Retrograde Tracheal Intubation

Retrograde tracheal intubation (RTI) is another viable option when conventional airway approaches fail. This skill can be taught in a variety of ways, including the use of a mannequin.10 The landmarks are the same as for cricothyroid puncture (Fig 15:2). Severe maxillofacial trauma, cervical or mandibular ankylosis, and upper airway masses are some of the potential conditions in which RTI may help. Another advantage of RTI is that it is not impeded by the blood that obscures fiberoptically guided intubation.

The insertion of a retrograde translaryngeal catheter is a less invasive option than cricothyrotomy. This technique can be time-consuming and will not be quick enough for apneic patients. Before beginning the procedure the patient should be preoxygenated. Bag-valve-mask ventilation can continue to be performed without interrupting this technique. Then consider administering translaryngeal anesthesia via an 18-gauge needle through the caudal aspect of the membrane.

Alignment of the needle bevel with the syringe markings will help determine the bevel direction after puncture of the cricothyroid membrane. The initial angle of the needle should be 30 to 45° cephalad, and a 70- to 75-cm flexible-tip guidewire is advanced through the needle. The wire is then grasped in the oropharynx or nares with Magill forceps. Occasionally the wire will exit spontaneously.

Another option when hemorrhage is present is to insert a 75-cm CVP catheter and insufflate. To locate the tip, observe for bubbles and use forceps. J wire, which can be slowly twisted once it arrives at the oropharynx, can also be easier to locate than a straight guidewire. Most central line kits will have 60- to 80-cm wires. Use of a multilumen catheter is yet another option.

The next step is to clasp the guidewire securely with a hemostat at the neck. Then the proximal end of the guidewire is threaded through the Murphy's eye on the ET tube. This allows more of the ET tube to enter the trachea before the guidewire is removed. With both hands, tighten the wire like a tightrope and advance the tube. When the ET tube will pass no further, cut the guidewire or catheter flush with the cricothyroid membrane to minimize soft tissue contamination.

If the tube will not pass through the cords, try a 90° counterclockwise tube rotation to bring the Murphy's eye anterior; this realigns the bevel. Another technique is to insert the guidewire end that exits the mouth into the suction port of a fiberoptic scope. The scope is then inserted over the retrograde guidewire and functions as an antegrade guide.

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