Does the Site of Anterior Tracheal Puncture Affect the Success Rate of Retrograde Intubation? A Prospective, Manikin-Based Study

Abstract

Background. Retrograde intubation is useful for obtaining endotracheal access when direct laryngoscopy proves difficult. The technique is a practical option in the “cannot intubate / can ventilate” scenario. However, it is equally useful as an elective technique in awake patients with anticipated difficult airways. Many practitioners report difficulty successfully advancing the endotracheal tube due to anatomical obstructions and the acute angle of the anterograde guide. The purpose of this study was to test whether a more caudal tracheal puncture would increase the success rate. Methods. Twenty-four anesthesiology residents were randomly assigned to either a cricothyroid or a cricotracheal puncture group. Each was instructed how to perform the technique and then attempted it on a manikin at their assigned site. Data collection included whether the trachea was intubated, the number of attempts required, and the total time. Results. Both groups displayed a high degree of success. While the group assigned to the cricotracheal site required significantly more time to perform the procedure, they accomplished it in fewer attempts than the cricothyroid group. Conclusion. Retrograde intubation performed via a cricotracheal puncture site, while more time consuming, resulted in fewer attempts to advance the endotracheal tube and may reduce in vivo laryngeal trauma.

Retrograde intubation: An old new technique

“…We believe that training in retrograde intubation would definitely be an advance that could increase the success rate of the technique as well as decrease 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 anaesthesiology curriculum.…”

“…Tüfek et al 8 stated that retrograde intubation is a simple quick procedure when performed by experienced practitioners. Some authors affirm that in the hands of those retrograde intubation is incontestable in specific situations such as blood and secretions in the airway 13,21,22 , trismus 9,23 , congenital anomalies [9][10][11] , limited mouth opening 8 , and bone and joint disorders such as rheumatoid arthritis, ankylosing spondylitis 7 , airway tumours 21,22 or failed intubation with the direct laryngoscopic technique 22,24 .…”

“…There is also a report about the successful placement of a doublelumen endotracheal tube using the retrograde intubation technique to perform an approach to a lesion in the right lung 12 . Retrograde intubation can be performed using local anaesthesia with or without sedation, or under general anaesthesia with or without spontaneous ventilation, depending upon the patient, the operator, and the clinical situation 13,14 . One of the greatest enhancements in retrograde intubation has been the introduction of the Cook Retrograde Intubation Set ®13 .…”

“…Owing to the emergence of new equipments for intubation such as laryngeal mask airway, fibre optic bronchoscope, airway bougie, lighted stylet, combitube and video laryngoscopy, the retrograde intubation 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. Regardless of the availability of more sophisticated tools, anaesthetists are occasionally faced with scenarios Competing interests: none declared.…”

Retrograde intubation in a dog with severe temporomandibular joint ankylosis: case report

“…The RI of the trachea is an established airway management technique that can be used to place an ETT when more conventional methods (e.g. direct laryngoscopy) have failed [ 9 ].…”