retrograde intubation: an old–new technique · 2014-05-21 · retrograde intuba-tion can be...

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For citation purposes: Vieira D, Lages N, Dias J, Maria L, Correia C. Retrograde intubation: an old new technique. OA Anaesthetics 2013 Nov 01;1(2):18. Co

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Retrograde intubation: an old–new techniqueD Vieira1*, N Lages2, J Dias1, L Maria1, C Correia3

AbstractIntroduction In the last decade, a new boom of scientific articles about retrograde intubation has been published. Case reports, applications, technique vari-ations and comparison with other techniques reintroduce the scientific discussion of the technique, its indi-cations, contraindications, complica-tions and technical advances. Despite the complications and contraindica-tions linked to retrograde intuba-tion, its utility is incontestable in specific situations. Although the suc-cess rate of retrograde intubation is variable, some authors affirm that in the hands of those who use the tech-nique frequently, retrograde intuba-tion appears to have a high success rate. We believe that training in ret-rograde intubation would definitely be an advance that could increase the success rate of the technique as well as decrease the complications associ-ated with it. Conclusion Recent developments are happening to enhance the retrograde intubation technique, such as the combination with laryngeal nerve block, fibre optic bronchoscopy and ultrasound guid-ance. During the booming phase of advances in airway management tech-nologies, anaesthesiologists should sometimes return to the basics and learn and practice simple techniques

like retrograde intubation that can save patient lives.

IntroductionRetrograde endotracheal intubation was first described by Butler and Cirillo1 in 1960 as a way to remove the tracheostomy tube in neck sur-gery. In this procedure, a catheter is passed towards cephalad through the tracheostomy site and emerged in the mouth; then, the catheter is sutured to an endotracheal tube and it is pulled into the trachea. Waters2, in 1963, described passing a plastic tube through the cricothyroid mem-brane and then using it as a guide to intubate patients.

Basically, retrograde intubation encompasses the introduction of a wire into the larynx through a Tuohy needle (Figure 1) in the cricothyroid membrane or membranous space between the cricoid cartilage and the first tracheal ring and blindly retro-grade emerging in the mouth or nos-tril (Figure 2). Then, the technique proceeds with the antegrade guiding of a tracheal tube into the airway us-ing the wire as a guide (Figure 3). Fi-nally, with the orotracheal tube which is already present in the trachea, the wire is removed and the position of the tube is confirmed by capnogra-phy and auscultation.

The technique evolved between the 60s and 80s, and underwent a lot of developments to improve its effectiveness. It has been used in conscious, sedated or apnoeic pa-tients3–5. It has been performed in the supine, prone and sitting posi-tions6 and has been used successfully in both adults7,8 and the paediatric population9–11 as young as 4 months old. There is also a report about the successful placement of a double-lumen endotracheal tube using the

retrograde intubation technique to perform an approach to a lesion in the right lung12. Retrograde intuba-tion can be performed using local an-aesthesia with or without sedation, or under general anaesthesia with or without spontaneous ventilation, depending upon the patient, the op-erator, and the clinical situation13,14. One of the greatest enhancements in retrograde intubation has been the introduction of the Cook Retrograde Intubation Set®13. It made possible the use of the technique not only in urgent situations, but also in unpre-dictable situations in which there is no time to assemble all the compo-nents necessary for the procedure from different kits.

The use of the retrograde wire technique to assist the management of difficult airway was first reported in 198115. Retrograde intubation is recognised as a useful technique in airway management, which is includ-ed in the difficult airway algorithm of the American Society of Anesthesi-ologists16 in 1993 and maintained in the review of this algorithm 10 years later in 200317.

Owing to the emergence of new equipments for intubation such as laryngeal mask airway, fibre op-tic bronchoscope, airway bougie, lighted stylet, combitube and video laryngoscopy, the retrograde intu-bation was somehow put aside in the management of predictable and non–predictable difficult airways in the 90s. The evidence from a study conducted by Harris et al.13 suggests that the procedure is not widely taught and is felt by some to be an antiquated technique in a world of fibre optic visualisation tools. Re-gardless of the availability of more sophisticated tools, anaesthetists are occasionally faced with scenarios

* Corresponding author Email: [email protected] Resident Physician, Department of Anesthe-

siology, Centro Hospitalar Alto Ave, Guima-rães 4835-044, Portugal

2 Specialist Registrar, Department of Anesthe-siology, Centro Hospitalar Alto Ave, Guima-rães 4835-044 Portugal

3 Consultant in Anesthesiology, Department of Anesthesiology, Centro Hospitalar Alto Ave, Guimarães 4835-044 Portugal

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been used successfully in many clini-cal situations14.

