Blind nasal intubation - NYSORA | NYSORA

Blind nasal intubation

Learning objectives

  • Describe the indications and contraindications for blind nasal intubation
  • Describe the technique for blind nasal intubation
  • Describe the possible repositioning actions and complications of blind nasal intubation


  • Blind nasal intubation was originally used in spontaneously breathing patients anesthetized with an inhalational agent, but has been modified for intubating awake patients, with or without sedation
  • Useful technique for patients with a difficult airway
  • Has been largely replaced by fiber-optic intubation, but remains a relevant and easy alternative when a fiber-optic scope is not available or fiber-optic intubation has failed
  • Indicated when there are structural abnormalities in the mouth or limited mouth opening

Indications & contraindications

  • Indications
    • Known difficult intubation or previous nasal intubation
    • Anticipated difficult intubation
    • After failed intubation in an unanticipated difficult airway
    • Known or suspected difficult mask ventilation
    • Unstable C-spine
  • Contraindications
    • Absolute
      • Patient refusal or inability to cooperate
    • Relative
      • Lack of trained personnel
      • Risk of impending airway obstruction
      • Coagulopathy or bleeding in airway
      • Allergy to local anesthetic
      • Base of skull fracture 



blind nasal intubation, airway anesthesia, lidocaine, sedation, vasoconstrictor, atlantoaxial joint, c-spine, epistaxis, polyps, nasotracheal tube, septum, bevel, inferior turbinate, hypopharynx, glottis, laryngeal inlet, trachea, laryngospasm, capnography, cuff

  • Clinical findings for tube repositioning to facilitate successful intubation:
PositionClinical findingsAction
TracheaBreath sounds through tube maintained as it is advanced, coughing through tubeConfirm ETCO2, bilateral air entry
AnteriorBreath sounds heard through tube but unable to advance further, bulge felt anteriorly at level of hyoid, coughing mostly through tubeWithdraw tube 2 cm, reduce neck extension or externally manipulate larynx before readvancing
Left/right piriform fossaNo breath sounds, unable to advance tube, no coughing, a bulge may be seen or palpated superio- lateral to larynxWithdraw tube until breath sounds return, rotate tube to midline or turn head towards bulge and readvance
EsophagusTube advances smoothly with loss of breath sounds, no cough, larynx elevatedWithdraw tube until breath sounds return and try the following maneuvers before readvancing:
• Head extension
• Cricoid pressure
• Inflate cuff with 15 mL of air to direct the tip anteriorly. Advance until resistance met, ensure breath sounds retained (at laryngeal
inlet), slowly deflate cuff while maintaining some advancing pressure on tube to enter trachea


  • General complications:
    • Oversedation
    • Respiratory depression
    • Airway obstruction
    • Apnea
    • Trauma
    • Bleeding
    • Laryngospasm
    • Vomiting
    • Local anesthetic allergy
    • Toxicity
    • Risk of aspiration due to loss of laryngeal reflexes
  • Specific complications related to nasal route
    • Epistaxis
    • Turbinate or polyp fracture
    • Retropharyngeal laceration
    • Retropharyngeal abscess and mediastinitis
    • Intracranial placement in basal skull fracture and pneumocephalus
  • Specific complications related to blind technique:
    • Airway trauma from multiple intubation attempts
    • Obstruction caused by the epiglottis being pushed into the glottic opening
    • Esophageal intubation

Suggested reading

  • Pollard BJ, Kitchen, G. Handbook of Clinical Anaesthesia. Fourth Edition. CRC Press. 2018. 978-1-4987-6289-2.

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