• Dongwook Won, Hyerim Kim, Jee-Eun Chang, Jung-Man Lee, Seong-Won Min, Jiyun Jung, Hyo Jun Yang, Jin-Young Hwang, and Tae Kyong Kim.
• From the Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea (DW, HK, JEC, JML, SWM, JYH, TKK), Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea (JJ, HJY).
• Eur J Anaesthesiol. 2021 Feb 1; 38 (2): 157-163.

BackgroundFor nasotracheal intubation, the nasal pathway between the inferior turbinate and hard palate (lower pathway) is preferred for patient safety. However, selecting the lower pathway can be challenging because passage of the tube through the nasal pathway is usually performed blindly.ObjectivesWe investigated whether facing the bevel of the tracheal tube in the cephalad direction of the patient could help in advancing the tracheal tube through the lower pathway during nasotracheal intubation.DesignA randomised, blinded trial.SettingSMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea from January 2019 to March 2020.PatientsSixty-eight adult patients undergoing oromaxillary surgeries were enrolled in this study.InterventionsPatients were randomly allocated to undergo nasotracheal intubation with the bevel of the tube facing the cephalad direction (intervention group) or to the left (conventional group).Main Outcome MeasuresThe effects of bevel direction on the pathway of the tube in the nasal cavity, and the incidence of epistaxis were evaluated by fibreoptic bronchoscopy.ResultsThe success rate of the tracheal tube passing through the lower pathway was significantly higher in the intervention group than the conventional group (79.4 vs. 55.9%, relative risk 1.421, 95% CI 1.007 to 2.005, P = 0.038). The incidence of epistaxis was also lower in the intervention group than in the conventional group (41.2 vs. 73.5%, relative risk 0.560, 95% CI 0.357 to 0.878, P = 0.007).ConclusionsFacing the bevel of the tracheal tube in the cephalad direction of the patient facilitated selection of the lower pathway and reduced the incidence of epistaxis during nasotracheal intubation in patients undergoing oromaxillary surgery.Trial RegistrationClinicalTrial.gov, NCT03740620.Copyright © 2020 European Society of Anaesthesiology. All rights reserved.

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