In the last decade, a new boom of scientific articles about retrograde intubation has been published. Case reports, applications, technique vari-ations and comparison with other techniques reintroduce the scientific discussion of the technique, its indi-cations, contraindications, compli-cations and technical advances. The aim of this review was to discuss ret-rograde intubation.

DiscussionThe authors have referenced some of their own studies in this review. These referenced studies have been conducted in accordance with the Declaration of Helsinki (1964), and the protocols of these studies have been approved by the relevant ethics committees related to the institution in which they were performed. All human subjects, in these referenced studies, gave informed consent to participate in these studies.

Several problems have been re-ported with retrograde intubation, which is the most frequently failed intubation caused by the tracheal tube springing into the oesophagus after the guide is removed18. Most frequent complications are trauma to the larynx from the introduc-tion of the needle or wire, bleeding, haematoma, inadvertent puncture of oesophagus, the wire may pass distally into the trachea rather than into the mouth, oral or nasal trauma from the wire or passage of the en-dotracheal tube19, subcutaneous em-physema, pneumomediastinum, and infection18.

Retrograde intubation is contraindi-cated in the presence of unfavourable anatomy in the area of the crico-thyroid (non-palpable landmarks, pre- tracheal mass, severe flexion deformity of the neck), some laryn-gotracheal pathologic conditions, sig-nificant coagulopathy, and infection20.

Despite the complications and con-traindications described, the utility of

an extremely useful tool in the an-aesthesiologist’s armamentarium for managing difficult airways, and it has

where they are unable to ventilate or intubate. Although infrequently used, retrograde intubation can be

Figure 1: Placement of Touhy needle in airway and introduction of a wire into the larynx through the Tuohy needle.

Figure 2: Emerging of the wire in the mouth.

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who use the technique frequently, retrograde intubation appears to have a high success rate19. A Canadian National Survey demonstrated that older anaesthesiologists had more experience with the retrograde tech-nique and were more comfortable using it30. Limited teaching of retro-grade intubation is due to two fac-tors: the misperceived, exaggerated invasive nature of the procedure26,31 and the proximity of the cricothyroid puncture site to the vocal cords32. We believe that training in retrograde intubation would definitely be an ad-vance that could increase the success rate of the technique as well as de-crease the complications associated with it. This belief was expressed by Harris et al.13 also who mentioned that retrograde intubation should be included in any thorough anaesthesi-ology curriculum.

Recent developments are hap-pening to enhance the retrograde intubation technique. The success of retrograde intubation and other intubation techniques when per-formed with the patient who is awake depends on the patient’s col-laboration. Thereby, there are sev-eral ways to make the procedure less aggressive to the patient. Superior laryngeal nerve block, ultrasound guided or not, is frequently used to facilitate endotracheal intubation in patients who are awake33,34. In a case report made by the authors of this review22, they have described the use of ultrasound-guided superior laryngeal nerve block (Figure 4) and transcricothyroid membrane block ( Figure 5) to suppress reflexes from the larynx, vocal cords and trachea above to smooth a retrograde intu-bation procedure in a patient who is awake.

Some authors bring out the combi-nation of retrograde intubation and fibre optic bronchoscopy31. Fibre op-tic-aided retrograde intubation uses a long guide wire that emerges in the nostril; then the wire is inserted at the distal end of the working channel

objective of oxygen delivery to the trachea26.

Unfortunately, the success rate of retrograde intubation is variable27. Nevertheless, Barriot and Riou28 have reported that physicians trained in retrograde intubation can perform it in <5 minutes and in the same ar-ticle, they concluded that retrograde intubation is a technique that is easy to learn and that should be devel-oped for pre-hospital care of trauma patients. van Stralen et al.29 reported that after training in retrograde in-tubation by modelling, every subject successfully completed intubation at the first time. The mean time to perform the technique was 71 sec-onds (95% confidence interval ±4 seconds), with a range of 42–129 seconds. They concluded that retro-grade intubation can be taught easily with a mannequin. Tüfek et al.8 stated that retrograde intubation is a simple quick procedure when performed by experienced practitioners. Some au-thors affirm that in the hands of those

retrograde intubation is incontesta-ble in specific situations such as blood and secretions in the airway13,21,22, trismus9,23, congenital anomalies9–11, limited mouth opening8, and bone and joint disorders such as rheuma-toid arthritis, ankylosing spondylitis7, airway tumours21,22 or failed intuba-tion with the direct laryngoscopic technique22,24.

