Retrograde tracheal intubation

Last updated on Dec 9, 2024

Ever wanted to combine a Tuohy needle and an airway procedure?

Well here it is.

In 1960 - inspired by the vascular guidewire techniques we love so much - Drs Butler and Cirillo first intubated a patient by inserting a needle and guidewire into the trachea and out of the mouth, before railroading a tube over it in the conventional direction into the larynx.

This technique has been largely replaced by awake fibreoptic intubation, but that doesn't make it any less cool.

You also need to be able to describe it for exam purposes.

Indications

Un-intubatable via conventional techniques
Fibreoptic intubation is going to be prohibitively difficult - excessive secretions or bleeding, airway tumours

Contraindications

Unconscious patients at risk of aspiration
Agitated patient
Coughing
Cannot identify cricothyroid membrane
Local uncontrolled infection of the front of the neck
Severe uncontrolled coagulopathy
Anatomical pathology making safe cannulation of the trachea infeasible

Complications

Failure of procedure
Loss of airway
Hypoxia
Trauma
Bleeding
False passage
Laryngospasm
Subcutaneous emphysema
Infection

Equipment

There are purpose-built kits available, such as the Cook retrograde intubation kit, however a fairly standard set up would include:

Chlorhexidine
2 ml, 5 ml and 20 ml syringes
Hypodermic needle for local anaesthetic
1% lidocaine with 1:200 000 adrenaline
4% lidocaine
16G Tuohy needle
Epidural catheter or guidewire
Laryngoscope
Magill's forceps
Endotracheal tube
Lubricant
Artery forceps
Suction

Insertion

Supine with extended neck
Clean with chlorhexidine or equivalent
Identify cricothyroid membrane and laryngeal handshake
Local anaesthetic with adrenaline to skin over membrane
Advance needle through membrane and aspirate air to confirm position
Inject 4% lidocaine to airway at end expiration, to ensure lidocaine is inhaled first before coughing
Remove needle immediately, before the patient coughs (awake patients only)
Insert Tuohy needle through cricothyroid membrane, with tip pointing up towards the head
Aspirate air again to confirm position
Introduce guidewire or epidural catheter
Retrieve wire or catheter from mouth using Magill's forceps +/- laryngoscopy (in asleep patient)
Pull enough wire through to allow endotracheal tube to be railroaded and wire to be grasped at the distal end
Clamp both ends of the wire
Hold wire taught and advance endotracheal tube into trachea
Remove wire by pulling back through the endotracheal tube
Confirm correct tube position - ETCO2, Ausculatation, chest movement

For nasal intubation

Insert suction catheter into nose and retrieve from the pharynx
After retrieving wire from the pharynx, feed it into the oral end of the suction catheter and out of the nose
Intubate as above, but via the nose

Never force the needle or wire.