Nasotracheal intubation is a relatively simple procedure that
is performed rapidly without the aid or risks of neuromuscular blockade.1 This
method of intubation is sometimes favored in difficult airway cases,
especially when oral access is limited or impossible. Such conditions
include trismus, oral injuries, and obstructive oral processes such
as angioedema. Nasotracheal intubation is also the method of intubation
preferred by some authors for acute epiglottitis.2
Nasotracheal intubation is well tolerated by most patients and
produces less reflex salivation than orotracheal intubation, thus
leading to fewer attempts at self-extubation. The nasotracheal tube
is more easily stabilized and is generally easier to care for than
an orotracheal tube. This method prevents biting of the tube by
the patient and manipulation by the patient’s tongue.2,3
Nasotracheal intubation is indicated
in any patient with spontaneous respirations, especially those whose
period of intubation is anticipated to be brief.1–3 It
is indicated in patients who are unable to lie supine due to respiratory
distress from severe asthma, chronic obstructive pulmonary disease
(COPD), or congestive heart failure. It is also indicated in patients
who are unable to open their mouths due to facial trauma, mandibular
trauma, or trismus. Nasotracheal intubation can be performed in
patients with limited airway patency due to obstruction from neoplasm
or tongue swelling. Nasotracheal intubation is an appropriate method of
intubation in patients who require neck immobilization for suspected
cervical spine injuries as well as patients who are unable to move
their necks due to cervical kyphosis, severe arthritis, or post-radiation
fibrosis. Because they are often intubated for a short time, patients
with severe alcohol intoxication or drug overdose whose level of
consciousness is decreased are good candidates for nasotracheal
intubation.1–3 Nasotracheal intubation may be
performed in patients who have contraindications to paralytic agents.
Nasotracheal intubation is contraindicated in patients with apnea,
severe facial or maxillofacial fractures, basilar skull fractures,
head injury with an elevated intracranial pressure, nasal or nasopharyngeal
obstruction, patients receiving thrombolytics or parenteral anticoagulants,
and in the presence of a coagulopathy.1–3 It is
also contraindicated in patients with neck injuries, as the procedure
may increase morbidity and mortality.
Nasotracheal intubation should not be performed in neonates,
infants, or young children. The more anterior and cephalic position
of the airway in these age groups makes blind passage of an endotracheal
tube almost impossible. A patient must provide a degree of cooperation
during the procedure. A crying, kicking, and struggling child who
must be restrained is not a candidate for nasotracheal intubation.
- Nasal mucosa vasoconstrictor (4% cocaine, oxymetazoline,
- Nasal mucosa anesthetic (viscous lidocaine, cocaine, benzocaine
spray, xylocaine spray)
- Nasopharyngeal airways, multiple sizes
- Laryngoscope handle
- Laryngoscope blades, various sizes and types
- Endotracheal tubes, various sizes
- Endotrol tubes, various sizes (Mallinckrodt Medical, St. Louis,
- Magill forceps
- Suction apparatus
- Topical anesthetic (4% cocaine or 2% lidocaine
- Gauze strips
- Water-soluble lubricant or anesthetic jelly...
Log In to View More
If you don't have a subscription, please view our individual subscription options below to find out how you can gain access to this content.
Want remote access to your institution's subscription?
Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.
If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.
AccessEmergency Medicine Full Site: One-Year Subscription
Connect to the full suite of AccessEmergency Medicine content and resources including advanced 8th edition chapters of Tintinalli’s, high-quality procedural videos and images, interactive board review, an integrated drug database, and more.
Pay Per View: Timed Access to all of AccessEmergency Medicine
24 Hour Subscription $34.95
48 Hour Subscription $54.95
Pop-up div Successfully Displayed
This div only appears when the trigger link is hovered over.
Otherwise it is hidden from view.