One advantage of the retrograde technique is that unlike most intu-bation techniques, it can be accom-plished without requiring visible air-way landmarks14. The advantages of retrograde intubation over fibre op-tic bronchoscope-guided intubation include its applicability when blood and secretions are present in the up-per airway8, shorter procedural du-ration and a lower risk of subglottic oedema and stenosis25. Retrograde intubation is less invasive than nee-dle cricothyrotomy and surgical cricothyrotomy, and if the intuba-tion or ventilation scenarios are not possible, it can achieve the primary

Figure 3: Antegrade guiding of a tracheal tube into the airway using the wire as a guide.

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to come out through the proximal end of the working channel. The fibre optic bronchoscope with a preloaded tracheal tube is then rail-roaded through the nostril to the trachea, with direct visualisation of the tube with the fibre optic bronchoscope. This combination of techniques probably enhances the success rate of intubation.

A case report published by the au-thors of this review22 describes the use of ultrasound guidance in retrograde intubation in a patient with ulcer-veg-etating neoformation of the orophar-ynx and hypopharynx that required tracheostomy. In this case, ultrasound visualisation of the trachea and sur-rounding structures secure the loca-tion of the needle ( Figure 6 and Fig-ure 7) in the tracheal lumen, possibly to allow to reducing some of the com-plications that arise when retrograde intubation is “blindly” performed, like injury to blood vessels, subcutaneous emphysema or caudal migration of the guide wire. In a study conducted about the use of ultrasound in placing the cannula for tracheostomy, it was confirmed that the ultrasound had increased the success rate (43–83%) and decreased the time (110 s to 57 s) required for successful placement35. By performing the ultrasound guided in the retrograde intubation, authors have concluded that ultrasound guid-ance may be an upgrade in the retro-grade intubation technique and may decrease the likelihood of complica-tions and increase the success rate when compared with ‘blind’ retro-grade intubation22.

As the Anaesthesiology Scientific Society is interested in the resurgence of retrograde tracheal intubation, more developments are expected in the near future which will possibly decrease the complications and in-crease the efficiency of the procedure.

While retrograde intubation may never have the popularity of other airway management techniques, we believe that it is a useful alter-native in some difficult intubation

Figure 4: Performance of superior laryngeal nerve block with ultrasound guidance.

Figure 5: Performance of transcricothyroid membrane block with ultrasound guidance.

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specialized kits, that can be per-formed smoothly, easily and safely in experienced hands and it may pre-vent hypoxia, airway trauma, open cricothyrotomy or tracheostomy and can save patients’ lives in a range of situations.

ConclusionIn this review, the authors are not recommending retrograde intuba-tion as the method of choice for cop-ing with difficult trachea intubation. They only suggest that in times when advances in airway management technologies are booming, anaesthe-siologists should sometimes return to the basics and learn and practice simple techniques like retrograde in-tubation that can save patients’ lives. With no doubt, we can affirm that being comfortable with retrograde intubation is a valuable addition in airway management and should defi-nitely be a part of the capabilities of all anaesthesiologists.

References1. Butler FS, Cirillo AA. Retrograde tra-cheal intubation. Anesth Analg. 1960 Jul–Aug;39:333–8.2. Waters DJ. Guided blind endotracheal in-tubation. For patients with deformities of the upper airway. Anaesthesia. 1963 Apr; 18:158–62.3. Hung OR, al-Qatari M. Light-guided ret-rograde intubation. Can J Anaesth. 1997 Aug;44(8):877–82.4. Ramsey CA, Dhaliwal SS. Retrograde and submental intubation. Atlas Oral Maxillofac Surg Clin North Am. 2010 Mar;18(1):61–8.5. Rosenblatt WH, Wagner PJ, Ovassapian A, Kain ZN. Practice patterns in managing the difficult airway by anesthesiologists in the United States. Anesth Analg. 1998 Jul;87(1):153–7.6. Osborn IP, Cohen J, Soper RJ, Roth LA. Laryngeal mark airway – a novel method of airway protection during ERCP: com-parison with endotracheal intubation. Gastrointest Endosc. 2002 Jul;56(1): 122–8.7. Raval C, Patel H, Patel P, Kharod U. Ret-rograde intubation in a case of ankylos-ing spondylitis posted for correction of

Figure 6: Performance placement of Touhy needle in airway – Positioning ultrasound probe in cricothyroid membrane.

