Nasal intubation is a rarely required emergency intubation technique and it is much less frequently used now than it was before the widespread use of muscle relaxants.  Within an algorithm for emergency airway management it is always performed in spontaneously breathing patients, never after the administration of muscle relaxants (rapid sequence intubation).  It can be ideal in patients with oral pathology (bypassing the mouth altogether) or in patients with short safe apnea times in whom rapid sequence intubation is being deliberately avoided. Nasal intubation using endoscopic (or fiberoptic) imaging is extremely valuable in emergency patients who have laryngo-tracheal pathology, such as burns, caustic injury, or laryngeal cancers.  Imaging allows assessment of these airways while the patient is spontaneously breathing and prior to attempted tube passage from above, In some of these cases it is preferable to establish a surgical airway below the level of the lesion as a primary means of airway management.

In patients with predicted difficult orotracheal intubation, and in those with mechanical issues about the tongue and mouth (i.e., angioedema, Ludwig’s angina, tongue hematomas, jaw fracture, etc.), going through the nose bypasses the mouth altogether.  Patients can be intubated using the nasal route while preserving spontaneous ventilation.  Depending upon the patient, availability of fiberoptic equipment, and the skills of the operator, nasal intubation is ideally done using endoscopic imaging. Problems that can prevent endoscopic (fiberoptic) imaging include copious blood, secretions, or vomitus, and lack of patient cooperation.  The later problem can be addressed with pharmacologic adjuncts, such as benzodiazepines, opioids, and low dose ketamine.  Blind nasal intubation has a distinctly valuable role in emergency settings when rapid sequence intubation is contraindicated, the oral route is unavailable (obvious oral pathology, clenched jaws, limited mouth opening) and when fiberoptics are unavailable or inappropriate.

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