Anaesthesia, 1977, Volume 32, pages 273-276 APPARATUS
Bilateral nasopharyngeal tubes for outpatient dental anaesthesia
N. H. D O C T O R
Local analgesia used alone or with conscious sedation is the method of choice of pain relief in the dental chair for conservative procedures but small unco-operative children, nervous children and adults and patients on whom local analgesia has failed will require general anaesthesia. The procedures which may need to be undertaken under general anaesthesia include fillings and crown preparations and many cases require general anaesthesia for more than 15 minutes. The advantages and disadvantages of endotracheal intubation for dental outpatients have been hotly debated for many years.’-6 The known traumatic hazards and oedematous sequelae of endotracheal intubation which sometimes occur, particularly in children, have been weighed against the obvious advantages of having an assured airway. Goldman3 has gone so far as to say that ‘if endotracheal intubation is to be used for children’s dentistry the child should be treated as an in-patient’. Bilateral nasopharyngeal intubation has provided a satisfactory compromise in the author’s hands.
national, Clacton) in appropriate sizes are now used for all ages (2-5 years: FG26; 6-8 years: FG28; 9-12 years: FG30; 13-16 and adult females: FG32; adult males: FG34). Goldman tubes have blunt, rounded ends. They do not always keep a patent airway but they are atraumatic. They are at present used by the author to carry local analgesic gel through into the pharynx and to dilate the nostril before the insertion of the bevelled Robertazzi tubes. The proximal ends of the nasopharyngeal tubes are joined to two short lengths of corrugated catheter mount tubing by means of Magill nasal connectors (Fig. 1). The two corrugated tubes lead to a Carlen’s double lumen tube adaptor which has a female cone for the receipt of the male outlet of the anaesthetic circuit. In the author’s series demand flow anaesthetic machines (British Oxygen Company Walton V or Anaesthetic Equipment AE) have been used to supply nitrous oxide and oxygen and halothane has been vaporised by a Goldman inhaler or a Penlon Oxford Miniature vaporiser (OMV).
Apparatus The nasopharyngeal assembly is illustrated in Fig. 1. The author originally used latex Goldman nasopharyngeal tubes for adults and latex Robertazzi tubes for children. The manufacture of Goldman tubes has now been discontinued, however, and Robertazzi tubes (Davol Inter~
_
_
~ ~
Patients
All patients accepted for outpatient dental anaesthesia by the author are carefully assessed and fit. They are starved for at least 6 hours and accompanied by a responsible adult. Premedication is not given.
~
N. H. Doctor, FFARCS, Consultant Anaesthetist, Hackney Hospital, London E9 6BY.
273
274
N.H. Doctor
Fig. 1. Two Goldman (latex) close ended nasopharyngeal tubes connected to double ended catheter mount.
