HOW I DO IT
Modified Retrograde Intubation Technique for Rapid Airway Access Michael H. Hines, MD, J. Wayne Meredith, MD, Winston-Salem,North To reverse accidental extubation in the burn patient, a guide-wire can be passed retrograde through the cricothyroid membrane, and a thin tube changer can be placed over the guide-wire and down through the edematous airway and vocal cords. An endotracheal tube can then be passed over the tube changer to rapidly regain airway access.
O
neoftheconstantrisks for theintubated patient in the intensive care unit is accidental extubation. With the quick, coordinated response common to the intensive care unit setting, the airway is usually rapidly and fairly easily resecured by following the proper protocol for airway management. However, in patients with upper airway edema, especially those with vocal cord and hypopharyngeal edema secondary to thermal inhalation injury, this is not as easily accomplished. Even when visualization of the vocal cords is adequate, manipulation of the endotracheal tube through the swollen cords may be difficult. Many investigators believe that patients with this type of airway injury who are at risk for accidental extubation should be treated with an elective tracheostomy to secure the airway below the edematous hypopharynx and cords; conversely, there is a strong inclination to avoid traeheostomy in burn patients, especially in those with upper chest and neck burns, which commonly accompany thermal airway injuries. On two occasions, we have used a modification of a previously described technique in burn patients to regain rapid airway access after accidental extubation. In both instances, we provided adequate mask ventilation through a partial airway obstruction secondary to edematous cords but had made multiple unsuccessful attempts at reintubation under direct visualization. The technique used is a modification of a previously described retrograde intubation in which a catheter is placed through a needle inserted into the cricothyroid membrane and upward into the mouth [1-6]. In this Fromthe Departmentof Surgery,BowmanGraySchoolof Medicine, Wake Forest UniversityMedical Center at Winston-Salem,North Carolina. Requests for reprints shouldbe addressedto MichaelH. Hines, MD, Departmentof Surgery,BowmanGraySchoolof Medicine,300 SouthHawthorneRoad,Winston-Salem,NorthCarolina27103. ManuscriptsubmittedJuly 19, 1989,and acceptedSeptember 19, 1989.
Carolina
modification, a guide-wire is placed retrograde and a thin tube changer is inserted over it to gain access to and effectively separate the cords, allowing passage of an endotracheal tube over the tube changer. TECHNIQUE While the patient receives ventilation through a mask, the neck is quickly prepared with povidone-iodine and draped with sterile towels. We use a commercially available, prepackaged central venous access kit containing a large-bore needle and a flexible J wire. The needle is inserted in a cephalad direction through the cricothyroid membrane into the tracheal lumen at a 45-degree angle (Figure 1A). The J wire is then passed through the needle upward into the trachea and between the cords into the oropharynx, where the assistant giving ventilation can grasp it with McGill forceps and bring it out through the mouth. The needle is then removed from the skin and pulled off the wire (Figure 1B). The patient again receives oxygen by mask ventilation for a few minutes. Then, a commercially available, 29-inch pliable plastic endotracheal tube changer is passed from above over the wire and down toward the cords (Figure 1C). It is carefully guided between the cords under direct laryngoscopic visualization, with the wire being kept under moderate tension to direct the tube changer between the cords. Once the tube changer has passed through the cords, it will stop along the anterior trachea at the site where the wire enters (Figure 1C). The wire is removed, and the tube changer is passed distally to the carina. The endotracheal tube is then placed over the tube changer and advanced carefully to and through the cords (Figure 1D), under direct visualization when possible. Once the endotracheal tube is in the proper position, the tube changer is removed (Figure 1E), the cuff is inflated, the patient receives ventilation, and the tube is secured. Radiographic confirmation of tube placement is obtained. COMMENTS This technique offers a fast, effective way to replace an endotracheal tube in the