Reverse tube direction and epistaxis in left nasotracheal intubation: a randomized controlled trial

Abstract

Background: The incidence of epistaxis during nasotracheal intubation via the left nostril is more frequent than that during intubation via the right nostril. This study evaluated the effect of the reverse bevel and tip direction of the nasotracheal tube on the incidence of epistaxis during nasotracheal intubation via the left nostril.

Methods: Patients undergoing right-sided maxillofacial surgery requiring left nasotracheal intubation were randomly allocated to the control (tracheal tube in the conventional direction) or reverse (a 180˚ reverse direction, with the tube bevel facing the nasal septum and the leading edge (i.e., the tip) of the bevel pointing away from the nasal septum) groups (n = 37 for both). The primary outcome was the incidence of epistaxis evaluated using videolaryngoscopy.

Results: The incidence of epistaxis in the reverse group was significantly lower than that in the control group (9 [24.3%] vs. 20 [54.1%], P = 0.009; relative risk: 0.45, 95% CI [0.24, 0.85], absolute risk reduction: 29.8%, number needed to treat: 3). The severity of epistaxis was significantly lower in the reverse group (P = 0.002). The first attempt nasal passage (P = 0.027) was significantly higher in the reverse group. Postoperative nasal pain was lower (P < 0.001), and patient satisfaction was higher (P < 0.001) in the reverse group. Nasotracheal tube-related complications did not occur in either group.

Conclusions: The reverse bevel and tip direction of the nasotracheal tube reduced the incidence and severity of epistaxis and increased patient satisfaction among patients undergoing left nasotracheal intubation.

Keywords: Airway management; Complications; Epistaxis; Intubation; Nose; Patient satisfaction.

Fig. 1.

External and anatomical views in the control (A) and reverse groups (B). Control group: patients who underwent nasotracheal intubation via the left nostril with the conventional bevel direction (the bevel of the nasotracheal tube faced the opposite side of the nasal septum and the leading edge [i.e., the tip] of the bevel of the nasotracheal tube was pointing toward the nasal septum). Reverse group: patients who underwent nasotracheal intubation via the left nostril with a 180˚ reverse bevel and tip direction (the bevel of the nasotracheal tube faced the nasal septum and the leading edge of the bevel of the nasotracheal tube was pointing away from the nasal septum).

Fig. 2.

Consolidated Standards of Reporting Trials (CONSORT) flowchart. Control group: patients who underwent nasotracheal intubation via the left nostril with the conventional bevel direction. Reverse group: patients who underwent nasotracheal intubation via the left nostril with a 180˚ reverse bevel and tip direction.

Fig. 3.

Comparison of the incidences of epistaxis between the control group (blue bar) and reverse group (orange bar). The incidence of epistaxis was significantly lower in the reverse group than that in the control group. Control group: patients who underwent nasotracheal intubation via the left nostril with the conventional bevel direction. Reverse group: patients who underwent nasotracheal intubation via the left nostril with a 180˚ reverse bevel and tip direction.