Correspondence Address:
Dr. Reena
Department of Anaesthesiology, Heritage Institute of Medical Sciences, Mohansarai-Ramnagar Bypass, Bhadwar, Varanasi - 221 311, Uttar Pradesh
India

Full Text



Sir,

The technique of retrograde intubation (RI) was first described by Butler and Cirillo in 1960[1] since then it underwent many developmental changes to improve its efficacy and success rates. Patients with mandibular fracture often present with very limited mouth opening and are difficult to intubate. Various modalities are described to intubate such patients, among which RI is one such technique.

A 40-year-old American Society of Anesthesiologists (ASA) Grade I female was posted for fracture reduction and plating of mandibular fracture [Figure 1]. Airway examination revealed very limited mouth opening of <1 finger breadth, loose upper central incisors and buck teeth. Mallampati grading was not possible. Sternomental distance and thyromental distances were 14 and 6.5 cm, respectively. Neck movements were within normal limits. In the absence of fibreoptic bronchoscope, we were left with three choices: blind nasal, RI, or tracheostomy. We chose to perform retrograde nasal intubation in a conscious patient. Blind nasal intubation requires multiple attempts and may cause airway bleeding while tracheostomy was reserved as a lifesaving method should there was a failure to secure airway through RI. The possibility of failure of the procedure or need to perform tracheostomy was explained to the patient, and a consent stating the same was obtained. In the preoperative area, the patient was given injection glycopyrrolate 0.2 mg intramuscular 1 h before surgery. She was nebulized with xylocaine 4% for 15 min, followed by gargling with xylocaine viscous 2% thrice, each for 5 min. Xylometazoline 1% nasal drops were instilled thrice in each nostril every 10 min intervals. All monitors such as Spo2, electrocardiogram, and noninvasive blood pressure were attached in the OT and basal values noted. The patient was positioned in full neck extension with a pillow under the shoulder. Under full aseptic precaution, cricothyroid area was infiltrated with 1 ml injection xylocaine 2%, followed by transtracheal injection of 3 ml of xylocaine 2% to anesthetize the glottis area. Tuohy's needle 18-gauge was inserted through the cricothyroid membrane with bevel facing cephalad, tracheal entry was confirmed with palpable air entry in the saline filled syringe attached to the needle. Then, the urology J-tipped guide wire was inserted through the needle with its malleable end upward, which came out of the left nostril of the patient without any difficulty [Figure 2]. Flexometallic endotracheal tube size 7.0 was inserted over the guide wire and pushed into the trachea fixing both ends of the guide wire. Cuff was inflated, and tube position confirmed with equal bilateral air entry and capnography after removing the guide wire. At the same time, the patient was given intravenous fentanyl 100 μg, injection propofol 100 mg, and vecuronium 5 mg. Anesthesia was maintained with oxygen in air 50% with isoflurane. The intraoperative period was uneventful, and the patient was extubated after regaining full consciousness.{Figure 1}{Figure 2}

Retrograde intubation is a simple technique but is not practiced usually because it is felt as an outdated technique in this advanced airway management era. The technique has again gained much limelight recently which is obvious by a number of publications in the last decade.[2],[3],[4] The advantages are shorter procedural time, applicable even in the presence of blood and secretions, less invasive in comparison to cricothyrotomy. Injury to larynx, trachea or esophagus, hematoma, failed intubation, subcutaneous emphysema, pneumomediastinum, and infection are the possible complications. A number of modifications have been done in the technique to minimize risk and increase success rates. Cook RI set is a preassembled set for this procedure which cut shorts the time wastage in emergency situations.[3] We used J-tipped urology guide wire which is better than epidural catheter, as former is easier to negotiate through narrow spaces such as trachea, larynx, nasopharynx, and ultimately nostrils. Awake RI is well-tolerated by adult patients after adequately anesthetizing the upper airway which includes lignocaine nebulization and spray, gargling with lignocaine viscous and nerve blocks. Ultrasound-guided blocks to facilitate RI has also been described.[4]

Retrograde intubation has been included in difficult airway algorithm of ASA (2003) but not included by DAS (2015) algorithm.[2] RI has been observed as “an underused elective or emergency intubation technique in the management of the difficult airway.”[5] Unfamiliarity and exaggerated perception of invasive nature have made it a rarely taught or practiced procedure.[2] It is suggested that residents should undergo training of RI through audiovisual methods, in manikin simulators or cadavers. The success rate of RI is variable, still in experienced hands, it is a simple, quick technique.

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