Indian Journal of Critical Care Medicine
Volume 25 | Issue 3 | Year 2021

Video Laryngoscopy-guided Nasal Intubation: One More Bullet in Our Rifle

Alessio Cittadini1https://orcid.org/0000-0003-3944-9609, Federica Marsigli2https://orcid.org/0000-0002-3858-7914, Andrea Sica3https://orcid.org/0000-0002-8072-4492, Domenico P Santonastaso4https://orcid.org/0000-0003-1304-7724, Emanuele Russo5https://orcid.org/0000-0002-6531-5527, Emiliano Gamberini6https://orcid.org/0000-0001-9403-5244, Vanni Agnoletti7https://orcid.org/0000-0002-7595-2669

1–7Department of Anesthesia and Intensive Care, Maurizio Bufalini Hospital, Cesena, Emilia Romagna, Italy

Corresponding Author: Federica Marsigli, Department of Anesthesia and Intensive Care, Maurizio Bufalini Hospital, Cesena, Emilia Romagna, Italy, Phone: +39 3467386400, e-mail: federica.marsigli@gmail.com

How to cite this article: Cittadini A, Marsigli F, Sica A, Santonastaso DP, Russo E, Gamberini E, et al. Video Laryngoscopy-guided Nasal Intubation: One More Bullet in Our Rifle. Indian J Crit Care Med 2021;25(3):351.

Source of support: Nil

Conflict of interest: None

Keywords: Critical care, COVID-19, Fiberoptic bronchoscopy, ICU, Intubation.

To the Editor,

We appreciate the attention that the authors have addressed to the paper “Nasal intubation: A comprehensive review”,1 demonstrating how nasotracheal intubation (NTI) is a historically established, effective, and safe technique despite being underused in the current practice.

In our intensive care unit (ICU), a multidisciplinary unit with 17 beds, both trauma and neuro-ICU, we routinely perform NTI for long-term ventilation to reduce patients’ discomfort, and our gold standard is to perform NTI through flexible fiberoptic bronchoscopy guidance.

In any case, we deem the approach under the video laryngoscope guide can offer several advantages. NTI under video laryngoscope guidance is easier to perform also for less experienced users while mastering fiberoptic intubation requires a longer learning curve.2 Video laryngoscope also appears to be safe for awake intubation and can achieve overall and first-attempt success rates comparable to fiberoptic bronchoscopy.2 Thanks to the avoidance of hyperextension of the neck, this technique is to be preferred in particular patients, such as spine trauma or in cases where the mouth opening is significantly reduced for anatomical reasons or injuries resulting from the trauma. A comparison of the hemodynamic response between the two procedures is not well studied but evidence seems to favor video laryngoscopy.3

Moreover, we should stress how fiberoptic bronchoscopy procedures have the potential of bioaerosolization associated with patient coughing, sneezing, or talking, or during the use of suction. Therefore, endotracheal intubation, extubation, connection, and disconnection of the ventilatory circuit in patients infected with coronavirus disease (COVID-19) may cause aerosolization that may contaminate personal protective equipment, exposed body parts, or even the airway of the person handling the patient's airway.4 Video laryngoscopy is ideally recommended in patients infected with COVID-19 to increase the distance between the operator's and the patient's face to minimize the contamination risk.

Finally, it is remarkable how, despite the importance of the success rate or safety of tracheal intubation in the critically ill patient, this area is still scarcely explored.5

We believe video laryngoscopy-guided NTI is as affordable and safe as other NTI techniques in selected settings, so we kindly invite the authors to include this in their review.


Alessio Cittadini https://orcid.org/0000-0003-3944-9609

Federica Marsigli https://orcid.org/0000-0002-3858-7914

Andrea Sica https://orcid.org/0000-0002-8072-4492

Domenico P Santonastaso https://orcid.org/0000-0003-1304-7724

Emanuele Russo https://orcid.org/0000-0002-6531-5527

Emiliano Gamberini https://orcid.org/0000-0001-9403-5244

Vanni Agnoletti https://orcid.org/0000-0002-7595-2669


1. Chauhan V, Acharya G. Nasal intubation: a comprehensive review. Indian J Crit Care Med 2016;20(11):662–667. DOI: 10.4103/0972-5229.194013.

2. Heuer J, Heitmann S, Crozier T, Bleckmann A, Quintel M, Russo S. A comparison between the GlideScope® classic and GlideScope® direct video laryngoscopes and direct laryngoscopy for nasotracheal intubation. J Clin Anesth 2016;33:330–336. DOI: 10.1016/j.jclinane.2016.04.022.

3. Alhomary M, Ramadan E, Curran E, Walsh S. Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation: a systematic review and meta-analysis. Anaesthesia 2018;73(9):1151–1161. DOI: 10.1111/anae.14299.

4. Cook T. Personal protective equipment during the coronavirus disease (COVID) 2019 pandemic—a narrative review. Anaesthesia 2020;75(7):920–927. DOI: 10.1111/anae.15071.

5. Cabrini L, Landoni G, Baiardo Redaelli M, Saleh O, Votta C, Fominskiy E, et al. Correction to: Tracheal intubation in critically ill patients: a comprehensive systematic review of randomized trials. Crit Care 2019;23(1):325. DOI: 10.1186/s13054-019-2634-z.

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