retrograde intubation

1. Retrograde Intubation
1
DR ZIKRULLAH

2. HISTORY
 The first reported case of retrograde intubation (RI)
was by Butler and Cirillo in 1960.
 The technique involved passing a red rubber
catheter cephalad through the patient's previously
existing tracheostomy. When the catheter exited the
oral cavity, it was tied to the endotracheal tube (ET),
allowing it to be pulled into the trachea.
 The first person to perform RI as presently practiced
was Waters, a British anesthesiologist in Nigeria.
 The name “retrograde intubation,” used by Butler
and Cirillo, is a misnomer. The technique is actually
a translaryngeal guided intubation, but for historical
reasons we continue using the name retrograde
intubation.

3. INDICATIONS
1. Failed attempts at laryngoscopy, LMA, or
fiberoptic intubation.
2. Urgent establishment of an airway where
visualization of the vocal cords is
prevented by blood, secretions, or
anatomic derangement in scenarios in
which ventilation is still possible.
3. Elective use when deemed necessary in
clinical situations such as unstable
cervical spine, maxillofacial trauma, or
anatomic anomaly.
3

4. CONTRAINDICATIONS
1. Unfavorable Anatomy
 Lack of access to cricothyroid muscle (severe
flexion deformity of the neck)
 Poor anatomic landmarks (obesity)
 Pretracheal mass (thyroid goiter)
2. Laryngotracheal Disease
 Malignancy
 Stenosis
3. Coagulopathy
4. Infection (Pretracheal Abscess)
4

5. ANATOMY

6. TECHNIQUES - Preparation
POSITIONING
 The ideal position for RI is the supine sniffing
position with the neck hyperextended.
 In this position, the cervical vertebrae push the
trachea and cricoid cartilage anteriorly and
displace the strap muscles of the neck laterally.
 As a result, the cricoid cartilage and the structures
above and below it are easier to palpate.
 RI can also be performed with the patient in a
sitting position, which may be the only position in
which some patients can breathe comfortably.
 Potential cervical spine injury or limited range of
motion of the cervical spine may necessitate RI
with the neck in a neutral position.

7. SKIN PREPARATION
 Although most documented RIs have not been
elective, every effort should be made to perform
RI using aseptic technique.
 Prophylactic antibiotics in diabetic or
immunocompromised patients may be used.

8. ANESTHESIA
 If time permits, the airway should be anesthetized to
prevent sympathetic stimulation, laryngospasm, and
discomfort.
 Many different combinations of techniques have been
described:
1. Translaryngeal anesthesia during intravenous
sedation or general anesthesia
2. Translaryngeal anesthesia with superior laryngeal
nerve block
3. Translaryngeal anesthesia (4 mL 2% lidocaine)
with topicalization of the pharynx (aerosolized or
sprayed)
4. Glossopharyngeal nerve block and superior
laryngeal nerve block with nebulized local
anesthetic

9. ENTRY SITE
 The
transtracheal
puncture for RI
can be made
either above or
below the cricoid
cartilage.
 The CTM is
relatively
avascular and
has less
potential for

10.  The disadvantage of the CTM
is that initially only 1 cm of ET
is actually placed below the
vocal cords and the angle of
entry of the ET into the
trachea is more acute.
 An initial puncture performed
at the cricotracheal ligament
or lower affords the added
advantage of the ET traveling
in a straighter path as well as
allowing a longer initial length
of ET below the vocal cords.
 The disadvantage is that this
site (below the cricoid
cartilage) has more potential
for bleeding.

11. TECHNIQUES
I. CLASSICAL TECHNIQUE
The classical technique of RI is performed
percutaneously using a standard 17-gauge Tuohy
needle and epidural catheter
 After positioning, skin preparation and
anaesthesia, a right hand–dominant person should
stand on the right side of a supine patient.
 The left hand is used to stabilize the trachea by
placing the thumb and third digit on either side of
the thyroid cartilage.
 The index finger of the left hand is used to identify
the midline of the Cricothyroid membrane and the
upper border of the cricoid cartilage.

12.  A small incision through the skin and
subcutaneous tissue with a No. 11 scalpel blade
is recommended.
 The right hand then grasps the Tuohy needle
and saline syringe like a pencil and performs the
puncture, aspirating to confirm placement in the
lumen of the airway.
12

13. Standard No. 17 Tuohy needle (with saline-filled syringe) is advanced (with
bevel pointing cephalad) through the cricothyroid membrane at a 90-
degree angle (trying to stay as close as possible to the upper border of the
cricoid cartilage). Entrance into the trachea is verified by aspiration of air

14. Angle of Tuohy needle is changed to 45 degrees with bevel pointing
cephalad (again verifying position by aspirating air)

15.  Once the Tuohy needle is in place, the epidural
catheter is advanced into the trachea.
 When advancing the epidural catheter, it is
important to have the tongue pulled anteriorly to
prevent the catheter from coiling up in the
oropharynx.
 The catheter usually exits on its own from either
the oral or nasal cavity. A hemostat should be
clamped to the catheter at the neck skin line to
prevent further movement of the epidural
catheter.
 If the catheter has to be retrieved from the
oropharynx, preferred instrument is a nerve
hook . Magill forceps have been used.
15

16. Epidural catheter is advanced through the vocal cords and into the
pharynx. During this time the patient is asked to stick tongue out, or
tongue can be pulled out manually. Most of the time the epidural
catheter comes out of the mouth on its own. Tuohy needle is then
withdrawn to the caudal end of epidural catheter.