Figure 7: Performance placement of Touhy needle in airway–ultrasound image showing Touhy needle inside airway.

situations where ventilation is se-cured, such as trauma, upper airway masses, bleeding, secretions or ana-tomical anomalies.

Retrograde intubation has a high level of skill retention36 and is a simple and useful technique, with commonly available equipment or

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Anesthesiologists Task Force on Manage-ment of the Difficult Airway. Anesthsesi-ology. 1993 Mar;78(3):597–602.17. American Society of Anesthesiolo-gists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American So-ciety of Anesthesiologists Task Force on Management of the Difficult Air-way. Anesthesiology. 2003 May;98(5): 1269–77.18. Henderson J. Airway management in the adult. In: Miller RD, Eriksson LI, Fleisher LA, et al., editors. Miller’s an-esthesia. 7th ed. Philadelphia: Elsevier Churchill Livingstone; 2009.p1573–610.19. Orebaugh SL. Retrograde intubation. In: Orebaugh SL, editor. Atlas of airway management: techniques and tools. 1st ed. Philadelphia: Lippincott, Williams & Wilkins; 2007.20. Burbulys D, Kiai K. Retrograde intu-bation. Emerg Med Clin North Am. 2008 Nov;26(4):1029–41.21. Rosenblatt WH, Sukhupragarn W. Air-way management. In: Barash PG, Cullen BF, Stoelting RK, et al., editors: Clinical an-esthesia. 7th ed. Philadelphia: Lippincott, Williams & Wilkins; 2013.p762–802.22. Vieira D, Lages N, Dias J, Maria L, Cor-reia C. Ultrasound-guided retrograde in-tubation. Anaesthesia. 2013 Oct;68(10): 1075–6.23. Seavello J, Hammer GB. Tracheal in-tubation in a child with trismus pseudo-camptodactyly (Hecht) syndrome. J Clin Anesth. 1999 May;11(3):254–6.24. Carlson CA, Perkins HM, Veltkamp S. Solving a difficult intubation. Anesthesi-ology. 1986 Apr;64(4):537–8.25. Shantha TR. Retrograde intubation using the subcricoid region. Br J Anaesth. 1992 Jan;68(1):109–12.26. Dhara SS. Retrograde tracheal intu-bation. Anaesthesia. 2009 Oct;64(10): 1094–104.

deformity of spine. Saudi J Anaesth. 2010 Jan;4(1):38–41.8. Tüfek A, Uçan MC, Tokgöz O, Çelik F, Ağaçayak S. Evaluation of retrograde in-tubation in patients with limited mouth opening. J Anesth. 2013 Aug;27(4): 631–2.9. Krishna R, Shenoy TV, Goneppanavar U. Airway management in an infant with congenital trismus: the role of retrograde intubation. South Afr J Anaesth Analg. 2012 May;18(5):267–9.10. Sharma R. Retrograde nasal intuba-tion technique in Pierre Robin Syndrome: a suggestion. Paediatr Anaesth. 2010 Mar;20(3):281.11. Hasani R, Shetty A, Shinde S. Retro-grade intubation: a rare case of golden-har syndrome posted for posterior fossa surgery in the sitting position. J Neuro-surg Anesthesiol. 2013 Oct;25(4):428.12. Heck Jda R, Martins FK, Tsukasan MT, Cristofoli V, Pipkin M, da Silveira ML, et al. Retrograde orotracheal intubation with a double-lumen tube. Rev Bras Anestesiol. 2011 Jul–Aug;61(4):474–8.13. Harris EA, Arheart KL, Fischler KE. Does the site of anterior tracheal punc-ture affect the success rate of retrograde intubation? A prospective, manikin-based study. Anesthesiol Res Pract. 2013;2013: 354317.14. Dauber M. Role of retrograde intu-bation. In: Glick DB, Cooper RM, Ovas-sapian A, editors. The difficult airway: an atlas of tools and techniques for clini-cal management. New York: Springer Science+Business Media; 2013.p191–9.15. Borland LM, Swan DM, Leff S. Difficult pediatric endotracheal intubation: a new approach to the retrograde technique. Anesthesiology. 1981 Nov;55(5):577–8.16. American Society of Anesthesiolo-gists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway. A report by the American Society of

retrograde intubation: an old–new technique · 2014-05-21 · retrograde intuba-tion can be...

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