Retrograde intubation using a guidewire was first described in 1960. The technique involves puncturing the trachea (usually at the cricothyroid membrane) with a large bore needle (e.g. 16 gauge), passing a guidewire into the trachea, and then threading the guidewire cephalad. Once visualized in the oropharynx, an endotracheal (ET) tube can then be threaded over the guidewire and passed through the airway. This technique can be especially helpful in challenging obstructed or “dirty” airways with poor visualization of the vocal cords. A review article by Dhara is a great, comprehensive overview of the procedure (1). Several case reports and studies also suggest that this may be a procedure that should be considered by emergency physicians, rather than performing a cricothyrotomy, in the “cannot intubate, cannot ventilate” situation.
The Data
One case report describes a 60-year-old patient with a subdural hematoma. The patien't’s Glasgow Coma Score (GCS) was deteriorating, so the physicians proceeded with intubation. Following multiple attempts, they could not visualize the vocal cords and failed intubation after passing a bougie. At that time, an ENT specialist was called to perform for a cricothyrotomy. While waiting for the ENT surgeon, retrograde intubation was successfully attempted, sparing the patient from a cricothyrotomy (2).
In another case series performed at Loma Linda, a Level 1 trauma center in Southern California, intubations performed over 8 years were reviewed in the electronic medical record (EMR). There were 1681 charts reviewed with 313 excluded due to lack of sufficient documentation of the intubation. There were 8 attempted retrograde intubations (in other words, 1 in every 170 intubations were attempted retrograde), with 4 successful attempts and 4 unsuccessful attempts. Median time to intubation for the successful attempts was 3 minutes. The 4 unsuccessful attempts had issues with identifying the cricothyroid membrane, hypoxia, or inability to pass the ET tube (3).
Another study was completed in the prehospital setting in trauma patients requiring intubation. 19 patients received retrograde intubation with first pass success of 100% and mean time to intubation at 5 minutes. The authors concluded that retrograde intubation may be a valid method for difficult airways in the traumatic setting, even when performed by prehospital clinicians (3,4).
Discussion
The above studies are not a comprehensive review of the data. Given the rarity of using retrograde intubation, most publications on the topic are case reports, done in a very controlled operative room setting, or completed on mannequins or cadavers. Therefore, there is not strong data to support its use on real patients in the emergency department. Furthermore, with the more widespread use of fiberoptics, video laryngoscopy, the bougie, and other adjuncts, retrograde intubation should already be very rarely considered.
Authored by Kathryn McGregor, MD; Taylor Wahrenbrock, MD; and Eric Leser, MD.
References:
Dhara SS. Retrograde tracheal intubation. Anaesthesia. 2009 Oct;64(10):1094-104. doi: 10.1111/j.1365-2044.2009.06054.x. PMID: 19735401.
Bagam KR, Murthy S, Vikramaditya C, Jagadeesh V. Retrograde intubation: An alternative in difficult airway management in the absence of a fiberoptic laryngoscope. Indian J Anaesth. 2010 Nov;54(6):585. doi: 10.4103/0019-5049.72662. PMID: 21224990; PMCID: PMC3016593.
Gill M, Madden MJ, Green SM. Retrograde endotracheal intubation: an investigation of indications, complications, and patient outcomes. Am J Emerg Med. 2005 Mar;23(2):123-6. doi: 10.1016/j.ajem.2004.03.002. PMID: 15765328.
Barriot P, Riou B. Retrograde technique for tracheal intubation in trauma patients. Crit Care Med 1988;16(7):712-3