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Irrigação Nasal
Irrigação Nasal
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Technical note
a r t i c l e i n f o a b s t r a c t
Keywords: Nasal irrigation is a grade A recommendation treatment, which is essential in many pathological con-
Nasal irrigation ditions. Very heterogeneous practices are observed in paediatrics as a result of poor instruction in this
Nasal lavage technique. We propose to describe the nasal irrigation technique developed by a team of respiratory phys-
Nasal spray
iotherapists in Lille for the management of cystic fibrosis and bronchiolitis. This technique is intended
Nasal obstruction
for children over the age of 6 months, as it requires an oral breathing reflex and cough reflex that are not
Infection
systematically acquired before this age. Nasal irrigation is performed on a 30◦ upward inclined plane on
a calm and cooperative child, away from meals. The child is maintained gently, without pressure, in the
fencing position with the head turned away from the practitioner. Using a continuous flow spray, the
practitioner grasps the top of the upper nostril and irrigates the nostril for an average of 3 s (6 mL per
nostril). These steps are then repeated until satisfactory patency is achieved in both nostrils. This tech-
nique constitutes a practical tool to help healthcare professionals and parents perform nasal irrigation in
young children over the age of 6 months.
© 2020 Elsevier Masson SAS. All rights reserved.
1. Introduction 2. Technique
The healthcare professional assesses the child and asks the par-
∗ Corresponding author at: Service d’ORL et de chirurgie cervico-faciale, Centre
ents about the child’s general state of health, last visit to the doctor
F.-X. Michelet, Hôpital Pellegrin, CHU de Bordeaux, place Amélie-Raba-Léon, 33076
and any recent or ongoing treatment. The healthcare professional
Bordeaux cedex, France. identifies any potential risks, such as breath-holding spells or gas-
E-mail address: ludovic.de-gabory@chu-bordeaux.fr (L. de Gabory). troesophageal reflux disease that require increased caution when
https://doi.org/10.1016/j.anorl.2020.08.004
1879-7296/© 2020 Elsevier Masson SAS. All rights reserved.
108 L. de Gabory et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 138 (2021) 107–113
Table 1
Description of the various steps of paediatric nasal irrigation.
performing nasal irrigation. Although no contraindications have before irrigation and delivered with an atraumatic nasal tip adapted
been reported in the literature, nasal irrigation is not recommended to the child’s age. To avoid irritative rhinitis in children with chronic
in children with swallowing disorders, epistaxis or suspected for- conditions, it is preferable to use an isotonic or slightly hypertonic
eign body in the upper airways. neutral pH solution [8,9]. When the material is ready, the parent
Before performing nasal irrigation, the healthcare professional hands the child over to the practitioner, who will then perform the
must evaluate upper airway patency by means of the Rosenthal test, procedure.
adapted to infants and used in clinical practice by physiotherapists The successive steps of nasal irrigation are described in Figs. 1–4
[7]. This test of upper airway patency should be performed before and Video S 1 [see the additional material accompanying the online
and after nasal irrigation. version of this article].
In practice, the Rosenthal test, also known as the oral occlusion Certain techniques are adapted to the child’s age (infant or
test, consists of placing a hand underneath the child’s chin to gently young child).
close the mouth and counting the number of nasal inspirations. A
child with totally patent nostrils should be able to breathe through 2.4. Positioning of the child and the practitioner
the nose 10 times without trying to open the mouth, with no signs
of distress and no increase in heart rate. The child is positioned in the supine position on an examina-
tion table with a 30 degree upward tilt (Figs. 1a and 3a). The child
2.3. Preparation remains in a resting position (supine with the head to one side)
throughout the procedure to avoid any risk of aspiration in the
The child must be calm and the parents must be informed about event of regurgitation, reflux, or swallowing of part of the irrigation
the procedure, which should be performed in a suitable environ- solution.
ment. The nasal irrigation device and the solution should also be For irrigation of the left nasal cavity, the child’s head is turned
tested before the procedure. Several in vitro and in vivo studies towards the right and the practitioner stands to the child’s left. After
have shown that mineral-rich solutions, such as undiluted seawa- checking the child’s temperature, the practitioner sprays the child’s
ter, are the most effective irrigation solutions [8–10]. The irrigation hand to show the gentle pressure and comfortable temperature of
technique is carried out with a sterile, reusable, continuous spray at the spray, to reassure the child and ensure that he or she remains
room temperature or placed in lukewarm water for several minutes calm and cooperative.
