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Nasotracheal intubation involves insertion of an endotracheal tube through the nose and into the trachea. It is possible only on patients with intact respiratory efforts: for example, individuals with congestive heart failure or acute pulmonary edema. The approach may be possible for patients who cannot lay supine: for example, patients entrapped after a motor vehicle collision. In contrast with orotracheal methods, nasotracheal intubation is often possible in awake patients and those with intact gag reflexes or trismus.

Successful nasotracheal intubation requires a skilled and experienced operator. The rescuer chooses an endotracheal tube one‐half size smaller than customary for orotracheal intubation, inserting the tube into the nares without a stylet, and directing the endotracheal tube inferiorly and anteriorly toward the vocal cords. We recommend first entering the right nostril, which is often larger than the left nostril. The rescuer coordinates insertion of the tube through the vocal cords with patient inhalation. The nasal passage may be dilated by initially inserting a nasal airway for several minutes prior to attempting tracheal tube placement. The nasal airway is then removed prior to placing the tube.

The Endotrol endotracheal tube has a special trigger device that provides directional control of the tip, flexing it to facilitate its correct trajectory toward the larynx as the tube is advanced [32]. A potentially helpful adjunct is the Beck Airway Airflow Monitor (BAAM^®; Great Plains Ballistics, Lubbock, Texas). When placed on the connector end of the endotracheal tube, the device “whistles” as air is exhaled though the endotracheal tube approaching vocal cords. Important complications associated with nasotracheal intubation include nasal trauma and epistaxis, sinusitis (which may cause sepsis), and perforation of the cribiform plate with subsequent intracranial placement [33–37].