Awake intubation through nose

Nasotracheal intubation!

As a repeat cancer patient I’ve spent 20 years toughening myself up for medical procedures. If you’re going to be nervous about needles and other brief but maybe painful assaults on your body, you’re going to have a difficult life. So I’ve found ways to cope, chanting, breathing, mantras, reciting poems, singing songs, even basking in the pride of getting through things without flinching.

I can remember the day when a camera down my throat or a nasogastric tube coming out filled me with fear but now they are just unpleasant. Covid tests, people, are NOTHING compared with head and neck cancer procedures.

Yep, I take a pride in being a tough gal at 74. Day before yesterday though, I met my match in the dreaded awake intubation through the nose. I had it done in 2014 for a short top up op and again two days ago.

It’s because my mouth opening is so limited after surgeries that they can’t poke the tube through my mouth like normal people and if it goes through the nose you need the patient awake to breathe on cue. I guess this is to safely navigate the tube into the airway. I don’t really know why to tell the truth.

Remember how hospital theatres were emptied for surgery during the height of the Covid crisis in March and that was because theatres have ventilators that can be used to help Covid patients breathe? I didn’t even know we were ventilated during general anaesthetics. I mean you’re asleep by the time you have the tube into your lungs. Usually. So on two occasions I’ve had a concerned and frowning anaesthetist come up to me and warn me about the procedure. They don’t seem to like doing it and know that they are putting a patient through something pretty gruesome.

In 2014 it felt as if something huge was being put up my nose and I couldn’t breathe for a while (or thought I couldn’t) then I went under. I remember it clearly though: the determined cheerfulness of the staff the many people around the bed, little things being poked up and then a huge thing and I struggled against it. But nowhere near as bad as the anaesthetist’s concern seemed to suggest.

So this time I knew what to expect and the pre-op anaesthetist explained that there would be just a six second time period when I’d feel suffocated. Okely dokely. I watched a You Tube on the procedure. A couple of people in my support group said it was okay and that you even got cocaine up your nose.

Except that the procedure I had on Wednesday was worse. It was different. I had about 30 minutes on a nebuliser breathing in local anaesthetic before the surgery with a concerned, nervous looking anaesthetist pacing in and out waiting for the previous op to finish. I felt uncomfortable at first propped up on the bed with the nebuliser. My back! But a kind technician gave me a heated blanket and soon a sort of mild euphoria kicked in. Just mild, and I didn’t feel sedated in any way. I was fully compos mentis.

I certainly didn’t feel as if my nose had been numbed though. My lips were. I wondered if this way of numbing the breathing passages was going to be as successful as poking local up my nose which is what I think they did last time.

I remember the wheeling into the theatre. The waiting surgeon scrolling on his phone, the usual coterie of staff to help you shift over to the operating table, the good cheer.

At one stage I had the cocaine as a vasoconstrictor I think but no euphoria there. And some stuff to swish around my mouth which stung but got better as it went on. And then I looked up (not sure the order) and saw the tube as it was about to be put in my nose. It’s like a narrow hose pipe with a white pointed tip – I could feel that blimmin’ thing going up every centimeter of my nose and then down the bend and it was not only uncomfortable but it pinched and hurt quite a bit. It felt as if there was a sharp hook at the end and that I was going to swallow it.

I could breathe perfectly okay – no feeling of suffocation at all – but the pain (was it pain?) and discomfort and worry that the tube was not going where it should go – the anesthetist’s obvious difficulty in seeing where the tube was going – all these things were horrible and little tears squeezed out of my tightly shut eyes.

“Give her more sedation,” the anaesthetist said. That is the last thing I remember!

Sooooo, yes I would go through it again. It’s a brief thing really but both times I have wondered (especially this time) why is it necessary to go through such trauma. Are there better ways of numbing the airway? Couldn’t more sedation be used from the start?

My point is that surgery usually involves pain and discomfort afterwards but the good thing about surgery is that you go under peacefully as you count down. Having that peaceful transition from conscious to unconscious is like a given for surgery and to lose that is sad.

As a patient advocate in my own small way and someone interested in the patient experience I wanted to express what I thought about this procedure. I’m never going to get a chance to talk to an anaesthetist about it.

There are plenty of studies on the internet which downplay the patient response a bit so I wanted to get the patient experience down here before I forget. (But I’ll never forget because these things are etched in your memory.)

If anyone reads this and needs to have awake intubation through the nose, don’t be put off. Get them to talk you through it and ask for sedation. The benefits of surgery are worth it.