This episode delivers a deep dive into awake nasotracheal intubation / nasal intubation with a bronchoscope. We cover when to choose the nasal route, how to prepare the patient and equipment, and how to avoid common pitfalls. We break down nostril selection, airway preparation, tube and scope choice, pharmacologic adjuncts, topical anesthesia techniques, and operator positioning. Practical pearls cover managing limited tube lengths, minimizing complications, and ensuring safety. Listeners will leave with a step-by-step framework for successful, atraumatic nasal fiberoptic intubation in high-acuity settings. In a future episode we will go through oral bronchoscopic intubation as well.
When to Go Through the Nose
When you can’t go through the mouth
Airway Cart
A bunch of very specific stuff is needed. It is much easier to have a dedicated place with all of the equipment for awake intubations of all varieties.
Do not improvise or half-ass
Prep
Which Nostril
Occlude one nostril and listen to inhalation and exhalation
When in doubt, go for the right to get faster intubation and lower epistaxis rates[doi: 10.1097/EJA.0000000000001462]
Decide Tube First or Scope First
Place a Nasal Airway – Slit or Non-Slit
Sunmed Adjustable Flange Nasopharyngeal Airways
24 F or 26 F
Usually Stocked are the 18 F
Use the nasal airway for applying the Lidocaine Ointment
Put a slit into the airway if you don’t want to go tube first
Hook Knives
What Tube?
Most tubes get shorter as their ID size decreases
In the Shiley the 6.5 is just as long as the 8.0, but drops dramatically at size 6.0
In the Rusch line, they get progressively smaller all the way down
For Men, you generally need at least 28-30
For Women, 26-28
Estimating formula: Depth at nares (cm) ≈ (Patient height in cm ÷ 10) + 6–7
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Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