17. Pull epidural catheter out of the mouth to an appropriate length; then
clamp a hemostat flush with the skin

18.  Originally, the catheter was threaded through the
main distal lumen (beveled portion) of the ET.
Bourke and Levesque modified the technique by
threading the catheter through the Murphy eye,
reasoning that this would allow an additional 1
cm of ET to pass through the cords.
18

19. Cross section of larynx and trachea with endotracheal tube (ET) and
catheter guide passing through the cricothyroid membrane. A, Catheter
passes through end of ET, and 1 cm of ET passes the cords. B, The
catheter exits the side hole, allowing 2 cm of ET to pass beyond the
vocal cords.

20.  When the ET is being advanced over the
epidural catheter, a moderate amount of
tension should be employed.
 Excessive tension pulls the ET anteriorly,
making it more likely to be caught up
against the epiglottis, vallecula, or anterior
commissure of the vocal cords.
 If there is difficulty in passing the opening of
the glottis, the ET can be rotated 90
degrees counterclockwise or exchanged for
a smaller tube.

21. Thread a well-lubricated endotracheal tube (ET) over the epidural
catheter. Maintain a moderate amount of tension on the epidural
catheter as you advance the ET (arrow) forward; you will feel a small
click as ET travels through the vocal cords

22. When the endotracheal tube (ET) reaches the cricothyroid membrane
(CTM), it is important to maintain pressure (small arrows), forcing the ET into
the oropharynx (large arrow) to cause continuing pressure against the CTM
with the tip of the ET. (Note: moderate tension is still maintained on the
epidural catheter.)

23. Have an assistant remove hemostat (large arrow) while pressure is
maintained (small arrow) to push the endotracheal tube up against the
cricothyroid membrane. (The epidural catheter may be cut flush with the
hemostat before hemostat is removed.)

24.  Ideally, one would like to verify that the ET is
below the vocal cords before removing the
epidural catheter. The methods are the
following:
1.By direct vision, using the FOB.
2.If the patient is breathing spontaneously, by
listening to breath sounds through the ET
3.By capnography, using a fiberoptic elbow
adapter connected to a capnograph
4.By luminescent techniques using a light
wand.
24

25. Simultaneously (straight arrows) remove epidural catheter as you
advance the endotracheal tube (ET). The tip of the ET will drop from its
position up against the CTM to midtrachea (curved arrow). Advance ET to
desired depth

26. II. GUIDEWIRE TECHNIQUE:
 The modified technique using a guidewire was
developed because the flexible epidural catheter
is prone to kinking.
26

27. Equipment consists of an 18-gauge angiocatheter, a J-
tip guidewire (0.038-inch outer diameter and 110 to
120 cm in length), and a guide catheter.

28. Advantages of Using
guidewire
1. The J tip tends to be less traumatic to the
airway.
2. Retrieval of the guidewire from the oral or nasal
cavity is easier.
3. The guidewire is less prone to kinking.
4. The guidewire can be used with the FOB.
5. The guidewire is easy to handle.
6. The technique takes less time to perform than
the classical technique.
28

29. TECHNIQUE
Angiocatheter (18-gauge) placed at 90-degree angle to the cricothyroid
membrane, aspirating for air to confirm position.

30. Angle is changed to 45 degrees (again aspirating air to confirm position)

31. Advance sheath of angiocatheter cephalad, and remove needle.

32. Advance J-tip guidewire through angiocatheter sheath

33. Retrieve end of guidewire from mouth as in classical technique. Remove
angiocatheter (small arrow)

34. Clamp hemostat flush with neck skin, and advance tapered tip of guide
catheter (inset) over guidewire into mouth
Various types of antegrade guide catheters have been used: FOBs,
nasogastric tubes, suction catheters, plastic sheaths from Swan-Ganz
catheters, Eschmann stylets, and tube changers.

