Eur J Anaesthesiol 2021; 38:157–163

ORIGINAL ARTICLE

Effect of bevel direction on the tracheal tube pathway

during nasotracheal intubation
A randomised trial
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
Downloaded from http://journals.lww.com/ejanaesthesiology by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 05/02/2021

BACKGROUND For nasotracheal intubation, the nasal path-
way 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.
OBJECTIVES We 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.
DESIGN A randomised, blinded trial.
SETTING SMG-SNU Boramae Medical Center, Seoul
National University College of Medicine, Seoul, Korea from
January 2019 to March 2020.
PATIENTS Sixty-eight adult patients undergoing oromaxillary
surgeries were enrolled in this study.
INTERVENTIONS Patients 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 MEASURES The effects of bevel direc-
tion on the pathway of the tube in the nasal cavity, and the
incidence of epistaxis were evaluated by fibreoptic bron-
choscopy.
RESULTS The 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 ¼ 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 ¼ 0.007).
CONCLUSIONS Facing 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 REGISTRATION ClinicalTrial.gov, NCT03740620.
Published online 1 October 2020

Introduction
Nasotracheal intubation (NTI) is an airway instrumenta-
tion procedure that is required for some oromaxillary
surgeries to provide adequate intra-oral access.1 The
whole process of NTI can be divided into two consecu-
tive parts, that is the nasal part and oral part. The oral
part, the latter half of the NTI, is similar to orotracheal
intubation except for the requirement for Magill forceps
to advance the tracheal tube from the posterior
pharyngeal arch into the glottis. The nasal part, the
former half of the NTI, is carried out in the vessel-rich
and narrow nasal cavity.1 As the nasal cavity is narrow and
divided into sections by turbinates, the cuff of the tra-
cheal tube or even the tracheal tube itself may cause
trauma to the vessel-rich nasal mucosa.1,2 Therefore, epi-
staxis is a common complication during NTI with inci-
dence rates of 18 to 88%.2–4 In rare cases, severe epistaxis

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)
Correspondence to Tae Kyong Kim, MD, PhD, Assistant Professor, Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Seoul
National University College of Medicine, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul 07061, Republic of Korea
Tel: +82 2 870 2519; fax: +82 2 870 3863; e-mail: ktkktk@gmail.com

