Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Should EMS Use Nasotracheal Intubation

At EMT-Medical Student, Joe Paczkowski writes about nasotracheal intubation and independent judgement.

In case you haven’t heard yet, California is working towards officially introducing (pdf) (underlined is new legislation. . . . the following line from the proposed Critical Care Paramedic scope of practice struck me as odd.

“1. perform digital and nasotracheal intubation;” -pg 11

Wait, shouldn’t the scope of practice (albeit the basic scope of practice for all paramedics) be “intubation?”[1]

Welcome to California, where reality isn’t. Of course you could state the same thing about most other states.

Some of you are saying, Of course, nasotracheal intubation is dangerous, so restriction is appropriate. What if someone put the tube in the brain of a trauma patient?

What if the patient is not a trauma patient? Should the majority of our medical patients have their airway management choices limited because of the possibility of trauma, specifically a basilar skull fracture?

That would be silly.

But, is a basilar skull fracture really an appropriate contraindication for nasotracheal intubation?

At the end of the day, we seek an answer to the question: “Is nasotracheal intubation contraindicated in the presence of severe facial or skull trauma?” and the answer is an unequivocal “No.” As with all procedures performed on patients in our emergency care systems, adherence to proper technique is essential. The progressive and systematic shift from BNTI to rapid sequence intubation will eventually render the question moot in all but a very small number of cases.[2]

Is this too vague?

the answer is an unequivocal “No.”


▸ adjective: admitting of no doubt or misunderstanding; having only one meaning or interpretation and leading to only one conclusion (“Unequivocal evidence”)
▸ adjective: clearly defined or formulated (“The plain and unequivocal language of the laws- R.B.Taney”)[3]

leading to only one conclusion

And that conclusion is that nasotracheal intubation is safe in the presence of severe facial or skull trauma as long as proper technique is used.

Of course, Dr. Ron Walls is only describing BNTI as performed by doctors.

Although properly conducted rapid sequence intubation is undoubtedly a superior technique for airway management in the acutely traumatized patient, BNTI continues to be used in many prehospital and hospital systems.[2]

At no point does Dr. Walls suggest that he is excluding EMS from his conclusion that BNTI is safe in the presence of severe facial or skull trauma.

Maybe this Dr. Walls just doesn’t understand airway management.

Amazon has several of his books, including the Manual of Emergency Airway Management, the manual for the National Emergency Airway Course. Go read the reviews (the only negative review is that the one reviewer did not think the images were clear enough).[4] What about research? Dr. Walls has dozens of airway research articles listed at PubMed.[5]

Why do I spend any time on who Dr. Walls is? Because this conclusion is not easy to demonstrate through research. There are not large numbers of BNTIs to study to demonstrate a clear complication level. He does mention that the only 2 papers documenting intracranial placement of a nasotracheal tube (BNTI in the brain) both indicated very poor technique.

it remains a mystery as to how the endotracheal tube could have been inserted with such a severely cephalad orientation when the technique of nasotracheal intubation requires insertion of the tube virtually perpendicular to the coronal plane of the patient.[2]

Cephalad means toward the top of the patient.
Perpendicular to the coronal plane means straight back.
You have to turn 90 degrees from one to the other. Up is wrong. Straight back is correct.

For those who put a lot of faith in credentials, does it help that Dr. Walls is Chief of Emergency Medicine at Harvard?

Furthermore, provided standard concerns are met like maintaining oxygenation, isn’t the goal of putting an appropriately sized tube into the slightly larger (and correct) tube, and the ensuing confirmation, more important than how that is achieved?[1]

Absolutely, but this is based on ignorance and fear, not on doing what is best for the patient.

Why is the skill of direct laryngoscopy more important and sacred than the intervention of intubation when other skills can achieve the same goal? Furthermore, if paramedics cannot be trusted to pick the correct mechanical skill when providing the intervention of intubation, what does that say about paramedics, and why are paramedics not fighting back?[1]

There are plenty of paramedics who should not be allowed to intubate, but as long as we have EMS organizations that do not have competent and aggressive oversight from their medical director(s), this will continue.

Maybe we need to publicize bad airway management to ridicule the medical directors and the organizations that allow dangerous medics to attempt intubation.

For some, concern for their patients does not appear to be motivation enough.


[1] Independent Judgement
EMT-Medical Student

[2] Blind nasotracheal intubation in the presence of facial trauma–is it safe?
Walls RM.
J Emerg Med. 1997 Mar-Apr;15(2):243-4. No abstract available.
PMID: 9144068 [PubMed – indexed for MEDLINE]

[3] Unequivocal
OneLook Dictionary Search

[4] Manual of Emergency Airway Management

[5] “Walls RM”[Author]
Author Search – 79 results as of 9/27/2011



  1. Besides the problem associated with making protocols laws to legistlate judegment…here’s my take on BNTI.

    In 10 years I’ve done it twice. Knowing what I know now, I would not have, because we could have ventilated both patients with a BVM until we got to the hospital.

    BNTI should be considered right before crich. In a true can’t ventilate situation, where there is no access to the patient’s mouth for a King/Combi/LMA, BNTI is the next best option. Dr. Levitan, the Airway Cam guy, discussed a case where he used it on a patient he did not feel comfortable intubating orally. If you have problems with it, you still have access to the patient’s neck to crich.

    There is a very small niche of patients who would benefit from BNTI, and I would hate to see it taken away by California’s legal system.

  2. I’ve used nasal intubation numerous times through the years. I like it. I like to think that BNTI is more idiot proof than standard ETI, but that may just be wishful thinking (along with having worked in a burn center for a while).

    I would not hesitate to use BNTI as opposed to a crich. I’m not sure how you can equivocate the two. The mere thought of some of the medics out there trying to perform a crich has got to make some attorneys very, VERY happy.