patient with edematous vocal cords; the airway is secured, while the hazards and time required for emergency bedside tracheostomy are avoided. The technique will usually allow placement of a tube large enough to continue bronchoscopic evaluation through the tube and to provide access via bronchoscopy for good pulmonary cleansing. Unlike previously described retrograde intubation techniques intended for patients with cervical spine injuries, cervical spine deformities, or poorly visualized cords, this technique is for use in patients with burned airways and tight swollen cords [110], in whom passage of an endotracheal tube, even under ideal visualization, is difficult, and patients in whom bronchoscopic intubation is impossible because of poor
THE AMERICANJOURNALOF SURGERY VOLUME159 JUNE 1990 597
HINES AND MEREDITH
A
B
Cricothyroid
I
Epiglottis
Vocal Cords
E
Figure 1. A, the needle is inserted while the patient is being ventilatedwith a mask. B, the wire is placed through the needle and through the cords into the oropharynx (1) where it will be grasped by the McGill forceps (2) and brought out through the mouth; the needle is then removed (3). C, the tube changer is inserted over the wire (1) and the wire is removed (2). D, the tube changer is advanced to the carina (1) and the endotracheal tube is inserted over it (2). E, the endotracheal tube is advanced to the proper position, and the tube changer is removed (1); the tube is connected to the oxygen source (2). visualization and tightness of the cords. It is especially useful in patients with upper chest and neck burns, because it can be performed through the burn site, thereby avoiding a tracheostomy incision. It can also be performed easily during cardiopulmonary resuscitation. We believe that this technique causes less vocal cord damage than forceful attempts to place an endotracheal
598
tube between swollen cords in the absence of wire guidance. We use the tube changer over the wire to gain access to the cords and to dilate the opening between them before inserting the endotracheal tube. We use a wire instead of a catheter because it is much less likely to kink, it is longer and easier to work with, and it can be held under tension. It is required for use with the tube
THE AMERICAN JOURNAL OF SURGERY VOLUME159 JUNE 1990
EDITORIALCOMMENT
changer because the catheters are much too short. We emphasize, however, that this technique requires the ability to give the patient ventilation with a mask during the procedure. A patient with dislodgment of an endotracheal tube who has a totally obstructed airway secondary to edema still requires immediate airway access and is a candidate for emergency needle cricothyroidotomy. In two instances, we have successfully replaced dislodged endotracheal tubes between edematous vocal cords using this modified technique of retrograde wire guidance. The method is simple, quick, and safe; it uses routine equipment available in all intensive care units; and it avoids the hazards of emergency tracheostomy in patients with neck and upper chest burns. Although retrograde intubation is described in the anesthesia and emergency medicine literature [1-3,5,8-10], this modification is particularly applicable to the patient with thermal injury to the airway. We report it now in order to explain its advantages and to bring it to the attention of surgeons caring for burn patients.
REFERENCES 1. Butler FS, Cirillo AA. Retrograde tracheal intubation. Anesth Analg 1960; 39: 333-8. 2. Waters DJ. Guided blind endotracheal intubation for patients with deformitiesof the upper airway. Anaesthesia 1963; 18: 15862. 3. PowellWF, Ozdil T. A translaryngealguide for tracheal intubation. Anesth Analg 1967; 46: 231-4. 4. Manchester GH, Mani MM, Masters FW. A simplemethod for emergencyorotracheal intubation. Plast Reconstr Surg 1972; 49: 312-5. 5. Bourke D, LevesquePR. Modification of retrograde guide for endotracheal intubation. Anesth Analg 1974; 53: 1013-4. 6. Salem MR, Mathrubhutham M, Bennett EJ. Difficult intubation. N Engl J Med 1976; 295: 879-81. 7. Linscott MS, Horton WC. Management of upper airway obstruction. Otolaryngol Clin North Am 1979; 12: 351-73. 8. Roberts JR, Hedges JR, Clinicalproceduresin emergencymedicine. Philadelphia: WB Saunders, 1985: 22-4. 9. Miller RD. Anesthesia. 2nd ed. New York: Churchill Livingstone, 1986: 539. 10. Rosen P, Baker FJ. Emergencymedicine:conceptsand clinical practice. 2nd ed. St. Louis: CV Mosby, 1988: 60.