0265-0215 Copyright ß 2020 European Society of Anaesthesiology and Intensive Care. Unauthorized reproduction of this article is prohibited.
DOI:10.1097/EJA.0000000000001347
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
 158 Won et al.
Fig. 1. Upper and lower pathways in the nasal cavity.
Middle
turbinate
Upper pathway
Inferior
turbinate
Lower pathway
may jeopardise tracheal intubation,2,5 and complications,
such as accidental turbinectomy, retropharyngeal wall
laceration, bacteraemia and cranial bone fracture, may
occur.1,6–10 Thus, reducing the risk for complications
during NTI has been a challenging task for anaesthesio-
logists.
Two working spaces are available during NTI, that is the
upper pathway between the middle turbinate and infe-
rior turbinate and the lower pathway between the infe-
rior turbinate and the floor of the nasal cavity (Fig. 1).11
When the tracheal tube passes through the upper path-
way, excessive force may be applied to the structures of
the nasal cavity, such as the middle turbinates, resulting
in complications such as accidental middle turbinectomy
or fracture of the bony structure of the middle turbi-
nate.6 – 8,10,12,13 Unlike the inferior turbinate, which is a
part of the facial bones, the middle turbinate is part of the
cranial bones, and therefore, fracture of the middle
turbinate may cause cranial fractures and leakage of
cerebrospinal fluid.10 Therefore, the lower pathway
has been considered a better route for passage of the
tracheal tube during NTI.4,14 Advancing the tracheal
tube through the lower pathway during NTI is also
advantageous because it reduces the risk for epistaxis.3,14
Migration of tubes between pathways is usually pre-
vented because of the proximity of the inferior turbinate
and nasal septum in the majority of patients, and there-
fore, selecting the lower pathway during NTI has been
an important issue.14
Several methods, such as the use of a reinforced tracheal
tube, use of a nasogastric tube or fibreoptic nasendoscopy
prior to NTI and nasal tip lifting, may facilitate selec-
tion of the lower pathway during NTI.3,4,14,15 How-
ever, no previous studies have utilised the mechanical
characteristic of the tracheal tube, such as the bevel of the
Eur J Anaesthesiol 2021; 38:157–163
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
tube, to determine the pathway. The bevel of the tube
may guide the pathway of the tube as it enters the side of
the nasal turbinate. We designed this randomised con-
trolled trial based on the hypothesis that directing the
bevel of the tracheal tube in the cephalad direction of the
patient may facilitate tracheal tube through the lower
pathway during NTI.
Materials and methods
Ethics
The study protocol was approved by the Institutional
Review Board of SMG-SNU Boramae Medical Center,
Seoul, South Korea (approval no. 30-2018-76; on 2
August 2018 and registered at ClinicalTrials.gov
(NCT03740620). Written informed consent was obtained
from each participant prior to surgeries. The study pro-
tocol conformed to the ethical guidelines of the Declara-
tion of Helsinki.
Study design and patient selection
From January 2019 to March 2020, patients aged 18 years
or older undergoing general elective surgeries requiring
NTI at SMG-SNU Boramae Medical Center were
included in the study. Patients with known deformities
of the nasal cavity, history of severe epistaxis or epi-
staxis within a month, current coagulation abnormality
or history of fracture or operation of the cranial base
were excluded. History of nasal congestion and history
of recurrent epistaxis were asked of all participants.
History of nasal congestion was defined as the discom-
fort experienced during breathing due to decreased
nasal patency within a month. History of recurrent
epistaxis was defined as repeated episodes of mild to
moderate spontaneous nosebleed, which were not self-
limited and required treatments as cauterisation or
nasal packing.16
Randomisation and blinding
On the morning of surgery, patients were allocated to the
intervention group or conventional group according to a
random sequence produced by a web-based random
sequence generator (http://randomizer.org). Group
assignments were kept in an opaque envelope by a
research assistant who was not involved in the study.
Patients and assessors who evaluated the nasal cavity
were blinded to the group allocation. However, the
intubating anaesthesiologists could not be blinded to
the group allocation, as it was not possible to conceal
the tracheal tube during NTI.
Anaesthesia procedures
All patients entered the operating room without any
premedication. Routine monitoring included electrocar-
diography, noninvasive blood pressure monitoring and
pulse oximetry. After adequate pre-oxygenation, anaes-
thesia was induced with intravenous lidocaine (30 mg),
fentanyl (1 to 2 mg kg1), propofol (1.5 to 2 mg kg1) and
 Effect of bevel direction during nasotracheal intubation 159

rocuronium (0.6 mg kg1). During manual mask ventila-
tion using sevoflurane 6 to 8% in 100% oxygen, cotton
swabs soaked in topical epinephrine 0.1% were applied in
both nostrils to prevent epistaxis during intubation and to
assess nasal patency. A tracheal tube (Mallinckrodt Pre-
formed Nasal RAE tube; Covidien, Mansfield, Massa-
chusetts, USA) was put into a bottle of sterile isotonic
saline at 408C for thermosoftening 10 min before intuba-
tion (inner diameter 7.0 mm for men and 6.5 mm for
women). The tracheal tube was lubricated with sterile,
water-soluble jelly immediately before intubation.
Unless specifically preferred by the surgeon, a suitable
nostril was selected on the basis of a review of nasal
radiographs and the presence of nasal congestion.
In the conventional group, the tracheal tube was inserted
with the bevel of the tube facing the patient’s left, that is
the default direction. In the intervention group, the
tracheal tube was inserted into the nostril with the bevel
of the tube facing the patient’s cephalad direction by
rotating 908 counterclockwise from the default position,
and then the tube was turned 908 clockwise back to the
default position after the cuff of the tube had passed the
posterior nasal aperture (Fig. 2). In both groups, the
tracheal tube was directed caudally in the nasal cavity
and Magill forceps was used to assist the tracheal intuba-
tion.
The procedure time was recorded from insertion of the
tube into the nostril to the time when capnography
became evident on the monitor. Time measurements
were subdivided as follows: nasal procedure time,
defined as the time interval between insertion of the
tube and insertion of the direct laryngoscope into the
mouth; oral procedure time, defined as the time interval
between insertion of the direct laryngoscope and the
confirmation of the capnography. NTI was performed by
two anaesthesiologists each with more than 10 years of
experience. After NTI, the nasal pathway was evaluated
with the fibreoptic bronchoscope (outer diameter
4.1 mm, Olympus LE-P; Olympus Optical Co., Tokyo,
Japan). In addition, the severity of nasal bleeding was
evaluated by direct inspection of the mouth and pharynx
using the laryngoscope. Both the nasal pathway and the
severity of nasal bleeding were examined by indepen-
dent assessors unaware of the intervention. The severity
of nasal bleeding was graded using a four-point scale: no
epistaxis; mild epistaxis (blood on the tracheal tube only
or tinged on the posterior pharyngeal wall); moderate
epistaxis (blood pooling in the pharynx); or severe epi-
staxis (blood in the pharynx sufficient to impede intuba-
tion).17,18 Resistance while advancing the tube via the
nasal cavity was also graded on a three-point scale: slight
(when the tracheal tube passed nasal cavity smoothly);
moderate (when the tube was redirected because of

