NAVEL Mnemonic: Drugs for Endotracheal Tube Administration

In emergency situations where intravenous (IV) access is unavailable or delayed, intratracheal instillation provides a lifesaving alternative for drug administration. However, not all medications can be delivered through an endotracheal tube, which is why respiratory therapists, paramedics, and critical care providers must remember the NAVEL mnemonic.

This simple acronym helps healthcare professionals quickly recall which drugs can be safely instilled into the trachea during resuscitation or life-threatening events.

Understanding the indications, dosing adjustments, and administration techniques for these medications is essential for effective emergency airway management.

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What is Intratracheal Instillation?

Intratracheal instillation is the process of delivering medications directly into the trachea via an endotracheal tube (ETT). This method is primarily used in cardiac arrest and critical care scenarios when IV or intraosseous (IO) access is unavailable.

Although IV administration is the preferred route for emergency drugs due to its rapid systemic absorption, ET instillation serves as a backup option to ensure that critical medications can still be delivered. Drugs administered through the ET tube are absorbed through the alveolar-capillary membrane and enter the bloodstream, though at a slightly slower rate than IV medications.

What Does NAVEL Stand For?

NAVEL is a mnemonic used to remember the five medications that can be administered via intratracheal instillation in emergency situations when intravenous (IV) or intraosseous (IO) access is unavailable.

NAVEL Stands For:

• N – Naloxone (Narcan) – Reverses opioid overdose.
• A – Atropine – Treats bradycardia by increasing heart rate.
• V – Vasopressin – Used as an alternative to epinephrine for vasoconstriction during cardiac arrest.
• E – Epinephrine – First-line drug for cardiac arrest and anaphylaxis.
• L – Lidocaine – Used for ventricular arrhythmias, such as ventricular tachycardia (VT) and ventricular fibrillation (VF).

Note: By memorizing NAVEL, healthcare providers can quickly recall which medications are safe for endotracheal administration in critical situations.

Medications Approved for Intratracheal Instillation

To simplify drug selection for ET administration, healthcare providers use the NAVEL mnemonic, which stands for:

1. Naloxone (Narcan) – Reversal Agent for Opioid Overdose

• Indication: Used to reverse respiratory depression and sedation caused by opioid overdose.
• Mechanism of Action: Naloxone is an opioid antagonist that rapidly blocks opioid receptors, restoring normal breathing.
• Common Scenario: A patient in respiratory arrest due to opioid toxicity when IV access is not immediately available.

2. Atropine – Treatment for Bradycardia

• Indication: Used to increase heart rate in cases of symptomatic bradycardia or asystole.
• Mechanism of Action: Atropine is an anticholinergic that blocks the vagus nerve’s effects on the heart, leading to an increase in heart rate.
• Common Scenario: A patient experiencing severe bradycardia with hemodynamic instability.

3. Vasopressin – Alternative to Epinephrine for Vasoconstriction

• Indication: Used during cardiac arrest as an alternative to epinephrine to improve blood pressure and circulation.
• Mechanism of Action: Vasopressin is a vasoconstrictor that increases peripheral vascular resistance, improving blood flow to vital organs.
• Common Scenario: A patient in pulseless cardiac arrest where IV administration is delayed.

4. Epinephrine – First-Line Drug for Cardiac Arrest

• Indication: Used in cardiac arrest, anaphylaxis, and severe hypotension.
• Mechanism of Action: Epinephrine is a beta-adrenergic agonist that increases heart rate, cardiac output, and blood pressure while promoting bronchodilation.
• Common Scenario: A patient in asystole, ventricular fibrillation (VF), or pulseless electrical activity (PEA) requiring immediate resuscitation.

5. Lidocaine – Antiarrhythmic for Ventricular Dysrhythmias

• Indication: Used to treat ventricular tachycardia (VT) and ventricular fibrillation (VF).
• Mechanism of Action: Lidocaine is a sodium channel blocker that stabilizes cardiac membranes and reduces ectopic ventricular activity.
• Common Scenario: A patient in VF or VT that is resistant to defibrillation.

Administration Guidelines for Intratracheal Instillation

When administering medications through an endotracheal tube, specific dosage adjustments and techniques must be followed to ensure drug effectiveness:

• Increase the Dose: Medications administered via ET instillation require 2 to 2.5 times the standard IV dose to achieve therapeutic effects.
• Dilution is Required: The drug should be diluted with 10 mL of sterile saline or sterile water to aid in distribution within the lungs.
• Proper Delivery Method: After administration, manual ventilation should be provided using a bag-valve mask (BVM) or ventilator to ensure the drug reaches the lower airways and is absorbed effectively.
• Use ET Instillation as a Last Resort: While ET administration is an option, IV and intraosseous (IO) routes are preferred whenever possible for faster drug absorption and effectiveness.

Additional Consideration: Exogenous Surfactant for Neonates

While not part of the NAVEL mnemonic, another important medication administered via direct tracheal instillation is exogenous surfactant.

• Indication: Used to treat neonatal respiratory distress syndrome (RDS) in premature infants who lack sufficient surfactant.
• Administration: Delivered directly into the trachea via an endotracheal tube to improve lung compliance and oxygenation.

Key Takeaways

• The NAVEL mnemonic helps recall which drugs can be given via ET instillation: Naloxone, Atropine, Vasopressin, Epinephrine, and Lidocaine.
• ET administration is used in emergencies when IV/IO access is unavailable.
• Doses must be increased (2 to 2.5 times the IV dose) and diluted with 10 mL of saline or sterile water.
• Manual ventilation is necessary after drug instillation to ensure absorption.
• Exogenous surfactant is also administered via direct tracheal instillation in premature infants with respiratory distress syndrome (RDS).

Note: Understanding when and how to use ET drug administration is critical for respiratory therapists, paramedics, and critical care providers. By memorizing the NAVEL mnemonic and key administration principles, healthcare professionals can make quick, life-saving decisions in emergency situations.

Final Thoughts

Intratracheal instillation is a vital emergency technique used when intravenous or intraosseous access is unavailable. The NAVEL mnemonic—Naloxone, Atropine, Vasopressin, Epinephrine, and Lidocaine—provides a simple yet effective way for healthcare professionals to recall which medications can be safely administered via an endotracheal tube.

While ET drug delivery can be lifesaving, it requires proper dosage adjustments, dilution, and ventilation techniques to ensure effectiveness. Additionally, exogenous surfactant plays a crucial role in neonatal care and is another important medication delivered via direct tracheal instillation.

Understanding the indications, mechanisms, and administration guidelines for these drugs is essential for respiratory therapists and critical care providers to respond effectively in high-stress, life-threatening situations.