Nasotracheal Intubation

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Hi all,

I know several of you use primarily NT intubation in your units from some of your posts.... I have just started out in a new unit, and this is all they use. I'm having a hard time believing that NT intubation is more stable and comfortable. I can't see how shoving a 2.5 ETT down the nare of a 450gm 23 weeker is less traumatic and more comfortable than a quick ET intubation:madface:. I have yet to see oral aversion caused by ETTs that couldn't be corrected. We used to use ETT's with premade tube holders in my last unit, and maybe had one or two accidental exubations. So what's the rationale behind this method?

:) We love neobars where I work currently. Though, I have been in hospitals where "they just don't work".... I think all nicu eqipment affected by geography or something.

Our OTs say that paci use with an orally intubated kid can cause the ET to rub up against the palate a lot which they don't love, even with the neobars. We still do it, but it's really hard to keep the paci in anyways. I've been on some units that use palate protectors on their babies to prevent the ET from causing grooves in the palate which allows us to give them pacis without OT getting on us.

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Specializes in NICU, Infection Control.

"...What ENT problems does nasal intubation cause?..."

#1 in my mind would be cosmetic. It definitely distorts the nose. Depending on the size of the nose and the size of the tube, a deviated septum w/attendant sinus and ear infection issues could be a problem throughout the baby's childhood.

My son had a Repogle tube placed NG for NEC (he wasn't my son @ the time, that came later); he had numerous ear infections, sinus infections, a deviated septum, etc., because the Repogle was too big for his nose.

I didn't look up any studies on this, so can't cite reference(s). So, I guess I would have to confess bias. It just seems like a bad idea to me.

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Specializes in NICU- now learning OR!.
I've worked with both and MUCH prefer NTs...

I think this might be symptomatic of second unit syndrome. I truly think whatever a nurse started out doing in their first unit will always seem best to them.

I dunno about that..... Staring down the huge, gaping nare of a little baby that was nasally intubated for a long period is pretty gross. They still don't necessarily nipple better (IMO) either...

Jenny

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I dunno about that..... Staring down the huge, gaping nare of a little baby that was nasally intubated for a long period is pretty gross. They still don't necessarily nipple better (IMO) either...

Jenny

My experience has been that they do nipple a lot better than kids who have been orally intubated. I see a ton of kids with bad oral aversions after oral intubation, almost never saw them in units that did nasal intubations. We didn't have kids with huge deformed gaping nares either. That's just my experience for what it's worth, it may not be yours after your time in your NICU. I'm not discounting your experience, just pointing out that a different way of doing things isn't necessarily barbaric considering some of us have positive experiences with it. Either approach has its pros and cons.

I really do believe in second unit syndrome, especially in NICU. I think there are so many topics in the NICU where two approaches can be argued for and supported with research. It will often simply come down to provider preference. I've seen it with narcotic use, the use of piccs vs pivs, securing ETs with tape or neobars, using in-line or open suction, using indocin/ibuprophen or doing surgical ligations... the list goes on and on and on. Over the last 5 years I've worked on several units and it never fails that every unit will do something another unit's nurses would be horrified to hear about.

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Specializes in Neonatal ICU (Cardiothoracic).
I really do believe in second unit syndrome, especially in NICU. I think there are so many topics in the NICU where two approaches can be argued for and supported with research. It will often simply come down to provider preference. I've seen it with narcotic use, the use of piccs vs pivs, securing ETs with tape or neobars, using in-line or open suction, using indocin/ibuprophen or doing surgical ligations... the list goes on and on and on. Over the last 5 years I've worked on several units and it never fails that every unit will do something another unit's nurses would be horrified to hear about.

You hit the nail on the head, fergus! I've spent almost a month on my new unit, and I stress out more over the way things are done differently than about the new stuff I'm doing, like cardiacs, single lung ventilation, and ECMO. While I am horrified by the lack of emphasis on developmental care and gestational age-appropriate pain assessment/management, the lack of new tools/equipment that I took for granted, like premade ETT holders (spend and hour taping a tube that can be done in 2 minutes?) inline ballard sx catheters (disconnect a kid from an oscillator to sx? how is that not increasing risk of infection, loss of recruited lung volume?) and modern vents (babylogs? infant stars? what pieces of crap!) We never give surfactant here, even 23 weekers... All stuff that is completely foreign to me. People look at me like I have two heads when I ask about giving a few mics of fentanyl before an extended PICC line placement on a vented kid. I'm trying hard not to be the new nurse that starts every sentence with "Where I worked, we did it THIS way..." but I've gone from an expert to a novice again. I believe that when you've made yourself believe that there's only one right way to do something, it's time to move to another unit. There are things I am passionate about, and beliefs I will never let go of, and as fergus mentioned, I am passionate about developmental care and pain management. It's something I've spent a lot of time researching and teaching others. Other people have other "soapboxes..." That's mine! Thanks for the input, guys.....Lets just say that I won't be nasally intubating any of my pts as an NNP... I don't care how stable they are, compared to an "unstable" ETT. I've seen too many nasal septum erosions in the 4 weeks I've been here to believe it's more safe/comfortable..... just my 0.02....