L. de Gabory et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 138 (2021) 107–113 109
Fig. 1. Successive steps of nasal irrigation in young children (2.5 years) from positioning of the child to instillation of the solution: (a) position; (b and c) immobilization in
the “fencer’s” position; (d) position of the spray; (e and f) instillation of the solution.
2.5. Immobilization of the child in the “fencer’s” position spray is applied to the superior and lateral margins of the child’s
upper nostril. This contact with the nostril is painless and avoids
The practitioner’s right hand grasps and extends the child’s right any trauma to the nasal septum, even when the child moves. The
forearm to simulate the “fencer’s” position (Figs. 1b,c–3b). This nasal tip of the spray should be directed at an angle of 45◦ with
position is natural in infants and corresponds to the archaic asym- respect to the plane of the palate, towards the contralateral inner
metric tonic neck reflex [11]. The purpose of this position is to canthus and vice versa on the other side. The practitioner actuates
immobilize the child’s shoulder girdle. The practitioner gently tilts the spray and maintains the instillation for an average of 3 s, while
the child’s head towards the right so that he or she is looking away monitoring the infant’s tolerance (Fig. 1e,f – Video S1). The treat-
from the practitioner. The practitioner then slides paper tissues ment should be stopped and resumed later in the presence of any
underneath the child’s cheek to prevent the solution from leak- change in behaviour suggestive of discomfort.
ing onto the table during irrigation and examines the appearance The solution enters via the upper nostril to emerge through
of the secretions. the lower nostril. The irrigation fluid is collected on tissues placed
The practitioner then immobilizes the child’s right forearm by underneath the child’s cheek. The same procedure is repeated on
applying gentle pressure. The practitioner’s right forearm is placed the other side by reversing the movements and positions described
in contact with the child’s left cheek (without pressure), preventing above (Fig. 2a–c and Fig. 4b–d).
the child from turning his/her head to the left.
2.7. Nose blowing
2.6. Nasal irrigation
The infant remains in the supine position: the practitioner’s
The practitioner’s left hand grasps the spray and places it on his right hand releases the child’s extended right arm and places
right forearm to ensure stability during irrigation (Figs. 1d–3c). The his hand on the left cheek with the thumb underneath the chin
110 L. de Gabory et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 138 (2021) 107–113
Fig. 2. Successive steps of nasal irrigation in young children (2.5 years) from repetition of irrigation to evaluation of efficacy: (a–c) contralateral irrigation; (d) bilateral nose
blowing; (e and f) verification of upper airway patency.
(Fig. 3d). During expiration, the practitioner’s thumb prevents the With his right index finger (while keeping the palm of the hand
child from opening the mouth and encourages nose blowing. The on the top of the infant’s head), the practitioner blocks the right
practitioner’s left hand collects the secretions with a tissue (Fig. 3e). nostril, forcing the child to breathe through the left nostril (Fig. 2f
This procedure can be repeated unilaterally by alternately obstruct- and Fig. 4f) and vice versa for the other side.
ing the right nostril and then the left nostril with the index finger
(Fig. 3f and Fig. 4a). 2.9. Evaluation of pain/discomfort
The young child is seated (Fig. 2d), the practitioner slides his left
hand underneath the child’s chin to maintain the mouth closed after The tolerance of nasal irrigation is assessed using the FLACC
inspiration in order to generate nasal expiration. The practitioner (Face, Legs, Activity, Cry and Consolability) scale, a validated and
collects the secretions with his right hand. This procedure can be reproducible scale in young children unable to verbalize pain
reproduced unilaterally by alternately blocking the right nostril and [12,13]. Each of the 5 items on the scale is scored between 0 and 2,
then the left nostril with the index finger. resulting in a total score ranging from 0 to 10 (0: relaxed and com-
fortable child, 1–3: mild discomfort, 4–6: moderate pain and/or
2.8. Verification of bilateral upper airway patency discomfort, 7–10: severe pain or major discomfort). The FLACC
score should remain less than 5 for the duration of nasal irrigation.