Fig. 2. Bevel direction of the conventional group and the intervention group.

90˚
rotation

Conventional group Intervention group

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 160 Won et al.

Fig. 3. CONSORT Flow Diagram.

Enrollment

Assessed for eligibility (n = 68)

Excluded (n = 0)
Not meeting inclusion criteria (n = 0)
Declined to participate (n = 0)
Other reasons (n = 0)

Randomised (n = 68)

Allocation

Allocated to the intervention group (n = 34) Allocated to the conventional group (n = 34)
Received allocated intervention (n = 34) Received allocated intervention (n = 34)
Did not receive allocated intervention Did not receive allocated intervention
(give reasons) (n = 0) (give reasons) (n = 0)

Analysis

Analysed (n = 34) Analysed (n = 34)

Excluded from analysis (give reasons) (n = 0) Excluded from analysis (give reasons) (n = 0)

resistance); obstructed (when NTI failed because of
resistance).4
Statistical analyses
The primary study endpoint was the success rate of
tracheal tube passing through the lower pathway. Sec-
ondary endpoints included the intubation time, nasal
passage time and nasal bleeding. Continuous data are
expressed as the mean  standard deviation and signifi-
cance was tested with Student’s t-test for data with a
normal distribution determined using the Kolmogorov–
Smirnov test. Nonnormal data are expressed as the
median [interquartile range] and significance was tested
with the Mann–Whitney U test. Categorical data are
expressed as number (percentage) and were tested for
significance using the x2 test or Fisher’s exact test.
Ordinal data, such as severity of bleeding and resistance
during insertion, were tested with the Mann–Whitney U
test. In addition, we assessed the relationship between
the tracheal tube nasal pathway and incidence of epi-
staxis using multivariate logistic regression analyses. Vari-
ables included in the univariate logistic regression were
age, sex, BMI, American Society of Anesthesiologists
(ASA) status classification, tube pathway, selected nostril
and randomised group allocation. Only variables with P
value less than 0.2 in univariate analyses were entered
into multivariate logistic regression.
Calculation of the sample size was based on a study that
reported the success rate of tracheal tube passing through
the lower pathway as 26.7% during NTI by the conven-
tional method.15 Taking a 40% increase in the success rate
as clinically significant, each group required 29 patients to
detect a difference with a type I error of 0.05 and power of
0.8. To allow for a 15% dropout rate, we included
68 patients in this study. All statistical analyses were
performed using SPSS (version 19.0; IBM corp., Armonk,
New York, USA). In all analyses, P value less than 0.05 was
taken to indicate statistical significance.
Results
A total of 68 patients were enrolled in the study, and no
patients met the exclusion criteria. Patient enrolment
was started on 14 January 2019. The conventional group
and the intervention group each consisted of 34 patients
(Fig. 3). The baseline patient characteristics are sum-
marised in Table 1. Patient demographic data, including

Eur J Anaesthesiol 2021; 38:157–163

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 Effect of bevel direction during nasotracheal intubation 161

Table 1 Patient demographics and baseline characteristics

Intervention group Conventional group P

(n U 34) (n U 34)
Age (years) 46.74  19.72 45.53  18.38 0.795
Height (cm) 164.26  12.21 165.87  10.72 0.567
Weight (kg) 66.70  15.97 66.05  12.69 0.853
Female 14 (41.2) 10 (29.4) 0.310
ASA 1/2/3 20/13/1 22/11/1 0.898
History of recurrent epistaxis 0 (0.0) 2 (5.9) 0.493
History of nasal congestion; None/Left/Right/Both 26/1/3/4 19/6/4/5 0.175
Appearance (Wider side); Left/Right/Same 2/2/30 4/4/26 0.460
Radiologic evaluation (Wider side); Left/Right/Same 14/7/13 7/10/17 0.183
Selected nostril; Left/Right 21/13 15/19 0.145

Data are presented as the mean  standard deviation or number (%). ASA, American Society of Anesthesiologists status classification.

