Case report: nasotracheal intubation--look before leaping to assess the laryngeal view

To describe an airway management plan, including oral to nasal endotracheal tube exchange, when nasal intubation is required in the unanticipated difficult airway.

A nasal intubation was required for a patient undergoing oropharyngeal surgery. Following loss of consciousness and paralysis, a Cormack-Lehane class 3 view was obtained, and pressure over the thyroid cartilage failed to reveal the vocal cords. An Eschmann bougie was inserted into the oropharynx and blindly entered the trachea. An orotracheal tube was advanced into the trachea over the bougie, and the patient was ventilated with 100% O2 following the bougie's removal. An endotracheal tube was then guided through the right nostril into the hypopharynx. An Eschmann bougie was inserted into the nasal tube, and advanced towards the glottic opening under laryngoscopic view. Digital pressure applied to the oral tube at the base of the tongue brought the vocal cords into view. The oral endotracheal cuff was deflated, and the bougie (inserted into the nasal tube) was advanced into the trachea alongside the orotracheal tube. The orotracheal tube was withdrawn, and the nasal tube was advanced into the trachea over the bougie. The patient's O2 saturation and end-tidal CO2 concentration remained at 99-100% and 30-33 mmHg, respectively, during these maneuvers, which required only a few minutes to perform.

When nasotracheal intubation is required, a plan of airway management is required to safely secure the airway. We emphasize the importance of direct laryngoscopy prior to insertion of an endotracheal tube through the nose, and describe a strategy for oral to nasal tracheal tube exchange.