Refining the Clinical Pathway for Nasotracheal Intubation: An Updated Decision Making Algorithm

Nasotracheal Intubation (NTI) is a common route of airway management in many situations. Over the years, numerous techniques and approaches have been described in performing NTI safely and effectively, including many innovative techniques being published in recent years. However, there hasn't been a summary of the recent approaches to NTI, especially in an easy, clinically applicable decision making format. In fact, the last algorithmic approach to nasal intubation in the literature was published in 2008. This comprehensive review details an updated analysis of NTI techniques along with a new adapted algorithmic outline to approach NTI in a methodical and stepwise manner. There is also an extensive review of techniques to control epistaxis, which is the most commonly encountered complication during NTI. The newly adapted NTI algorithm simplifies the initial approach to three options: Routine Asleep NTI, Awake NTI, and an Initial Orotracheal Intubation (OTI) followed by Conversion to NTI. Older techniques, such as blind NTI, flexible intubation scope guided, "look before you leap" approach and cuff inflation technique, are discussed along with incorporation of newer techniques, such as videolaryngoscope guided, hybrid, alignment approach, and OTI to NTI conversion. Uniquely, this manuscript reviews all published techniques for converting OTI to NTI and categorizes them into two pathways: direct conversion (with glottic visualization) or indirect conversion (without glottic visualization). Furthermore, original animated videos have been created and attached to help elucidate these conversion techniques visually.