Contributor: Alec Coston, MD

Educational Pearls:

What are nasal intubations and when do we use them?

Nasal intubations function similarly to oral intubations with the end goal of passing an endotracheal tube (ETT) through vocal cords and into the trachea to allow for a patent and secure airway, but differ in the main access point for the ETT (nare v.s. mouth).
Nasal Intubations are seldom preferred to oral intubations as they carry risk for inducing bleeding from trauma to the nasal passages.
Indications for nasal intubations include:

Anatomical abnormalities that may make access through the mouth difficult (i.e. tumors, macroglossia, or rare dental hardware that clenches the jaw shut).
Physiological states such as severe angioedema.

Nasal intubations are often done with the patient awake and could be advantageous if the patient is presenting in a severely hypoxic state such that prolonged hypoxia in a traditional RSI protocol may be detrimental.
A 2023 retrospective analysis in Germany found that nasal intubations were associated with requiring less sedation than oral intubations and had more spontaneous breathing during hospitalization than oral intubations.

How is a nasal intubation performed?

Consider the use of an anxiolytic medication such as versed to calm the patient down but not fully sedate them.
If there is adequate time without immediate patient compromise, consider glycopyrrolate to reduce airway secretions and dry up the mucous membranes.
Consider the use of Afrin or other local vasoconstrictor in target nare to minimize epistaxis.
Use 5% lidocaine ointment and lubricate an NPA and place it into the target nare. This will allow for local anesthesia as well as help to open up the nare slightly more.
Take 5% lidocaine ointment and place it on a tongue depressor and move it around the back of the tongue, allowing it to further anesthetize the oropharynx.
Remove the NPA and atomize/nebulize 4% lidocaine liquid into the nare and into the oropharynx for further anesthesia.
Insert the ETT without the bronchoscope through the nare and allow it to pass about 10 cm until visible in the oropharynx. This allows for a "clean" plastic tunnel to pass the bronchoscope through.
Advance both the ETT and bronchoscope, spraying lidocaine through the bronchoscope while advancing to allow for continued numbing.
Pass the ETT through the cords and inflate.
At this point, stronger sedation medications such as ketamine and propofol may be considered but the use of a paralytic like succinylcholine and rocuronium may not be needed to allow the patient to maintain their own negative pressure ventilation.

Which nare is the best to go through?

Most patients will have their right nare be the best (away from the septal deviation) according to a meta-analysis by Tan et al.
The right nare was generally associated with less epistaxis and lower intubation times.
However, do not always default to the right nare, and test which nare is more patent by occluding one nare at a time and assessing which one is less resonant (less resonant = more patent).

Key Takeaway?

Nasal intubations are rarer than oral intubations and can be more technically difficult, but may offer advantages in patients with difficult oral airways, but should never be first line.

References:

Grensemann J, Gilmour S, Tariparast PA, Petzoldt M, Kluge S. Comparison of nasotracheal versus orotracheal intubation for sedation, assisted spontaneous breathing, mobilization, and outcome in critically ill patients: an exploratory retrospective analysis. Sci Rep. 2023;13:12616. doi:10.1038/s41598-023-39768-1
Tan YL, Wu ZH, Zhao BJ, Ni YH, Dong YC. For nasotracheal intubation, which nostril results in less epistaxis: right or left?: A systematic review and meta-analysis. Eur J Anaesthesiol. 2021;38(11):1180-1186. doi:10.1097/EJA.0000000000001462
Holzapfel L. Nasal vs oral intubation. Minerva Anestesiol. 2003;69(5):348-352.

Summarized by Dan Orbidan, OMS2 | Edited by Dan Orbidan & Ahmed Abdel-Hafiz, NREMT-P