Nasal breathing is superior to oral breathing when performing and undergoing transnasal endoscopy: a randomized trial

Abstract

Background Transnasal endoscopy presents a technical difficulty when inserting the flexible endoscope. It is unclear whether a particular breathing method is useful for transnasal endoscopy. Therefore, we conducted a prospective randomized controlled trial to compare endoscopic operability and patient tolerance between patients assigned to nasal breathing or oral breathing groups.

Methods 198 eligible patients were randomly assigned to undergo transnasal endoscopy with nasal breathing or with oral breathing. Endoscopists and patients answered questionnaires on the endoscopic operability and patient tolerance using a 100-mm visual analog scale ranging from 0 (non-existent) to 100 (most difficult/unbearable). The visibility of the upper-middle pharynx was recorded.

Results Patient characteristics did not differ significantly between the groups. Nasal breathing showed a higher rate of good visibility of the upper-middle pharynx than oral breathing (91.9 % vs. 27.6 %; P < 0.001). Nasal breathing showed lower mean [SD] scores than oral breathing in terms of overall technical difficulty (21.0 [11.4] vs. 35.4 [15.0]; P < 0.001). Regarding patient tolerance, nasal breathing showed lower scores than oral breathing for overall discomfort (22.1 [18.8] vs. 30.5 [20.9]; P = 0.004) and other symptoms, including nasal and throat pain, choking, suffocating, gagging, belching, and bloating (all P < 0.05). The pharyngeal bleeding rate was lower in the nasal breathing group than in the oral breathing group (0 % vs. 9.2 %; P = 0.002).

Conclusions Nasal breathing is superior to oral breathing for those performing and undergoing transnasal endoscopy. Nasal breathing led to good visibility of the upper-middle pharynx, improved endoscopic operability, and better patient tolerance, and was safer owing to decreased pharyngeal bleeding.

Publication History

Received: 12 January 2022

Accepted after revision: 13 July 2022

Accepted Manuscript online:
14 July 2022

Article published online:
16 September 2022

• References

• 1 Kawai T. Improved transnasal examination of the upper gastrointestinal tract through advancements in ultrathin endoscopes. Dig Endosc 2022; 34 (Suppl. 02) 55-57
• 2 Kadayifci A, Parlar S, Aydinli M. et al. Unsedated transnasal versus conventional oral endoscopy in endoscopy naïve patients. Acta Gastroenterol Belg 2014; 77: 224-228
• 3 Trevisani L. Unsedated ultrathin upper endoscopy is better than conventional endoscopy in routine outpatient gastroenterology practice: A randomized trial. World J Gastroenterol 2007; 13: 906-911
• 4 Tsuboi M, Arai M, Matsumura T. et al. Utility of unsedated transnasal endoscopy for pharyngeal observation during esophagogastroduodenoscopy. A prospective study to assess cardiopulmonary function. Scand J Gastroenterol 2013; 48: 884-889
• 5 Alexandridis E, Inglis S, McAvoy NC. et al. Randomised clinical trial: comparison of acceptability, patient tolerance, cardiac stress and endoscopic views in transnasal and transoral endoscopy under local anaesthetic. Aliment Pharmacol Ther 2014; 40: 467-476
• 6 Atar M, Kadayifci A. Transnasal endoscopy: Technical considerations, advantages and limitations. World J Gastrointest Endosc 2014; 6: 41-48
• 7 Lin L-F, Ma K-Z, Tu H-L. A prospective randomized study comparing transnasal and peroral 5-mm ultrathin endoscopy. J Formos Med Assoc 2014; 113: 371-376
• 8 Thota PN, Zuccaro Jr. G, Vargo IIJJ. et al. A randomized prospective trial comparing unsedated esophagoscopy via transnasal and transoral routes using a 4-mm video endoscope with conventional endoscopy with sedation. Endoscopy 2005; 37: 559-565
• 9 Preiss C, Charton JP, Schumacher B. et al. A randomized trial of unsedated transnasal small-caliber esophagogastroduodenoscopy (EGD) versus peroral small-caliber EGD versus conventional EGD. Endoscopy 2003; 35: 641-646
• 10 Watanabe H, Watanabe N, Ogura R. et al. A randomized prospective trial comparing unsedated endoscopy via transnasal and transoral routes using 5.5-mm video endoscopy. Dig Dis Sci 2009; 54: 2155-2160
• 11 Cho S, Arya N, Swan K. et al. Unsedated transnasal endoscopy: a Canadian experience in daily practice. Can J Gastroenterol 2008; 22: 243-246
• 12 Tanuma T, Morita Y, Doyama H. Current status of transnasal endoscopy worldwide using ultrathin videoscope for upper gastrointestinal tract: Current status of transnasal endoscopy. Dig Endosc 2016; 28: 25-31
• 13 Birkner B, Fritz N, Schatke W. et al. A prospective randomized comparison of unsedated ultrathin versus standard esophagogastroduodenoscopy in routine outpatient gastroenterology practice: does it work better through the nose?. Endoscopy 2003; 35: 647-651
• 14 Hu C-T, Lei W-Y, Lin J-S. et al. Endoscopic meatus scoring scale versus sniff test to predict insertability before transnasal endoscopy: A prospective, randomized study. J Gastroenterol Hepatol 2017; 32: 1914-1921
• 15 Craig A, Hanlon J, Nursing D. et al. A comparison of transnasal and transoral endoscopy with small-diameter endoscopes in unsedated patients. Gastrointest Endosc 1999; 49: 292-296
• 16 Rodenstein DO, Stanescu DC. Soft palate and oronasal breathing in humans. J Appl Physiol Respir Environ Exerc Physiol 1984; 57: 651-657
• 17 Cheung J, Goodman KJ, Bailey R. et al. A randomized trial of topical anesthesia comparing lidocaine versus lidocaine plus xylometazoline for unsedated transnasal upper gastrointestinal endoscopy. Can J Gastroenterol 2010; 24: 317-321
• 18 Cheung J, Bailey R, van Zanten SV. et al. Early experience with unsedated ultrathin 4.9 mm transnasal gastroscopy: a pilot study. Can J Gastroenterol 2008; 22: 917-922
• 19 Dumortier J, Josso C, Roman S. et al. Prospective evaluation of a new ultrathin one-plane bending videoendoscope for transnasal EGD: a comparative study on performance and tolerance. Gastrointest Endosc 2007; 66: 13-19
• 20 Matsuo K, Metani H, Mays KA. et al. Effects of respiration on soft palate movement in feeding. J Dent Res 2010; 89: 1401-1406
• 21 Tangel DJ, Mezzanotte WS, White DP. Respiratory-related control of palatoglossus and levator palatini muscle activity. J Appl Physiol 1995; 78: 680-688
• 22 Chadha TS, Birch S, Sackner MA. Oronasal distribution of ventilation during exercise in normal subjects and patients with asthma and rhinitis. Chest 1987; 92: 1037-1041
• 23 Research Group of Endoscopic Screening for Gastric Cancer, Japanese Association of Gastroenterological Cancer Screening. Manual of gastric cancer screening for gastric cancer using nasal endoscopy. Saitama: Igaku-Shoin Ltd; 2014
• 24 Rotheray KR, Cheung PSY, Cheung CSK. et al. What is the relationship between the Glasgow coma scale and airway protective reflexes in the Chinese population?. Resuscitation 2012; 83: 86-89