Excellent question. One area which may extend the functional life of NTI as a skill set is its potential application the enlarging (pardon the pun) population of bariatric patients. When these folks require endotracheal intubation for airway and ventilatory support, their placement in the traditional recumbent position is risky due to pathophysiological consequences of their "Pickwickian" body habitus.

I wonder whether early intervention (prior to respiratory arrest) using NTI might provide a viable option? Fertile ground for clinical investigation, says I!

As anesthesiologists we are viewed as experts in airway skills and that necessary skill set cannot be over emphasized. Our difficult airway algorithm has been revisited again and again with new and effective changes to rescue us from disastrous situations. Thanks to Dr Archie Brain. I still remember one of mentors teaching me blind nasal intubation.

In todays practice, the only place that i can think of NTI being done might be in pediatrics, of course with few exceptions on the adult side. NTI for longer duration might pose more problems than good, but can`t back it up with evidence base.

So the question " saving NTI", useful skill set for perioperative practice, for ICU we need clinical investigation.

Of course OROTRACHEAL intubation (OTI) with RSI is the gold standard for the perioperative period and many patients admitted in the ICU’s, but NTI may be useful in case of a priori six to ten days of mechanical ventilation such as COPD requiring intubation or pneumonitis (60% of the mechanical ventilation days in medical ICU’s). Furthermore, when patient’s conditions improved and awake, NTI induces less agitation and largely documented less unplanned extubation.

Using EBM, nobody can argue which is the best route for long duration mechanical ventilation.

Unfortunately NTI is no more taught, thus young ICU’s physicians, except anesthesiologists and pneumologists, had never performed ….

Controlled randomized trial to compare NTI to OTI may be warranted, but before “old intensivists” should teach NTI technic.

So when teaching we may save NTI?

As someone who works in a non sterile environment I can imagine some instances where it may be beneficial over a surgical airway. It is a relatively simple maneuver and should be taught and practiced even if never utilized.

I perfectly agree with the personal comment of GS Rao.Orpoharyngeal clerance is much easier with NTI, and in some patients eating is possible....Unfortunately, according to the suspicion of paranasal sinutis and nosocomial pneumonitis, not EBM demonstrated , NTI was considered an "old route for old intensivists"...Of course a well CRT is required, but before, "youngs" have to learn how to practice NTI to avoid initial complications

I disagree on the higher risk of sinusitis. Indeed in all randomized trial the difference never reached a significant value. Thus, we have to reconsider our negative point of vue of NTI.

This is a very good question. We use NTI for several years. It was a safe and effective way to manage airway and to perform oral care. Also, it seems to be more comfortable for patients. Nevertheless, ease of training with orotracheal intubation (OTI), doubts about increase of infectious complications with NTI and nasal pressure ulcers with NTI were the main causative factors for increase in use of OTI. Probably, we need to revise this practice now.

The entire problem about the safety of NTI is the high suspicion of nosocomial sinusitis and/or pneumonitis.

If we analyze very cautiously the series were the intubation route was randomized and in which sinusitis was defined not only by radiographic evidence but also by 10(3) CFU/ml on sinus puncture material, Holzapfel et al observed no difference (p=.75) between the nasal and oral route ( Crit Care Med 1993, 21; 1132-8). Nosocomial pneumonitis incidence was higher in case of NTI but was not significantly different from OTI’s one (p=.11). Thus, nosocomial infectious adverse events during NTI appear identical to those of OTI

To revise this practice, we need to be convinced,

First, that NTI may be useful in the ICU for some patients which may require long MV, and is more comfortable during the awake period;

Second, that there is no evidence about the BEST route for tracheal intubation for ICU’s adult patients mechanically ventilated;

Third that we have to discuss with all the ED and ICU postgraduates, about the indications, complications during tube placement (largely preventable), advantages (no need to use tube guard…) of blind NTI and to teach the procedure.

To avoid bias in an expected RCT (Nasal vs Oral intubation in long VM duration), I believe that all ICU’s postgraduate and all intensivists should be trained and familiar with NTI technic, but…it may be a wishful thinking.

• Its a very good question. Now a days, in today's Anaesthesiologists blind nasal intubation (BTI) is a dying art. Its a great technique in the armamentarium of anesthesiologist specially in the scinario of NIL mouth opening and there is a lack  of advanced airway gadgets ( FOB ) at your centre. In some of Asean countries, even now FOB is not available in 60-70 % teaching Hospital. In the given scinario, it becomes  a greatly useful technique.