Name:
ACA- Hung 4e- Retrograde Intubation
Description:
ACA- Hung 4e- Retrograde Intubation
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/2fdb047c-e15f-494a-b6e3-ca14dc6e569b/videoscrubberimages/Scrubber_1.jpg?sv=2019-02-02&sr=c&sig=ZgVPnTxm2M0BxZ%2FsG%2Bcw89z88gv5cGqfLMWjEIGlfVA%3D&st=2025-01-15T11%3A37%3A15Z&se=2025-01-15T15%3A42%3A15Z&sp=r
Duration:
T00H08M10S
Embed URL:
https://stream.cadmore.media/player/2fdb047c-e15f-494a-b6e3-ca14dc6e569b
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/2fdb047c-e15f-494a-b6e3-ca14dc6e569b/Retrograde Intubation.mov?sv=2019-02-02&sr=c&sig=RIDbdQ9VYDlnYDaM7ypMqra%2FnPNlGs0mQOND%2FjGv%2FqQ%3D&st=2025-01-15T11%3A37%3A15Z&se=2025-01-15T13%3A42%3A15Z&sp=r
Upload Date:
2023-11-24T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
While retrograde intubation is not often considered to be a technique of choice in cannot intubate, cannot ventilate situations, it remains a useful technique, particularly in patients with a predicted difficult airway or in a cannot intubate, can ventilate failed airway. The technique can be performed either under general anesthesia or awake with skin infiltration and topical anesthesia.
Segment:1 Equipment.
Equipment-- a pre-assembled purpose design kit is commercially available.
To perform a retrograde intubation, the following essential equipment is required-- an 18-gauge needle or intravenous angiocath, number 17 Touhy needle, a five milliliter fluid filled syringe, a guide wire or an epidural catheter, a tapered anterograde guide catheter is required for the guide wire technique, an appropriately sized tracheal tube, two hemostats.
Segment:2 Techniques.
Segment:3 Classic Approach.
Techniques-- The Classic Approach-- the patient's head and neck is placed in a neutral position. A vertical puncture of the cricothyroid membrane is performed using a number 17 Touhy needle attached to a five milliliter fluid filled syringe. After confirmation of tracheal placement by the aspiration of free air, the syringe is removed. An epidural catheter is then inserted through the Touhy needle and advanced cephalad into the oropharynx.
The catheter can be readily retrieved from the mouth using either the operator's fingers or McGill forceps. After the removal of the Touhy needle from the anterior neck and to avoid accidentally pulling the epidural catheter through, a connector is attached to the distal end of the epidural catheter at the skin entry point.
The epidural catheter is then threaded through the lumen of the tracheal tube to emerge from its connector end. The hemostat is attached to the other end of the epidural catheter, emerging from the mouth. With both ends of the epidural catheter pulled reasonably taut, a well lubricated tracheal tube is then advanced into the glottic opening. Following confirmation of intratracheal placement of the tracheal tube using end-tidal CO2, the epidural catheter is removed through the neck.
Segment:4 Guidewire Technique.
The Guidewire Technique-- a vertical puncture of the cricothyroid membrane is performed using a number 18 angio cath attached to a five milliliter fluid filled syringe. After confirmation of tracheal placement, the needle and syringe are removed. A guidewire is then inserted through the angio cath and advanced cephalad into the oropharynx.
The wire can be retrieved from the mouth as described before. A hemostat is attached to both ends of the wire to allow easy pulling. A tapered tip guide catheter is advanced over the wire until it reaches the cricothyroid membrane.
A tracheal tube is then advanced over the guidewire and guide catheter into the trachea. The guidewire and the guide catheter are then removed together.
Segment:5 Trouble Shooting.
Troubleshooting-- one of the difficulties with the retrograde intubation is the inability to locate the tip of the tracheal tube when it is advanced to the cricothyroid membrane in the trachea.
In some situations, resistance is felt while advancing the tube into the glottis, when the tip of the tube catches the soft tissues, such as the epiglottis, vallecula or the arytenoids.
Segment:6 Modifications.
To prevent removing the epidural catheter or guidewire prematurely and to improve the success rate, a number of modifications have also been suggested.
Segment:7 Murphy’s Eye.
Murphy's Eye-- during the advancement of the tracheal tube, insertion of the epidural catheter or guidewire through the Murphy's Eye of the tracheal tube will allow about 2 centimeters of the tracheal tube to pass below the cricothyroid membrane, making the intubation more successful.
Segment:8 Subcricoid Tracheal Puncture.
Subcricoid Tracheal Puncture-- similarly, a subcricoid tracheal puncture will allow the tracheal tube to pass further below the vocal cords during the advancement of the tracheal tube.
Segment:9 Silk Pull-Through Technique.
Silk Pull-Through Technique-- this involves advancing an epidural catheter retrograde as in the classic technique. The tip of the epidural catheter is then tied to a 3-0 silk suture, and the suture is pulled anterograde through the cricothyroid membrane.
After tying the cephalad end of the suture to the Murphy's Eye, the suture is then used to pull the tracheal tube into the trachea. When the tracheal tube abuts up against the cricothyroid membrane, the tension of the suture is released to allow the tracheal tube to go deeper into the trachea. The suture is then cut and removed.
Segment:10 Flexible Bronchoscope Assisted Technique.
Flexible Bronchoscope Assisted Technique-- after retrieving the guidewire from the oral cavity, the wire is threaded through the suction channel of a flexible fiber optic bronchoscope.
With the guidewire held taught, the flexible bronchoscope loaded with the tracheal tube is then advanced over the guidewire into the oropharynx. Under indirect vision, while gliding along the guidewire, the bronchoscope is advanced into the glottis. The guidewire is then removed before advancing the bronchoscope further into the trachea. Put the tip of the bronchoscope above the carina.
The ensleeved tracheal tube is then advanced into the trachea.
Segment:11 Transillumination Using Trachlight.
Transillumination Using The Trachlight-- the placement of the light bulb of a light wand at the tip of the tracheal tube during retrograde intubation can potentially guide tube advancement, as a bright circumscribed glow can readily be seen in the anterior neck when the tip of the tracheal tube enters the glottic opening.
With the internal rigid stylet removed, the pliable trachlight is inserted into the tracheal tube alongside the guidewire or epidural catheter until the light bulb is positioned close to the tip of the tracheal tube, as shown in this video. While maintaining in the midline position, the assembly negotiates its way to the glottic opening. When the tip of the tracheal tube enters the glottic opening, a bright circumscribed glow can be seen readily below the thyroid prominence.
While relaxing the tension of the epidural catheter at the distal end, the tracheal tube and trachlight assembly can be advanced further into the trachea. The trachlight is then removed.
Segment:12 Complications.
Complications-- although rare, complications such as bleeding at the puncture site, hematoma, subcutaneous emphysema, pneumothorax, pneumomediastinum, pretracheal infection, trigeminal nerve trauma have all been reported with retrograde intubation.
Segment:13 Summary.
In summary, the retrograde intubating technique has been shown to be an effective and safe procedure for placing the tracheal tube in patients with a predicted difficult airway or perhaps in the cannot intobate but can ventilate failed airway. Unless one has extensive experience with the technique and is confident that it can be performed very quickly, it is not a rescue technique to be considered in the cannot intobate, cannot ventilate failed airway.
With proper patient selection and preparation, this technique can be a valuable adjunct in the management of a difficult airway in patients awake or under general anesthesia.
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