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Year : 2017  |  Volume : 11  |  Issue : 4  |  Page : 503

Gum elastic bougie as a guide in nasotracheal intubation: A novel technique

Department of Anaesthesiology, Goa Medical College, Bambolim, Goa, India

Correspondence Address:
Rohini Varadraj Bhat Pai
Department of Anaesthesiology, Goa Medical College, Bambolim, Goa
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sja.SJA_214_17

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Date of Web Publication22-Sep-2017

How to cite this article:
Bhat Pai RV, Kamat S, Kambli D. Gum elastic bougie as a guide in nasotracheal intubation: A novel technique. Saudi J Anaesth 2017;11:503

How to cite this URL:
Bhat Pai RV, Kamat S, Kambli D. Gum elastic bougie as a guide in nasotracheal intubation: A novel technique. Saudi J Anaesth [serial online] 2017 [cited 2022 Jun 24];11:503. Available from:


Nasotracheal intubation is needed for maxillofacial surgeries and tonsillectomies. Usually, the endotracheal tube (ETT) is passed through the nostrils after having assessed the patency of the nostrils preoperatively. Complications caused by nasal passage of the tube, such as turbinectomy or retropharyngeal dissection, have been reported, epistaxis being the most common complication, which occurs with an incidence of 18%–66%.[1]

We observed that in five cases with apparently patent nostrils, we had difficulty in negotiating the ETT (size 6.5 mm ID for female patients and 7 mm ID in male patients) through both nostrils. In the first case, we tried with a smaller-sized ETT but did not succeed. We thereafter guided the gum elastic bougie through one of the nostrils and it went in very easily. Over that, we railroaded the smaller-sized ETT and it slipped into the oropharynx with ease. Subsequently, we have tried the above technique in four more cases with a similar difficulty and found that we did not have to downsize the tube. The originally planned ETT passed easily over the bougie.

A number of anatomical variants including deviated nasal septum may be responsible for causing the difficulty in passage of ETT though the nares. Furthermore, Watton and Hung have reported a difficulty due to prominent anterior tubercle of the C1.[2]

In cases where the ETT does not pass easily through the nasopharynx, either we have to pass a much smaller-sized ETT, thereby increasing the chances of increased airway pressures or request the surgeon to do a submental intubation with the added work of changing the flexometallic tube used for submental to a portex ETT in case the patient needs postoperative intubation and ventilation.[2] Besides, the trauma caused by the repeated attempts can increase the bleeding and lower the chances of subsequent successful intubation.

To reduce the risk of epistaxis, a number of strategies have been suggested such as immersing the ETT in a bottle of warm sterile water or saline to soften the tube; using soft flexible nasotracheal tube, applying vasoconstricting nasal spray to the nasal mucosa or using a generous use of lubricant, telescoping the ETT through a red rubber catheter, preselecting the nare before placing the ETT using nasopharyngoscopy and using bronchoscope as an intubation guide.[2] Suggestion has been made to use flexible atraumatic catheter such as tube exchanger and urinary catheter to guide the passage of ETT through the nostrils into the nasopharynx.[2]

Besides the methods described above, a gum elastic bougie which is usually available in any setup can be used to aid the smooth passage of the nasotracheal tube making it less traumatic, easy, safe, cost- and time-effective method of nasal endotracheal intubation.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Piepho T, Thierbach A, Werner C. Nasotracheal intubation: look before you leap. Br J Anaesth 2005;94:859-60.  Back to cited text no. 1
Watton D, Hung OR. Unanticipated difficult nasal intubation due to a prominent anterior tubercle of the first cervical spine. J Anesth Perioper Med 2016;3:276-9.  Back to cited text no. 2


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