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Correspondence |
Massachusetts General Hospital & VA Boston Healthcare Service, Harvard Medical School, West Roxbury, USA, E-mail: kbleissner{at}yahoo.com
To the Editor:
Direct laryngoscopy remains the technique of choice to facilitate tracheal intubation. Alternative intubation techniques are required whenever an airway is deemed difficult or when tracheal intubation is unsuccessful. The retrograde intubation (RI) technique is an option for controlling the airway and is listed on the American Society of Anesthesiology difficult airway algorithm.1
We use a new technique for RI that utilizes an epidural kit (Braun, Bethlehem, PA, USA) and an 86-cm long Cook airway exchange catheter (CAEC) (Cook Critical Care, Bloomington, IN, USA), which are both commonly found in an anesthesia work room. In preparation, 20 cm of the CAEC are cut off the caudal end making it just short of a gum elastic bougie. Under standard monitoring, the patient is positioned supine with the neck in the neutral position or slightly extended. The patient’s airway is the topicalized with local anesthesia, and sedation may be titrated to effect while sterile solution is applied to the neck. Next, the cricothyroid membrane is punctured with a 17G epidural needle in a 45° angle with the bevel pointing rostrally. An epidural catheter (EC) is used for retrograde passage into the oral cavity. Pulling out the tongue and using a Magill forceps usually helps to retrieve the EC. The caudal end of the EC must be secured with a clamp or by an assistant. The EC is then threaded through the central lumen of the shortened CAEC and is secured at the rostral end once it appears. The CAEC is guided over the EC through the vocal cords. Pulling out the tongue and cricoid pressure may facilitate tracheal intubation. Once the CAEC stops because the EC prevents further passage, the EC is released at the rostral end and the CAEC is inserted carefully further into the trachea. Breath sounds through the CAEC may be heard, if the patient is still breathing spontaneously. An endotracheal tube (ETT) is then guided over the CAEC into the trachea. Laryngoscopy may facilitate this passage. The CAEC is removed and ventilation commenced. The EC is now typically visualized within the ETT and should be pulled out if the intubation is deemed successful. The RI can be performed in less then two minutes using this technique.
Retrograde intubation is an invasive technique that can be used to secure a difficult airway, but is not without limitations.2 The success rate is variable and may depend on the operators’ skill and technique.2 The failure to pass the ETT over the guide into the trachea or accidental extubation during removal of the guide are recognized problems. Alternative retrograde techniques utilize infracricoid puncture, a bronchoscope, a light wand or a multilumen catheter over the guide.3–5 Another frequent problem is the limited availability of guide wires of sufficient length and other equipment mentioned above.
The described technique utilizes equipment that is commonly found in the anesthesia workplace and is therefore readily available. Shortening the CAEC by 20 cm facilitates RI, since the EC is thus long enough to be easily retrieved and secured at the rostral end of the CAEC. The high success rate, speed and equipment availability make this technique an important tool for difficult airway management.
Footnotes
Accepted for publication February 2, 2007.
References
1 American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003; 98: 1269–77.[Medline]
2 Lenfant F, Benkhadra M, Trouilloud P, Freysz M. Comparison of two techniques for retrograde tracheal intubation in human fresh cadavers. Anesthesiology 2006; 104: 48–51.[Medline]
3 Sanchez AF, Morrison DE. Retrograde intubation. In: Hagberg CA (Ed.). Handbook of Difficult Airway Management. Philadelphia: Churchill Livingstone; 2000: 115–48.
4 Hung OR, al-Qatari M. Light-guided retrograde intubation. Can J Anaesth 1997; 44: 877–82.
5 Bissinger U, Guggenberger H, Lenz G. Retrograde-guided fiberoptic intubation in patients with laryngeal carcinoma. Anesth Analg 1995; 81: 408–10.[Medline]
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