Khan, Fauzia Anis

Mian, Mehmood

Siraj, Sheema

English

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eCommons@AKUDepartment of Anaesthesia Medical College, PakistanMarch 2017Physical manipulation of larynx as a technique forinsertion of nasogastric tubeSheema SirajAga Khan University, sheema.siraj@aku.eduMehmood MianAga Khan University, mehmood.mian@aku.eduFauzia Anis KhanAga Khan University, fauzia.khan@aku.eduFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_anaesthPart of the Anesthesia and Analgesia Commons, and the Anesthesiology CommonsRecommended CitationSiraj, S., Mian, M., Khan, F. A. (2017). Physical manipulation of larynx as a technique for insertion of nasogastric tube. Journal of theCollege of Physicians and Surgeons Pakistan, 27(3), 191-191.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_anaesth/285Sir,Nasogastric (NG) tube insertion is often a difficult task inpatients who are anesthesized and have endotrachealtubes in situ. The failure rate of insertion in the firstattempt is reported to be as high as 50% in neutralposition of the head.1 The most common sites ofimpaction of orogastric and NG tubes are the pyriformsinuses and arytenoid cartilages.2 Frequent unsuccessfulattempts may lead to hemodynamic instability(tachycardia, hypertension) and nasal mucosal bleed.Different methods have been suggested to reduce thenumber of unsuccessful attempts. These include the useof slit endotracheal tube, neck flexion with lateral neckpressure, use of glidescope, use of guidewire orangiography catheter.3 Physical lifting of the larynx offthe esophagus (reverse Sellick's maneuver) has beeninvestigated in one study only.4We report a case of a 40-year male Chinese patientwhere we used this method successfully. The Chinesepatients have larger superoposterior airway space, alarger nasopharynx and oropharynx cross-sectional areawith a smaller tongue thickness.5 These features distinguishthe Chinese population from other Asian races.Our patient weighed 75 kg with a body mass index (BMI)of 27.5 kg/m2 and was scheduled for laparoscopiccholecystectomy for cholelithiasis. The laboratoryparameters were normal except for mild hyponatremiawith sodium of 133 meq/l.After application of standard monitoring, general anaes-thesia was initiated. Gastric decompression wasrequired by the surgeons; therefore a NG tube of 16 Frwas attempted orally after lubricating the distal end ofthe tube with a water soluble gel. Two unsuccessfulattempts were made, but the NG tube failed to pass fromthe oropharynx into the esophagus. A third attempt wasmade by physically lifting the larynx off the esophagusby holding it on both sides with the help of thumb andindex finger (Figure 1). This simple physical maneuverresulted in the NG tube passing easily from theoropharynx into the stomach. NG tube placement wasconfirmed by auscultation at the epigastrium.This simple maneuver reduced the number of un-successful attempts and we recommend furtherresearch on it.REFERENCES1. Mahajan R, Gupta R. Another method to assist nasogastrictube insertion. Can J Anesth 2005; 52:652-3.2. Ozer S, Benumof JL. Oro-and nasogastric tube passage inintubated patients fiberoptic description of where they go at thelaryngeal level and how to make them enter the esophagus.J Am Soc Anesthesiol 1999; 91:137-43.3. Appukutty J, Shroff PP. Nasogastric tube insertion usingdifferent techniques in anesthetized patients: A prospective,randomized study. Anesth Analg 2009; 109:832-5.4. Mandal MC, Dolai S, Ghosh S, Mistri PK, Roy R, Basu SR,et al. Comparison of four techniques of nasogastric tubeinsertion in anaesthetised, intubated patients: A randomizedcontrolled trial. Indian J Anaesth 2014; 58:714.5. Liua Y, Lowea AA, Zengb X, Fub M, Fleethamc JA. Cephalometriccomparisons between Chinese and Caucasian patients withobstructive sleep apnea. Am J Orthod Dentofacial Orthop 2000;117:479-85.Journal of the College of Physicians and Surgeons Pakistan 2017, Vol. 27 (3): 191 191LETTER TO THE EDITORPhysical Manipulation of Larynxas a Technique for Insertion ofNasogastric TubeFigure 1: Physically lifting the larynx off the esophagus by holding it on bothsides with the help of thumb and index finger.Sheema Siraj, Mehmood Mian and Fauzia Anis KhanDepartment of Anaesthesiology, The Aga Khan UniversityHospital, Karachi.Correspondence: Dr. Sheema Siraj, Resident, Department ofAnaesthesiology, The Aga Khan University Hospital, Karachi.E-mail: sheema.siraj@aku.eduReceived: October 01, 2016;   Accepted: December 20, 2016.

Physical manipulation of larynx as a technique for insertion of nasogastric tube

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Physical manipulation of larynx as a technique for insertion of nasogastric tube

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