Technique Induction Children are normally induced with 30% oxygen: 70% nitrous oxide and up to 2% halothane. A few older children were induced with sleep doses of methohexitone, usually at the request of the child. Adults receive an intravenous induction. An indwelling needle (Butterfly Abbott) is inserted. Metoclopramide 10 mg is first administered to control regurgitation and vomiting and is followed by 20 mg of pentazocine. A mouth prop is inserted. Methohexitone 40 mg is administered and repeated at 20-30 second intervals until consciousness is lost. This usually occurs after between 80 and 120 mg of methohexitone have been given. Posture Patients are in the reclining position at the start
of induction but are placed fully supine as soon as they are semi-conscious. Intubation Approximately 1 ml of 2% water-soluble lignocaine gel is instilled' into each nostril. A sponge pad is placed over the eyes and forehead --care being taken to ensure that the lids are closed over the cornea. A Goldman Velcro harness is passed round the head and partly attached at one side leaving a short length free to secure the double catheter mount. A Goldman blunt-ended tube which has been well lubricated with 2% water-soluble gel is now gently passed through each nostril in turn. This dilates, lubricates and anaesthetizes the passage through to the pharynx in preparation for the introduction of the bevelled Robertazzi tubes which immediately follows. The tubes are attached to the catheter mount assembly,
Nasopharyngeal tubes for outpatient dental anaesthesia
secured with the Goldman Velcro harness and connected to the anaesthetic machine. Occasionally the Goldman tube can only be passed through one nostril. Single nasopharyngeal anaesthesia is then indicated. A single catheter mount and connector should, therefore, always be at hand. Maintenance
The jaw is supported by the anaesthetist throughout the procedure. Children are maintained on oxygen 30%, nitrous oxide 70% and halothane. Adults are given oxygen 30% and nitrous oxide 70% and supplemental 40 mg doses of methohexitone. These are administered whenever signs of light anaesthesia are observed (deep and rapid breathing, salivation swallowing, muscle movements, tightness of the lips and changes in pulse rate and rhythm). Monitoring. A pulse monitor is used in all cases. Depth of ventilation and patency of the system are checked by bringing the reservoir bag (which is normally kept switched off in the demand system) temporarily into circuit and observing it. Suction and packing. An efficient two-speed sucker is usedfor continuous aspiration of water, blood and debris. Butterfly type (D-J) sponge packs are used to isolate the teeth upon which the dental procedures are being carried out.
Results The author estimates that he used the technique in over lo00 of the 2363 outpatient dental
275
anaesthetics which he administered between January 1968 and the end of August 1975. In a recent more detailed survey over 3 months, 154 cases (65 children under 16 and 89 adults) had anaesthetic procedures lasting more than 15 minutes. Seven adults had surgical extractions of impacted or unerupted wisdom teeth and 147 had conservative dentistry including 14 crown preparations. Nasopharyngeal intubation was carried out on 92 of these 154 procedures. The principal indications are given in Table 1. Sixty seven of the 96 cases who received a n intraveneous induction left the chair within 5 minutes of the end of the procedure.
Complications
Complications have been negligible. Nasal bleeding of any significance has only been encountered on 3 occasions in over lo00 cases.
Discussion Bilateral nasopharyngeal intubation provides satisfactory operating conditions for conservative and minor dental surgery. It gives better access to anterior teeth for apicectomy and crown preparation than does the use of a nasal mask. If careful attention is paid to suction and packing and the support of the jaw the airway is easily kept patent and protected in the majority of cases without the need for endotracheal intubation, which might have unacceptable consequences for patients treated as outpatients.’
Table 1. Use of nasopharyngeal airways in 92 cases Indication
No. of cases
Extensive conservations Nasal obstruction Anterior fillings* Crown preparations Surgical extractions Small patients Obese patient with short neck
40 15
Total
92
13 13 7 3 1
* 3 Patients in this group also had extensive conservations.
276
N.H. Doctor Summary
The successful use of nasopharyngeal intubation for minor dental outpatient surgery and conservation is described and discussed.
2. 3. 4.
Key words EQUIPMENT; tubes, nasopharyngeal. ANAESTHESIA; dental, outpatient.
5.
6.
References I . THOMPSON, P.W. (1975) Day-case anaesthesia in the
7.
dental hospital. Proceedings of the Royal Society of Medicine, 68, 415. GREEN, R.A., COPLANS, M.P.(1973) Anaesthesia and Analgesia in Dentistry, pp. 253 & 142. H. K. Lewis, London. GOLDMAN, V. (1966) General anaesthesia for children's dentistry. British Dental Journal, 121, 468. HURDLEY, J. (1975) Intubation in outpatient dental anaesthesia. The need for intubation. Anaesthesia, 30,403. TOMLIN, P.J. (1975) Intubation in outpatient dental anaesthesia. Anaesthesia, 30, 404. YOUNG, T.M. (1975) Intubation in outpatient dental anaesthesia. Anaesthesia, 30,405. LEWIS,R.N., SWERDLOW, M. (1964) Hazards of endotracheal anaesthesia. British Journal of Anaesthesia, 36, 504.
