Retrograde intubation

Evaluation of retrograde intubation with different doses of dexmedetomidine infusion: A randomised controlled trial

Background

Retrograde intubation is one of the well-described and alternative methods of difficult airway management. It requires effective sedation and patient preparation. Study was done to evaluate intubating conditions during retrograde guided intubation with two different doses of dexmedetomidine.

Methods

This prospective randomized double blind parallel group trial was planned on 60 patients with difficult airway. Patients were divided in two groups to receive either dexmedetomidine 1.0 μg/kg (Group A) or dexmedetomidine 1.5 μg/kg (Group B) by intravenous (IV) route. The Modified Observer Assessment Awareness and Sedation (OAA/S) was measured as primary outcome and ease of intubation, facial grimace score, cough severity, hemodynamic response, patient recall and discomfort were assessed as secondary outcome during awake retrograde intubation.

Results

Groups were comparable in terms of demographic and baseline parameters. OAA/S (P = 0.001), cough severity (P < 0.001), facial grimace score (P < 0.001), grading of discomfort during procedure (P < 0.001) and recall of procedure scale (P = 0.038) were found significantly better/lower in Group B as compared to Group A. Hemodynamic parameters were better in Group B and showed significant difference during the retrograde intubation. However, ease of intubation scale, intubating time and complications were not significantly different (P > 0.05) between the two groups.

Conclusion

Retrograde intubation can be easily learned and performed with minimal complications. Dexmedetomidine in a dose of 1.5 μg/kg IV is optimum and safe for retrograde intubation with clinically manageable side effects.

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

Background

Orotracheal intubation in dogs is a common and easily-performed procedure that provides a patent airway during anaesthesia. In dogs with temporomandibular joint ankylosis or pseudo-ankylosis, airway management can be a challenging procedure since these dogs have a limited ability to open their mouth. Methods to provide safe, uneventful intubation in such patients may include minimally invasive techniques such as retrograde intubation using a guide wire and fibre-optic-aided laryngoscopy.

Case presentation

We report a case of a 16-month-old, intact female Bull Terrier weighing 17 kg, admitted to the hospital for surgical treatment of bilateral ankylosis of the temporomandibular joint. Intubation was achieved, without direct observation of the larynx, by retrograde intubation using a vascular access catheter and a vascular wire guide through cricothyroid membrane. Bilateral condylectomy was performed and the dog recovered uneventfully.

Conclusions

In conclusion, retrograde intubation was relatively simple to perform with the guide wire technique and no specific training or equipment were necessary.

Retrograde intubation through nasal route in patients with limited mouth opening undergoing oral and maxillofacial surgery

Background

Patients with limited mouth opening (LMO) often associated with difficult intubation. Retrograde intubation is an alternative technique of establishing definitive airway in these patients when blind nasal intubation fails and fiberoptic bronchoscope is not available. We tested the retrograde intubation through nasal route in patients with LMO less than 2 cm.

Materials and methods

The procedure was performed with some modification with regard to retrograde guide on 18 patients requiring maxillofacial surgical procedures to increase mouth opening. Indications for this technique were mandibular fracture (n = 6), oral submucous fibrosis (OSMF; n = 6), temporomandibular joint (TMJ) ankylosis (n = 4) and internal derangement of TMJ (n = 2). All patients were assessed for preoperative interincisal opening; during intubation through specific parameters and; also postoperative findings were observed.

Results

Mean time taken for successful intubation was 5.6 min ± 1.66. One patient had subcutaneous emphysema which was managed conservatively. Postoperatively, four patients had sore throat which resolved in few days. No other complications were encountered.

Conclusion

In conclusion, retrograde nasotracheal intubation is an effective and useful technique for airway control in patients with LMO and with only a small risk potential.

Quest for an Ideal Route of Intubation for Oral and Maxillofacial Surgical Manoeuvres

PURPOSE

The optimal route of intubation that may be planned for different oral and maxillofacial surgical manoeuvres.

MATERIALS AND METHODS

A study was performed on patients who underwent nasal, oral or submental route of intubation for elective oral and maxillofacial surgery under general anaesthesia. The study variables were the anaesthetic and surgeon factors that should be taken into consideration before intubation and during surgery, and also algorithms for uneventful surgical procedures. The outcome variables were influence of the 'route of intubation' on 'surgical technique' and vice versa. Overall results were compiled, tabulated and analysed using SPSS version 14.0.

RESULTS

The study sample comprised of 634 patients. It was found that 35 % (204) nasal, 7.5 % (4) oral and 0 % submental route of intubation had statistically significant influence on oral and maxillofacial surgical procedures and vice versa (p < 0.001).

CONCLUSION

This present study concluded that the surgical access and visibility was immensely improved by following the anaesthetic and surgeon factors in conjunction with algorithms described for uneventful oral and maxillofacial surgical procedures. Further, this has also substantially minimized the influence of the 'route of intubation' on 'surgical technique' and vice versa.

Does the site of anterior tracheal puncture affect the success rate of retrograde intubation? A prospective, manikin-based study

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 orotracheal intubation with a double-lumen tube

BACKGROUND AND OBJECTIVES

Difficult airway management in thoracic surgeries is a peculiar subject due to the demands of monopulmonary ventilation with double-lumen tubes. Flexible bronchoscopy guidance is extremely important, but it is not always available. The objective of this report was to describe a case of retrograde selective orotracheal intubation in the absence of specific endoscopy equipment for the procedure.

CASE REPORT

This is a patient with a history of retosigmoidectomy, admitted for a right thoracotomy for a lung lesion. Preoperative anesthetic evaluation did not reveal any clinical and physical exam particularities. After anesthetic induction and ventilation with face mask, two attempts of orotracheal intubation under direct laryngoscopy were ineffective due to difficult visualization of the vocal folds (Cormack-Lehane grade III). Due to the unavailability of specific material for selective endoscopic intubation it was decided to use the retrograde technique using the double-lumen tube. The patient was extubated in the operating room shortly after the end of the surgery without complications secondary to the alternative technique.

CONCLUSIONS

Retrograde selective orotracheal intubation is a minimally invasive technique, low cost, safe, and extremely useful whenever flexible bronchoscopy is not available.

Retrograde and submental intubation

Direct laryngoscopy remains the technique of choice for placing an endotracheal tube (ETT). However, alternative techniques are needed for the difficult airway or unsuccessful intubation. Retrograde intubation may be used in adult or pediatric patients, whether awake, sedated, or obtunded. Contraindications include nonpalpable neck landmarks, pretracheal mass, severe flexion deformities of the neck, tracheal stenosis, coagulopathies, and infections. Submental intubation allows simultaneous access to the dental occlusion and nasal pyramid without the morbidity associated with tracheostomy. Contraindications include patients who require long periods of assisted ventilation and a severe traumatic wound on the floor of mouth. Complications include localized infection and sepsis, poor wound healing or scarring, and postoperative salivary fistula.