RETROGRADE INTUBATION

Abstract

The failure to maintain a patient’s airway following the induction of general anesthesia is a major concern not only for anaesthesiologist but also for the operating surgeon. For securing the airway tracheal intubation using direct laryngoscopy remains the method of choice in most cases. However direct laryngoscopic intubation is difficult in 1.2% of cases and impossible in few cases, who seem to have normal airways . Appropriate planning is crucial to avoid morbidity and mortality when difficulty is anticipated with airway management. Many guidelines developed by national societies have focused on management of difficulty encountered in the unconscious patient; however, little guidance appears in the literature on how best to approach the patient with an anticipated difficult airway .

When planning how to approach the anticipated difficult airway, the primary focus should be on ensuring adequate oxygenation and ventilation and not simply on intubating the trachea.

Since retrograde intubation (RI) was first described 4 decades ago, many other alternative airway options have become available. Laryngeal mask airway, fiberoptic, and bougie-guided intubations are just a few of the techniques that emergency physicians currently use to rescue the difficult airway. Regardless of the availability of these more sophisticated tools, we are still occasionally faced with the patient whom we are unable to ventilate or intubate .

We consider retrograde intubation may have a place in patients with maxillo-facial trauma, cervical spine fractures, or when other techniques for management of the difficult airway fail, and deserves to be a part of the anesthetist’s armamentarium. This technique is easy to learn and has a high level of skill retention. Familiarity with this technique is a valuable addition to the airway-management armamentarium of emergency physicians caring for ill or injured patients. Variations of the technique have been described, and their use depends on the individual circumstances.

Retrograde intubation (RI) is recommended in the difficult airway algorithm of The American Society of Anesthesiologists (ASA) as an alternative non-invasive method of intubation when there is difficulty with tracheal intubation but the patient’s lungs can still be ventilated. The Canadian Society of Anesthesiologists recommends retrograde intubation when ventilation of lungs is not possible (from their algorithm for the management of the difficult airway). The guidelines from The French Society of Anesthesia and Intensive Care and The Italian Society of Anesthesia, Resuscitation, and Intensive Therapy (SIAARTI) mention retrograde intubation as an alternative awake intubati