35. Advance guide catheter to cricothyroid membrane

36. Advance endotracheal tube (ET) over entire structure (arrows). Use an ET
that has 6.0 to 7.0 mm internal diameter. Size of the ET is dictated by the
external diameter of the guide catheter

37. Advance endotracheal tube through vocal cords and up against the
cricothyroid membrane

38. Removal of wire and catheter as in classical technique, except that the
guidewire and guide catheter are removed simultaneously

39. III. SILK PULL-THROUGH TECHNIQUE:
 The basic principle involves advancing the
epidural catheter retrograde as in the classical
technique, attaching it to a length of silk,
attaching the length of silk to the tip of the ET,
and then using the catheter-silk combination to
pull the ET into the trachea.
39

40. Advantages of silk technique
1. Equipment is readily available in the operating
room.
2. The silk is intimately attached to the ET,
eliminating railroading.
3. Multiple attempts at intubation are allowed
without having to repeat the procedure (CTM
puncture) if it fails initially.
4.Oxygen can be delivered through the ET.
5.If necessary, postoperative reintubation can be
accomplished using the silk, which is left in
place until the time of discharge from the
recovery room.
40

41. After proceeding as in classical technique, when the epidural catheter
has exited the oral cavity, it is tied to a 3-0 noncutting silk suture (30-inch
length)

42. Pull the epidural catheter caudad until the silk suture exits the skin above
the cricothyroid membrane; then cut off the epidural catheter

43. Tie the suture to the Murphy eye as shown. Have assistant pull patient's
tongue forward. Begin pulling the suture with one hand while the opposite
hand holds the endotracheal tube (ET) steady and in midline. At all times
maintain tension on the suture while advancing the ET

44. Simultaneously pull the silk caudad (arrow) as you advance the
endotracheal tube (ET) (arrow) with the opposite hand. Advance ET to the
cricothyroid membrane.

45. Release the suture, and with the opposite hand advance the endotracheal
tube (ET) to desired depth. The suture partially retracts (arrow) into the
trachea as the ET is advanced (arrow) past the cricothyroid membrane. The
remaining suture is secured to the neck with transparent dressing. On
extubation the silk is left in place as a precaution, should reintubation be
required. The suture is removed in the recovery room upon patient's
discharge by cutting it flush with the skin and pulling it out of the oral cavity

46.  The combination of RI with direct laryngoscopy and RI using
FOB can improve the chance of successful intubation.
 The advantages of passing an FOB antegrade over a
guidewire placed by RI are as follows:
1. The outer diameter of the guidewire and the internal
diameter of the suction port of the FOB form a tight fit that
prevents railroading between both cylinders, allowing the
FOB to follow a straight path through the vocal cords without
being caught on anatomic structures.
2. The FOB acts as a large antegrade guide catheter and
prevents railroading of the ET.
3. When the FOB has passed over the wire through the
vocal cords, it can be advanced freely beyond the puncture
site to the carina, which eliminates the problem of distance
between vocal cords and puncture site.
4. Use of the FOB allows placement of the ET under direct
vision.
5. The FOB can be used by the less experienced
operator.
6. Oxygen can be delivered continuously through the FOB
with the guidewire still in place

47. Guidewire placed as in guidewire technique and pulled out to
appropriate length to accommodate fiberoptic bronchoscope
(hemostat in place).

48. Close-up view of J tip being fed into suction port of fiberoptic
bronchoscope.

49. J tip exiting from fiberoptic bronchoscope handle

50. Begin advancing the fiberoptic bronchoscope (armed with the
endotracheal tube) over the guidewire

51. Advance fiberoptic bronchoscope to the cricothyroid membrane

52. Have assistant remove hemostat (arrow)

53. Remove guidewire from the cricothyroid membrane (straight arrow). The
tip of the fiberoptic bronchoscope then drops into midtracheal position
(curved arrow

54. Retrograde Nasal Intubation
With the epidural catheter already in place, a 16-Fr red rubber urologic
catheter is advanced (arrow) through the nose

55. The tip of the urologic catheter is retrieved from the oral cavity

56. The epidural catheter is fed into the urologic catheter (inset) and may be
tied together

57. Urologic catheter is removed (arrow), with the epidural catheter now exiting
the nose. The epidural catheter can now be used as a nasotracheal guide

58.  In pediatric patients, the physician is faced
with the formidable problems of small
anatomic structures that are difficult to
palpate, immature anatomic structures such
as anterior larynx and narrow cricoid
cartilage, congenital anomalies, and
pathologic disorders that intimately affect the
airway (e.g., acute epiglottitis).
 RI has been used in the anticipated and the
unanticipated difficult pediatric airway,
primarily after failure of conventional
intubating techniques (blind nasal intubation,
direct laryngoscopy, or fiberoptic intubation).

59.  The technique used is the same as in the
adult, but a higher incidence of difficulties
has been reported, including problems in
cannulating the ET and inability to pass the
ET through the glottic opening
 A combination of fiberoptic with retrograde
guidewire intubation offers some
advantages (higher succuess rate, faster
intubation, no need to rely on anatomical
landmarks)

60. Complications
 Esophageal perforation
 Hemoptysis
 Intratracheal submucosal hematoma with distal
obstruction
 Laryngeal edema
 Laryngospasm
 Pretracheal infection
 Tracheal fistula
 Tracheitis
 Vocal cord damage
60