (DLS) in children undergoing general anesthesia for outpatient dental surgery. Eighty
      children (aged 5-15 years) were scheduled to undergo outpatient dental surgery under general
      anesthesia and who required nasotracheal intubation were included.
    

Detailed description: 
      Investigators 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 American Society of Anesthesia 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 nasotracheal intubation 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 direct laryngoscopy group (n = 40) or the fiberoptic bornchoscopy 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. 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 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
      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 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
      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): Internal
      diameter (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
      heat-softened 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. 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 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).
    

Intervention name(s): Direct laryngoscopy and fiberoptic bronchoscopy
Intervention type(s): Device
Intervention description(s): These devices is used in endotracheal intubation and tonopen for measuring of intraoculer pressure. I want to see whcih is better.
Other intervention name(s): tonopen
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Investigator)
Primary purpose: Other
Keywords: direct laryngoscopy; fiberopitc bronchoscopy; nasotracheal intubation