Preparation, patient position, and equipment are the same as for endotracheal intubation. Cocaine paste may be applied to the nasal mucosa beforehand if desired. After induction and neuromuscular blockade, the tube is passed carefully through the nostril. There may be some obstruction to the passage in the nasopharynx. This can usually be overcome by rotating the tube as it is gently advanced. Laryngoscopy is then performed and the tube advanced under direct vision. It may pass into the trachea unaided. If not, Magill's forceps can be used to grasp the distal end of the tube and direct it into the trachea. The cuff is then inflated and the procedure continued as before.
For blind nasal intubation the tube is passed though the nares as before and, while it is advanced, the intubator should observe the anterior neck. If the tube impinges in either pyriform fossa, the indentation can be seen. The tube is withdrawn, rotated to the opposite side, and advanced again. If the tube passes easily it will be in either the trachea or the esophagus; this can be differentiated by auscultation and/or capnography. If the tube appears to catch anteriorly in the midline, it is probably against the anterior part of the cricoid or in the vallecula; the patient's head should then be extended further if possible, and the tube withdrawn and advanced again.
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