Paramedics putting a patient in an ambulance - nasotracheal intubation do's and don'ts


The call came in as a patient being unresponsive. You arrive on scene to find an elderly woman, hunched in her wheelchair, semiconscious, with labored breathing. She has a history of stroke, and by the drooping appearance of her left side, which her family states is not normal, it appears she has had another.


Your first concern is her airway. Her O2 saturation is 89 percent, so you place her on a non-rebreather mask at 15 liters. Intubation appears imminent. The problem is, she has a debilitating kyphosis, which means placing her supine for intubation is going to be impossible. Your second choice? Nasotracheal intubation.

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Nasotracheal intubation is not a skill that is practiced with regularity. Because of that, many paramedics are hesitant to proceed. So, let's return to our patient and walk through the various do's and don'ts of nasotracheal intubation.


First, the advantages. Nasotracheal intubation provides a secure airway for patients who are breathing on their own, preventing aspiration of blood, vomit, or sputum. It is better tolerated than oral intubation in the patient who is semiconscious and is a good alternative if the patient is unable to open his or her mouth, is morbidly obese, or is unable to lay supine.


The disadvantages include possible damage to the delicate nasal tissues, the patient must be spontaneously breathing, and it is contraindicated in patients with possible basal skull fractures or facial trauma. Despite these disadvantages, it is a good alternative to oral intubation.


When to Intubate

Before you decide on intubation, you must first assess your patient to determine if he or she meets the criteria. A useful technique is to distinguish whether your patient is in respiratory distress versus failure. Generally, a patient in distress may exhibit the following signs and symptoms:

  • Mild anxiety
  • Normal LOC
  • Minimal cyanosis
  • Tachycardia with possible chest tightness
  • Abnormal breath sounds
  • Decreased O2 saturation


The patient in respiratory failure, on the other hand, needs immediate intervention and will exhibit the following:

  • Decreased level of consciousness
  • Use of accessory muscles or retractions
  • Tachycardia >130 bpm
  • Decreased O2 saturation, even with oxygen therapy
  • Pale skin and cyanosis
  • Diaphoresis
  • Absent breath sounds or abnormal respiratory patterns
  • Unable to speak due to dyspnea


Proceeding with Nasotracheal Intubation

You've determined your patient is exhibiting impending respiratory failure and decide nasotracheal intubation is your best option. Prepare the patient and your equipment, just as you would before oral intubation¹:

  • Pre-oxygenate the patient by placing him or her on a non-rebreather mask at 15 liters per minute.
  • If time permits and local protocols allow, apply a topical anesthetic such as 4 percent lidocaine mixed with a vasoconstrictor (0.25 percent phenylephrine or oxymetazoline) spray to the nasal mucosa. This will make tube insertion more comfortable for the patient and reduce bleeding.
  • Position the patient in the “sniffing” position with the proximal neck slightly flexed and the head slightly extended.
  • Inspect the nose and select the larger nostril as your passageway.
  • Assemble and check your equipment. Lubricate the distal end of a 7.0 cm or 7.5 cm nasotracheal tube. Check the cuff. Ensure that the plastic flange on the proximal end is securely fastened to the nasotracheal tube.
  • Insert the nasotracheal tube into the nostril with the flanged end of the tube facing the nasal septum. Gently guide the tube in the anterior-to-posterior direction (the angle should be parallel to the roof of the mouth).
  • As the tube is felt to drop into the posterior pharynx (at approximately 10 cm to 15 cm), listen closely to the patient’s breath sounds. Using the trigger found on the nasotracheal tube and gentle rotation, manipulate the tube until it’s positioned such that breath sounds are loudest.
  • When the patient inspires, pass the nasotracheal tube through the vocal cords. The patient may gag or cough.
  • Inflate the cuff with 5 mL to 10 mL of air.
  • Confirm tube placement (listen for bilateral breath sounds, lack of gastric sounds, and end-tidal CO2).
  • Secure nasotracheal tube (typically around 28 cm at the nare for men and 26 cm for women).


Keep the Suction Handy!

As with oral intubation, you want to have suction at the ready. If the patient has an altered LOC, he or she cannot protect his or her airway, so stay alert for critical suction scenarios that may develop in the semiconscious patient. By incorporating your portable suction unit into your airway bag or storing it next to other ALS equipment, you will always have it on hand when needed. There's never time to run back to the truck to retrieve the suction. Arrive prepared!


Once you know the do's and don'ts of nasotracheal intubation, you can approach the procedure with confidence. Nasotracheal intubation is a great alternative to the oral route. Just be sure your patient meets the criteria, have your equipment ready, and keep the portable suction unit nearby, just in case.


Editor's note: This blog was originally posted in Nov 2017, it has since been updated with new content. 


¹ 2013, Johnson, NJ and ET Dickinson

Swollen Tongue Necessitates Nasotracheal Intubation, JEMS online,