Role of Retrograde Intubation

Abstract

When the view into the upper airway is obscured by tumor, blood, or other visual obstructions of the upper airway, it can be helpful to introduce a guide from below the glottis directed cephalad to the mouth or nose, and use this to direct an endotracheal tube (ETT) into the trachea. Although the ETT is passed through the glottis in an antegrade direction, this technique is referred to as retrograde intubation. Retrograde intubation of the trachea was first described in 1960 by Butler and Cirillo [1]. The technique involves introduction of a wire through the cricothyroid membrane or the membranous space between the cricoid cartilage and the first tracheal ring into the airway. The wire is then directed cephalad and is used to help guide an ETT into the trachea. Although infrequently used, retrograde intubation can be an extremely useful tool in the anesthesiologist’s armamentarium for managing difficult airways, and it has been used successfully in many clinical situations. Common indications for the procedure include failure of other airway techniques, anatomical abnormalities, and the presence of blood or secretions in the proximal airway that obscure the glottic structures. Specialized kits are available that include all the necessary equipment for retrograde intubations (e.g., the Cook Retrograde Intubation Set, Cook Incorporated, Bloomington, IN), but the necessary supplies—consisting of a long guide wire approximately 0.38′′ caliber, a needle or large-bore intravenous catheter able to accommodate the guide wire, a hemostat, and a tube exchange catheter—are usually available without one of these kits.