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Scholarly Commons > HCA Healthcare Journal > Vol. 6 > Iss. 1 (2025)

 

Keywords

acute hypoxemic respiratory failure; awake intubation; blind nasal intubation; emergency intubation; oxymetazoline; pneumonia; trismus

Disciplines

Anesthesiology | Emergency Medicine

Abstract

Background

Airway management in emergency situations poses significant challenges, particularly in patients with difficult airway anatomy or comorbid conditions. Blind nasal intubation has been explored as a rescue technique when conventional methods fail. Masseter muscle rigidity (MMR), characterized by significant jaw muscle stiffness, is a recognized complication following succinylcholine administration that can complicate traditional approaches to securing an airway.

Case Presentation

A 75-year-old man with multiple comorbidities, including hypertension, prior stroke with paralysis, dementia, and a seizure disorder, presented with acute hypercapnic hypoxemic respiratory failure requiring emergent intubation. Orotracheal intubation failed due to trismus despite etomidate, succinylcholine, and rocuronium. Nasal fiberoptic intubation was unsuccessful, leading to blind nasal intubation as a rescue technique using oxymetazoline and surgical lubricant, successfully guided by breath sounds. Oxygen saturation remained stable, but post-intubation imaging revealed a right-sided tension pneumothorax which was subsequently managed via percutaneous decompression.

Conclusion

This case underlines the efficacy of blind nasal intubation as a rescue strategy in challenging airway management scenarios, particularly when conventional methods fail. While not the gold standard, blind nasal intubation offers a feasible alternative, especially in cases of limited mouth opening or compromised airway anatomy. This approach is also less invasive and requires fewer logistical resources than surgical cricothyrotomy, which typically necessitates an operating room and an ear, nose, and throat specialist.

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