Date Published: March 20, 2018
Author(s): Macario Camacho, Justin M. Wei, Lauren K. Reckley, Sungjin A. Song.
During anesthesia emergence, patients are extubated and the upper airway can become vulnerable to obstruction. Nasal trumpets can help prevent obstruction. However, we have found no manuscript describing how to place nasal trumpets after nasal surgery (septoplasties or septorhinoplasties), likely because (1) the lack of space with nasal splints in place and (2) surgeons may fear that removing the trumpets could displace the splints. The objective of this manuscript is to describe how to place nasal trumpets even with nasal splints in place.
The authors describe techniques (Double Barrel Technique and Modified Double Barrel Technique) that were developed over three years ago and have been used in patients with obstructive sleep apnea (OSA) and other patients who had collapsible or narrow upper airways (i.e., morbidly obese patients).
The technique described in the manuscript provides a method for placing one long and one short nasal trumpet in a manner that helps prevent postoperative upper airway obstruction. The modified version describes a method for placing nasal trumpets even when there are nasal splints in place. Over one-hundred patients have had nasal trumpets placed without postoperative oxygen desaturations.
The Double Barrel Technique allows for a safe emergence from anesthesia in patients predisposed to upper airway obstruction (such as in obstructive sleep apnea and morbidly obese patients). To our knowledge, the Modified Double Barrel Technique is the first description for the use of nasal trumpets in patients who had nasal surgery and who have nasal splints in place.
Some patients such as overweight or obese patients, obstructive sleep apnea (OSA) patients, and patients with craniofacial disorders are predisposed to upper airway obstruction. The act of changing from the upright to the supine position has been shown to reduce the upper airway volume by approximately 33% in a group of adult OSA patients . Given that OSA patients are already predisposed to upper airway obstruction when they are in the supine position, adding the additional variable of general anesthesia can further predispose patients to upper airway obstruction during anesthesia induction and emergence. Additionally, there are other patients who may be predisposed to upper airway obstruction to include (1) morbidly obese patients, (2) patients with craniofacial deformities (i.e., mandibular insufficiency, retrognathia, and transverse maxillary deficiency), (3) patients with gigantism or acromegaly, (4) patients with Down syndrome, and (5) patients with significant oropharyngeal tissue hypertrophy (i.e., tonsillar and adenoid hypertrophy).
Overall, we are excited to present the techniques from this manuscript as they have improved postanesthesia oxygen saturations, especially in OSA and morbidly obese patients. The techniques are easy to follow. First and foremost, this paper describes a technique that to our knowledge has not been described in the literature before, which is that it describes how to place nasal trumpets in patients who have undergone nasal surgery and have nasal splints in place. Nasal trumpets have been used safely as a method to help prevent upper airway obstruction on emergence from anesthesia. However, the major challenge prior to this manuscript is that there is no publication describing any method to place nasal trumpets in patients who have had nasal surgery. At first, we only used one nasal trumpet, but noticed that some patients still had desaturations. Then we used two nasal trumpets. Initially, nasal trumpets of same lengths were used; however, after logical reasoning, the authors came to the realization that having one shorter and one longer nasal trumpet would actually stent the airway much better. It makes sense that if two long nasal trumpets are used, then it is possible that the trumpets could be sitting in the piriform sinuses or at the base of tongue and therefore, tongue could still obstruct the airflow and prevent proper ventilation. If two short nasal trumpets are used and they reach just beyond the soft palate, the tongue could still obstruct the upper airway and negatively affect proper ventilation below the level of the nasal trumpets. However, as described in the Double Barrel Technique if you place one longer trumpet (extending to the piriform sinuses or to the level of the base of tongue) and you place one shorter nasal trumpet that extends just beyond the soft palate, then the combination of the two is very likely to stent the upper airway open (Figure 1).
The Double Barrel Technique allows for a safe emergence from anesthesia in patients predisposed to upper airway obstruction (such as in obstructive sleep apnea and morbidly obese patients). To our knowledge, the Modified Double Barrel Technique is the first description for the use of nasal trumpets in patients who had nasal surgery and have nasal splints in place.