Retrograde Intubation around an In Situ Combitube: A Difficult Airway Management Strategy

Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA.
Anesthesiology (Impact Factor: 5.88). 06/2005; 102(5):1061-2. DOI: 10.1097/00000542-200505000-00027
Source: PubMed
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    • "Significant improvements include the Water's technique, which uses an epidural catheter to guide the ETT [24], the use of the Murphy eye as a conduit for the retrograde wire [25], and the pairing of the retrograde technique with other airway management techniques in an effort to increase the success of placing the ETT in the trachea. Such adjunct techniques have included the use of a fiberoptic bronchoscope [26], a light wand [27, 28], a Combitube [29], a modified Eschmann stylet [30], an LMA [31, 32], a Mini-Trach II kit [33], a Cook airway exchange catheter [34], a gastric tube [35], and even a Fogarty embolectomy catheter [36]. Several clinicians have advocated the use of central venous access kits as a convenient collection of necessary supplies [37–39]. "
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    ABSTRACT: 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.
    Full-text · Article · May 2013 · Anesthesiology Research and Practice
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    ABSTRACT: During retrograde tracheal intubation, the short distance existing between the cricothyroid membrane and vocal cords may be responsible for accidental extubation. The insertion of a catheter into the trachea before the removal of the guide wire may help to cope with this problem. This work was conducted to study the impact of such a modification on the success rate and the duration of the procedure. Procedures of retrograde tracheal intubation following the classic and modified techniques were randomly performed in cadavers (n = 70). The duration of the procedure from the puncture of the cricothyroid membrane to the inflation of the balloon of the endotracheal tube was measured, and, at the end of the procedure, the position of the endotracheal tube was checked under laryngoscopy. The procedure was considered to have failed if it had taken more than 5 min or when the endotracheal tube was not positioned in the trachea. The mean time to achieve tracheal intubation was similar in both groups (123 +/- 51 vs. 127 +/- 41 s; not significant), but intubation failed significantly more frequently with the classic technique (22 vs. 8 failures; P < 0.05). All failures were related to incorrect positioning of the endotracheal tube. In four cases, both techniques failed. This efficient, simple modification of the technique significantly increases the success rate of the procedure, without prolonging its duration. These data should be confirmed in clinical conditions but may encourage a larger use of the retrograde technique in cases of difficult intubation.
    Full-text · Article · Feb 2006 · Anesthesiology
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    ABSTRACT: Secured airway is a must in spontaneous or assisted ventilation. A variety of methods are in clinical use for establishing an airway, of which endotracheal intubation is the most common. Difficulties in establishing a secured airway may deteriorate to a serious, and even a life-threatening situation. The management of difficult airways indicates the use of advanced, urgent means, and may lead to surgical intervention. This article describes an alternative technique for tracheal intubation, useful in such cases. Retrograde tracheal intubation is carried out by percutaneous insertion of a needle into the trachea in the subglotic region, passing a guidewire through the needle cephaled until it exits the mouth or nose and threading an endotracheal tube over the guidewire into the trachea. This technique is relatively easy and safe, and should be considered in difficult airway management.
    No preview · Article · Feb 2008 · Harefuah
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