Bilateral nasopharyngeal tubes for outpatient dental anaesthesia
N. H. D O C T O R
Local analgesia used alone or with conscious sedation is the method of choice of pain relief in the dental chair for conservative procedures but small unco-operative children, nervous children and adults and patients on whom local analgesia has failed will require general anaesthesia. The procedures which may need to be undertaken under general anaesthesia include fillings and crown preparations and many cases require general anaesthesia for more than 15 minutes. The advantages and disadvantages of endotracheal intubation for dental outpatients have been hotly debated for many years.’-6 The known traumatic hazards and oedematous sequelae of endotracheal intubation which sometimes occur, particularly in children, have been weighed against the obvious advantages of having an assured airway. Goldman3 has gone so far as to say that ‘if endotracheal intubation is to be used for children’s dentistry the child should be treated as an in-patient’. Bilateral nasopharyngeal intubation has provided a satisfactory compromise in the author’s hands.
national, Clacton) in appropriate sizes are now used for all ages (2-5 years: FG26; 6-8 years: FG28; 9-12 years: FG30; 13-16 and adult females: FG32; adult males: FG34). Goldman tubes have blunt, rounded ends. They do not always keep a patent airway but they are atraumatic. They are at present used by the author to carry local analgesic gel through into the pharynx and to dilate the nostril before the insertion of the bevelled Robertazzi tubes. The proximal ends of the nasopharyngeal tubes are joined to two short lengths of corrugated catheter mount tubing by means of Magill nasal connectors (Fig. 1). The two corrugated tubes lead to a Carlen’s double lumen tube adaptor which has a female cone for the receipt of the male outlet of the anaesthetic circuit. In the author’s series demand flow anaesthetic machines (British Oxygen Company Walton V or Anaesthetic Equipment AE) have been used to supply nitrous oxide and oxygen and halothane has been vaporised by a Goldman inhaler or a Penlon Oxford Miniature vaporiser (OMV).
Apparatus The nasopharyngeal assembly is illustrated in Fig. 1. The author originally used latex Goldman nasopharyngeal tubes for adults and latex Robertazzi tubes for children. The manufacture of Goldman tubes has now been discontinued, however, and Robertazzi tubes (Davol Inter~
_
_
~ ~
Patients
All patients accepted for outpatient dental anaesthesia by the author are carefully assessed and fit. They are starved for at least 6 hours and accompanied by a responsible adult. Premedication is not given.
~
N. H. Doctor, FFARCS, Consultant Anaesthetist, Hackney Hospital, London E9 6BY.
273
274
N.H. Doctor
Fig. 1. Two Goldman (latex) close ended nasopharyngeal tubes connected to double ended catheter mount.
Technique Induction Children are normally induced with 30% oxygen: 70% nitrous oxide and up to 2% halothane. A few older children were induced with sleep doses of methohexitone, usually at the request of the child. Adults receive an intravenous induction. An indwelling needle (Butterfly Abbott) is inserted. Metoclopramide 10 mg is first administered to control regurgitation and vomiting and is followed by 20 mg of pentazocine. A mouth prop is inserted. Methohexitone 40 mg is administered and repeated at 20-30 second intervals until consciousness is lost. This usually occurs after between 80 and 120 mg of methohexitone have been given. Posture Patients are in the reclining position at the start
of induction but are placed fully supine as soon as they are semi-conscious. Intubation Approximately 1 ml of 2% water-soluble lignocaine gel is instilled' into each nostril. A sponge pad is placed over the eyes and forehead --care being taken to ensure that the lids are closed over the cornea. A Goldman Velcro harness is passed round the head and partly attached at one side leaving a short length free to secure the double catheter mount. A Goldman blunt-ended tube which has been well lubricated with 2% water-soluble gel is now gently passed through each nostril in turn. This dilates, lubricates and anaesthetizes the passage through to the pharynx in preparation for the introduction of the bevelled Robertazzi tubes which immediately follows. The tubes are attached to the catheter mount assembly,
