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

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.

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.