Table 2 Effects of tracheal tube bevel on study outcomes

Intervention group Conventional group P

(n U 34) (n U 34)
Lower pathway 27 (79.4) 19 (55.9) 0.038
Resistance; Slight/Moderate/Obstructed 21/13/0 16/18/0 0.330
Epistaxis 14 (41.2) 25 (73.5) 0.007
Severity of epistaxis; None/Mild/Moderate/Severe 21/10/3/0 9/13/12/0 0.001
Intubation time (s) 47 [37 to 56] 44 [39 to 52] 0.504
Nasal passage time (s) 12 [9 to 19] 11 [9 to 18] 0.659

Data are presented as the mean  standard deviation, number (%) or median [IQR].

sex, age, weight, height and ASA status classification,
were comparable between the groups. Anatomical char-
acteristics, including history of nasal congestion and
epistaxis, gross appearance of the nostrils and radiologi-
cally evaluated deformities of the nasal cavities, were also
similar between the groups.
There was no failed intubation at the first attempt in both
groups. The success rate of tracheal tube passing through
the lower pathway was significantly higher in the inter-
vention group than the conventional group (79.4 vs.
55.9%, relative risk 1.421, 95% CI 1.007 to 2.005,
P ¼ 0.038) (Table 2). Nasal passage time and total intu-
bation time were similar between the two groups. The
resistance during nasal passage of the tracheal tube was
similar in both groups.
The incidence of epistaxis was significantly 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 ¼ 0.007). The severity of epistaxis was also different
between the groups (P ¼ 0.001). Moderate to severe
epistaxis was less frequent in the intervention group than
in the conventional group (8.8 vs. 35.3%, P ¼ 0.008). The
incidence of epistaxis was lower in the lower pathway
than the upper pathway, but the difference did not reach
the level of statistical significance (50.0 vs. 72.7%,
P ¼ 0.076). The effects of the tracheal tube bevel on
study outcomes are summarised in Table 2. According
to multivariate logistic regression analyses, ASA status
classification (odds ratio 0.303, 95% CI 0.106 to 0.862,
P ¼ 0.025) and group (odds ratio 5.415, 95% CI 1.683 to
17.417, P ¼ 0.005) were associated with epistaxis after
adjusting for age, pathway, nasal passage time and resis-
tance (Table 3).
Discussion
In this study, we showed that facing the bevel of the
tracheal tube in the patient’s cephalad direction
increased the success rate of tracheal tube passing
through the lower pathway during NTI and decreased
the incidence of epistaxis compared with conventional
NTI in patients undergoing oromaxillary surgeries.

Table 3 Comparison of variables associated with epistaxis during nasotracheal intubation

Epistaxis No epistaxis OR 95% CI P

Pathway
Upper pathway 16 (72.7) 6 (27.3) 1.454 0.396 to 5.344 0.573
Lower pathway 23 (50) 23 (50)
ASA 1/2/3 29/10/0 13/14/2 0.303 0.106 to 0.862 0.025
Group
Conventional 25 (73.5) 9 (26.5) 5.415 1.683 to 17.417 0.005
Intervention 14 (41.2) 20 (58.8)

Data are presented as number (%). ASA, American Society of Anesthesiologists status classification; CI, confidence interval; OR, odds ratio.