Nasopharyngeal tubes for outpatient dental anaesthesia
secured with the Goldman Velcro harness and connected to the anaesthetic machine. Occasionally the Goldman tube can only be passed through one nostril. Single nasopharyngeal anaesthesia is then indicated. A single catheter mount and connector should, therefore, always be at hand. Maintenance
The jaw is supported by the anaesthetist throughout the procedure. Children are maintained on oxygen 30%, nitrous oxide 70% and halothane. Adults are given oxygen 30% and nitrous oxide 70% and supplemental 40 mg doses of methohexitone. These are administered whenever signs of light anaesthesia are observed (deep and rapid breathing, salivation swallowing, muscle movements, tightness of the lips and changes in pulse rate and rhythm). Monitoring. A pulse monitor is used in all cases. Depth of ventilation and patency of the system are checked by bringing the reservoir bag (which is normally kept switched off in the demand system) temporarily into circuit and observing it. Suction and packing. An efficient two-speed sucker is usedfor continuous aspiration of water, blood and debris. Butterfly type (D-J) sponge packs are used to isolate the teeth upon which the dental procedures are being carried out.
Results The author estimates that he used the technique in over lo00 of the 2363 outpatient dental
275
anaesthetics which he administered between January 1968 and the end of August 1975. In a recent more detailed survey over 3 months, 154 cases (65 children under 16 and 89 adults) had anaesthetic procedures lasting more than 15 minutes. Seven adults had surgical extractions of impacted or unerupted wisdom teeth and 147 had conservative dentistry including 14 crown preparations. Nasopharyngeal intubation was carried out on 92 of these 154 procedures. The principal indications are given in Table 1. Sixty seven of the 96 cases who received a n intraveneous induction left the chair within 5 minutes of the end of the procedure.
Complications
Complications have been negligible. Nasal bleeding of any significance has only been encountered on 3 occasions in over lo00 cases.
Discussion Bilateral nasopharyngeal intubation provides satisfactory operating conditions for conservative and minor dental surgery. It gives better access to anterior teeth for apicectomy and crown preparation than does the use of a nasal mask. If careful attention is paid to suction and packing and the support of the jaw the airway is easily kept patent and protected in the majority of cases without the need for endotracheal intubation, which might have unacceptable consequences for patients treated as outpatients.’
Table 1. Use of nasopharyngeal airways in 92 cases Indication
No. of cases
Extensive conservations Nasal obstruction Anterior fillings* Crown preparations Surgical extractions Small patients Obese patient with short neck
40 15
Total
92
13 13 7 3 1
* 3 Patients in this group also had extensive conservations.
276
N.H. Doctor Summary
The successful use of nasopharyngeal intubation for minor dental outpatient surgery and conservation is described and discussed.
2. 3. 4.
Key words EQUIPMENT; tubes, nasopharyngeal. ANAESTHESIA; dental, outpatient.
5.
6.
References I . THOMPSON, P.W. (1975) Day-case anaesthesia in the
7.
dental hospital. Proceedings of the Royal Society of Medicine, 68, 415. GREEN, R.A., COPLANS, M.P.(1973) Anaesthesia and Analgesia in Dentistry, pp. 253 & 142. H. K. Lewis, London. GOLDMAN, V. (1966) General anaesthesia for children's dentistry. British Dental Journal, 121, 468. HURDLEY, J. (1975) Intubation in outpatient dental anaesthesia. The need for intubation. Anaesthesia, 30,403. TOMLIN, P.J. (1975) Intubation in outpatient dental anaesthesia. Anaesthesia, 30, 404. YOUNG, T.M. (1975) Intubation in outpatient dental anaesthesia. Anaesthesia, 30,405. LEWIS,R.N., SWERDLOW, M. (1964) Hazards of endotracheal anaesthesia. British Journal of Anaesthesia, 36, 504.
