Blind nasotracheal intubation (BNTI) remains a viable technique in the elective surgical patient and in emergency intubation, particularly for patients with challenging anatomy. In this procedure, an endotracheal tube (ETT) is placed through one of the nares into the nasopharynx (Fig. 18-1), then into the glottis, guided primarily by breath sounds, without visualization. At its best, it is a smooth, effective, and painless procedure. At its worst, BNTI is traumatic and uncomfortable and may make subsequent attempts at airway management more difficult by causing epistaxis or vomiting. BNTI requires preservation of spontaneous ventilation, so that audible inspiratory efforts can be detected and synchronized with tube placement. It is much less likely to be successful in the apneic patient. The breath sounds, when optimized, help to guide the tube into a position just above the glottis, so that controlled advancement of the tube allows correct placement. Whistles are available to attach to the end of the ETT to make ventilation through the ETT more audible, confirming placement of the tube in the airway. BNTI is less likely to be used in children than in adults, due to the lack of cooperation, the small size of the nares, and frequent hypertrophy of the adenoidal tonsils.

BNTI is supported anecdotally by case reports and case studies in both the emergency medicine and anesthesiology literature. In the National Emergency Airway Registry, this method was used in about 5% of all intubations, with a success rate of nearly 86%.¹ In Dronen’s² comparison of BNTI with direct laryngoscopy for intubations in the emergency department (ED), the 68% rate of successful endotracheal intubation was significantly lower than that for direct laryngoscopy, in which there were no failures. In addition, complication rates, mostly nasal bleeding and emesis, were much higher with BNTI. When paramedics used BNTI in 219 intubations, the rate of appropriate ETT placement improved from 58% to 72% when a directional tip control tube was used.³ BNTI in children is typically reserved for cases in which other methods of intubation are not feasible.⁴