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I hope things improve for you Steve. A month isn't a very long time. It may turn out to be just a crap unit, but it may turn out to be a place where you'll find some things you like too. I'm on a unit right now that does some things I HATE (yep, taking babies off oscillators to suction!!!ARGH), but I try to focus on what I like as well (they are excellent about pain meds for instance). Not giving some sort of surfactant replacement to 23 weekers is pretty shocking. How do they even survive?

If you choose to stay there long term you may be able to affect some change there. If you don't intend on staying or you've only been there a short time, you really can't do much about changing policies. None of those nurses or docs want to hear about how much better your last unit was. You'll just alienate them and make your life miserable. I have had the same frustrations you have, though probably about different issues (I like nasal intubation;)). I've learned to attempt to change what I can quietly and accept the rest without beating my head against the wall every day. I hope you can find that balance because I know how unhappy it is to leave work feeling like you didn't provide the baby with the care they deserved. I did leave one job over it. Hopefully this will turn out better for you.

Edited to add: they are going to be discussing nasal vs oral aversion at the conference in Vegas this November. I'm looking forward to it.

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Specializes in Neonatal ICU (Cardiothoracic).
Edited to add: they are going to be discussing nasal vs oral aversion at the conference in Vegas this November. I'm looking forward to it.

Cool! I won't be able to attend, but please start a thread once you do get back, so we can all find out what you learned! My plan is to be in this unit for at least 2 1/2 years while attending grad school, then deciding whether to return to my old unit as an NNP, or go somewhere else. I'm remaining flexible at this point, and not beating my head against the wall nearly as much as I used to. :banghead:

As far as the 23 weekers, I had a set of 23 week triplets on bubble CPAP, not one over 500 grams, not one having received surfactant. In fact, surf is rarely given here, and only as a rescue treatment. They do have the lowest CLD rate in the country. Their goal is to never intubate any baby unless it's the last resort, hence all admissions from 23 weeks on up are treated conservatively (bubble cpap) as needed. (Except for stuff like severe PPHN, CDH, etc...) It's crazy, and goes against everything I've ever been taught, but that's why I came here, because I knew they were the best, and while I may not agree with everything they do, I didn't want to graduate as an NNP without having seen the crazy stuff we see here. (for example, my preceptor said she has seen over 5 harlequin ichthyosis infants in the 4 yrs she's been here, and her first admission was a TGV with an intact septum that had to have a balloon septostomy at the bedside minutes after delivery!!!)

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Specializes in NICU/Neonatal transport.

We just recently had a harlequin, very interesting.

While some things are preference and style, there are other things that do violate evidence based practice, or other things we know to be true.

The disconnecting from oscillator amazes me. It takes over 24 hours to get full alveolar recruitment with an oscillator and every time you disconnect it, you have to restart the process.

What is considered their criteria for intubation? where are you with the low CLD? I find it very interesting. We have a big focus on treating bpd, but sometimes I feel the prevention of bpd is a little lacking.

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Specializes in Neonatal ICU (Cardiothoracic).
We just recently had a harlequin, very interesting.

While some things are preference and style, there are other things that do violate evidence based practice, or other things we know to be true.

The disconnecting from oscillator amazes me. It takes over 24 hours to get full alveolar recruitment with an oscillator and every time you disconnect it, you have to restart the process.

What is considered their criteria for intubation? where are you with the low CLD? I find it very interesting. We have a big focus on treating bpd, but sometimes I feel the prevention of bpd is a little lacking.

Yeah, I brought up the alveolar recruitment issue, but I'm too new, and noone's paying me any attention yet. Their rationale is that the "extra weight" of the ballard inline sx systems might worsen nasal septum necrosis (hmmmm... maybe we shouldn't be doing NT intubation then??) and that the inline sx catheters aren't big enough to adequately remove secretions. (NEVER had that problem at my last job)

According to the CLD info they've given me, their CLD rate is around 5-6% in all age groups. Not sure what their criteria is for intubation. So far it's been a CO2 >70, CDH, PPHN, etc... Noone seems to know what their policies are. I've asked to see the policy book, but have yet to find many useful policies that people are actually using. A nurse told me the other day that they don't practice NRP. They are certified in it, but never follow the guidelines. I marched right into the manager's office, and told them to expect that I will be utilizing NRP when appropriate to protect my license unless ordered otherwise by a physician. (at which point it'll get documented.)

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