With the child lying down or sitting, depending on the child’s Nasal irrigation is repeated until satisfactory patency is obtained
age, the practitioner places his left hand underneath the chin and in both nostrils. The frequency of nasal irrigation should be
prevents mouth opening in order to generate a gentle nasal inspira- adapted to the child’s age, health status and neurological devel-
tion (Fig. 2e–f and Fig. 4e,f). The practitioner’s index finger lifts the opment. Nasal patency should allow normal feeding. The parents
tip of the chin to ensure closure of the mouth (Fig. 2e and Fig. 4e). can perform nasal irrigation at home after therapeutic education
L. de Gabory et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 138 (2021) 107–113 111
Fig. 3. Successive steps of nasal irrigation in infants (7 months) from infant positioning to instillation of the solution: (a) position; (b) immobilization in the “fencer’s”
position; (c) instillation of the solution; (d–f) nose blowing.
and after ensuring that they comply with the practitioner’s recom- difficulties of this procedure [14]. Generalization of this procedure
mendations. is also hampered by the parents’ perception that their child would
not tolerate the procedure, despite clinical experience showing that
3. Discussion this procedure is well tolerated [7,15].
Few studies have been conducted on nasal irrigation in young
The technique described was developed in accordance with the children, and most of them present major methodological biases
neurological development and physiology of the upper airways in [4]. The modalities of irrigation (device, volume, duration) are not
children. This method constitutes a practical tool to help health- clearly defined; infants and young children cannot use adult devices
care professionals and parents perform nasal irrigation with the [4]. The volume of solution must always be adapted to the total
necessary precautions adapted to the child’s age. volume of the nasal cavities: from 1.76 to 2.10 cm3 for a 2- to 4-
By proposing a precise and standardized procedure, we want day-old newborn [16,17], 2.44 to 4.08 cm3 for a 1- to 2-year-old
to encourage practitioners and parents to perform nasal irrigation infant [18,19] and 3.5 to 4.14 cm3 for a 3- to 4-year-old child [19]. It
according to a reproducible and reliable method, as part of a safety, has been estimated that the volume required to effectively irrigate
optimization and quality control process. In an Italian survey, a nasal cavity must be equal to at least three times the volume of
55% of the 860 paediatricians surveyed considered that parental this cavity, i.e. a total of about 6 to 12 mL of solution depending on
refusal to perform nasal irrigation was mainly due to the technical the child’s age.
112 L. de Gabory et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 138 (2021) 107–113
Fig. 4. Successive steps of nasal irrigation in infants (7 months) from repetition of irrigation to evaluation of efficacy: (a) unilateral nose blowing (left nostril); (b–d)
contralateral irrigation; (e) verification of bilateral upper airway patency; (f) verification of unilateral upper airway patency.
4. Conclusion References
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[13] Manworren RC, Hynan LS. Clinical validation of FLACC: preverbal patient pain [17] Pedersen OF, Berkowitz R, Yamagiwa M, et al. Nasal cavity dimensions in
scale. Pediatr Nurs 2003;29(2):140–6. the newborn measured by acoustic reflections. Laryngoscope 1994;104(8 Pt
[14] Marchisio P, Picca M, Torretta S, et al. Nasal saline irrigation in preschool chil- 1):1023–8.
dren: a survey of attitudes and prescribing habits of primary care pediatricians [18] Djupesland PG, Lyholm B. Changes in nasal airway dimensions in infancy. Acta
working in northern Italy. Ital J Pediatr 2014;40:47. Otolaryngol 1998;118(6):852–8.
[15] Jeffe JS, Bhushan B, Schroeder Jr JW. Nasal saline irrigation in children: a study of [19] Liukkonen K, Virkkula P, Pitkaranta A. Acoustic rhinometry in small children.
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