Eur J Anaesthesiol 2021; 38:157–163

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 162 Won et al.
There are several obstacles to selection of the lower
pathway during NTI. First, nasal passage of the tracheal
tube is usually performed blindly. We cannot select the
lower pathway exclusively, as there are no clear haptic
indicators by which we can differentiate between the
upper and lower pathways blindly.14 Second, the axis of
the nasal vestibule does not agree with that of the lower
pathway, and therefore, the tracheal tube can be directed
cephalad while advancing the tube. To cope with the
disagreement of axes of the vestibule and lower pathway,
insertion of the tracheal tube in the caudal direction as
much as possible is recommended to accommodate the
two axes.3,14 Aiming in the caudal direction with gentle
traction of the shaft of the tracheal tube towards the
cephalad direction flattens the curve by lifting the nos-
trils, but the diameter of the tube can interfere with this
effort as the rim of the nostril has limited elasticity.
However, as shown in this study, facing the bevel of
the tracheal tube towards the cephalad direction during
insertion may increase the success rate of tracheal tube
passing through the lower pathway without increasing
other complications. When the bevel of the tracheal tube
encounters the turbinates, it may act as a wedge to guide
the tracheal tube to the lower pathway. NTI with the
tracheal tube bevel facing in the cephalad direction has
an additional advantage with regard to the trajectory of
the tracheal tube. When the tracheal tube meets the
posterior pharyngeal wall, the bevel facing the cephalad
direction of the patient would facilitate smooth transition
of the tracheal tube to the larynx.1
Epistaxis, the most frequent complication of NTI, also
occurred less frequently and its severity was reduced in
the intervention group compared with the conventional
group. Epistaxis can be reduced by decreasing mechani-
cal injury of the vessels and mucosa induced by the
tracheal tube. Epistaxis during NTI can be prevented
by selecting the lower pathway, blunting the tip of the
tracheal tube, thermosoftening or lubricating the tracheal
tube, or contracting the capillary mucous membranes
with topical vasoconstrictors.2,3,17–21 As no single
manoeuvre provides complete protection against epi-
staxis, they are usually done simultaneously.2,3,17,19 –22
In this study, changing the direction of bevel reduced the
incidence of epistaxis, consistent with a previous study
that used Parker Flex-Tip, which has a posterior-facing
bevel and soft tip.23,24
Interestingly, the intervention had a greater effect on
epistaxis in the left nostril (38.1% in intervention group
vs. 80.0% in conventional group, P ¼ 0.013) than the right
nostril (46.2% in intervention group vs. 68.4% in conven-
tional group, P ¼ 0.208). Some previous case reports
recommended that the bevel should be faced toward
the turbinates.22,25 That is, the leading edge of the bevel
should be advanced along the septal side. When the
leading edge of the tracheal tube is forced against soft
tissue, it may act as a blade and avulse the turbinates. In
Eur J Anaesthesiol 2021; 38:157–163
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the left nasal cavity, the leading edge of the tube could be
separated from the turbinates, but it would push against
Little’s area, which is the most vascularised region in the
nasal cavity, in the conventional group.26 By rotating the
tracheal tube 908 counterclockwise, the leading edge of
the tracheal tube could be separated from both Little’s
area and the turbinates. By contrast, in the right nostril,
the bevel faced the septum, advancing its leading edge
against the turbinates. Although contact with Little’s area
was avoided, the turbinates are also hypervascular tissue,
which can be damaged by the leading edge of the tracheal
tube.27 In the right nostril, the incidence of epistaxis was
also higher in the conventional group then the interven-
tion group, although the difference was not statistically
significant. The results should be interpreted with cau-
tion, however, as the statistical power may have been
inadequate for this secondary outcome and there may
have been bias. The selected nostril was not an indepen-
dent factor in logistic regression analyses.
This study has some limitations. First, blinding the
intubating anesthesiologists to group allocation was not
possible due to the nature of the intervention. However,
assessors who examined the severity of nasal bleeding
and the nasal pathway were blinded to the group alloca-
tion. Second, nasal intubation was conducted by skilled
investigators at NTI. Therefore, the results cannot be
directly extrapolated to less skilled operators. Third, the
results of this study in an Asian population may not be
extrapolated to other ethnicities. There may be differ-
ences in anatomy of the nasal cavity among races, as racial
differences in the cross-sectional area at the end of the
inferior turbinate have been reported.28 Lastly, this study
utilised fibreoptic bronchoscope only for evaluating the
nasal cavity. Nowadays, fibreoptic NTI is frequently
performed, especially for difficult intubation.1,29 A recent
study has shown that fibreoptic selection and guidance
during NTI reduce the incidence and severity of epi-
staxis in elective patients.4 However, fibreoptic NTI
requires both experience and skill to perform properly,
and the device is not always available for every NTI.1,30
Therefore, we believe that the technique to select the
lower pathway during NTI without fibreoptic broncho-
scope has a significant clinical value.
Conclusion
Orientating the tracheal tube such that the bevel faces the
patient’s cephalad direction may facilitate selection of the
lower pathway and reduce the incidence of epistaxis
during NTI in patients undergoing oromaxillary surgery.
Acknowledgements relating to this article
Assistance with the study: none.
Financial support and sponsorship: none.
Conflicts of interest: none.
Presentation: none.

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