EDITORIAL COMMENT Eleanor Asher, MD, Louisville,Kentucky All physicians are interested in simple but effective techniques to add to our repertoire of methods for situations when securing an airway is difficult and dangerous. The technique described in the previous paper by Hines and Meredith has merit in se-
Fromthe Departmentof Anesthesiology,Universityof LouisvilleSchoolof Medicine,Louisville, Kentucky.
lected cases. In using a tube changer to replace oral or nasal endotracheal tubes with defective cuffs, the endotracheal tube frequently lodges against the epiglottis or other pharyngeal structures and will not pass through the vocal cords without twisting the tube or using the laryngoscope to visualize and bypass the obstructing tissue. This same problem is known to occur when using retrograde intubation. In a patient
with edematous burns or with actual burn damage to the airway, this could be quite traumatic. I am unable to obtain any statistics on the m o r b i d i t y associated with tube changers, but since they are used only in adverse situations, it is logical to believe the risk-benefit ratio to be favorable. As the authors stated, the alternative to this technique could be tracheostomy, which can be problematic in a burn patient.
__~ EDITORIAL COMMENT Benjamin M. Rigor, MD, Louisville,Kentucky This modification of a retrograde intubation technique is very similar to that reported by Bogod et al [I], the only difference being that in that study, the authors used an epidural needle and an epidural catheter instead of a central venous access kit with a large-bore needle and J wire. Bogod et al used their technique with Fromthe Departmentof Anesthesiology,Universityof LouisvilleSchoolof Medicine,Louisville, Kentucky.
routine difficult intubations, whereas Hines and Meredith used it in two patients with burns of the neck and thorax and laryngeal edema. If the tip of the J wire is grasped with McGill forceps, is this method really less traumatic than direct laryngoscopy with small endotracheal tube intubation, or the use of a pediatric flexible bronchoscope and a small diameter endotracheal tube? If the J wire is too soft and flimsy, it might be difficult to direct it upward
toward the mouth. Can the use of the tube changer, which is more rigid and firm, also add to trauma in a patient with pre-existing laryngeal edema? This method is not new, and it is questionable whether it is less traumatic than other methods of endotracheal intubation. 1. Bogod D, Vaughan R, Latto P. Retrograde intubation. Presented at the World Congress of Anesthesia, May 27, 1988; Washington, DC.
THE AMERICAN JOURNAL OF SURGERY VOLUME 159 JUNE 1990 599
Modified Retrograde Intubation Technique for Rapid Airway Access Michael H. Hines, MD, J. Wayne Meredith, MD, Winston-Salem,North To reverse accidental extubation in the burn patient, a guide-wire can be passed retrograde through the cricothyroid membrane, and a thin tube changer can be placed over the guide-wire and down through the edematous airway and vocal cords. An endotracheal tube can then be passed over the tube changer to rapidly regain airway access.
O
neoftheconstantrisks for theintubated patient in the intensive care unit is accidental extubation. With the quick, coordinated response common to the intensive care unit setting, the airway is usually rapidly and fairly easily resecured by following the proper protocol for airway management. However, in patients with upper airway edema, especially those with vocal cord and hypopharyngeal edema secondary to thermal inhalation injury, this is not as easily accomplished. Even when visualization of the vocal cords is adequate, manipulation of the endotracheal tube through the swollen cords may be difficult. Many investigators believe that patients with this type of airway injury who are at risk for accidental extubation should be treated with an elective tracheostomy to secure the airway below the edematous hypopharynx and cords; conversely, there is a strong inclination to avoid traeheostomy in burn patients, especially in those with upper chest and neck burns, which commonly accompany thermal airway injuries. On two occasions, we have used a modification of a previously described technique in burn patients to regain rapid airway access after accidental extubation. In both instances, we provided adequate mask ventilation through a partial airway obstruction secondary to edematous cords but had made multiple unsuccessful attempts at reintubation under direct visualization. The technique used is a modification of a previously described retrograde intubation in which a catheter is placed through a needle inserted into the cricothyroid membrane and upward into the mouth [1-6]. In this Fromthe Departmentof Surgery,BowmanGraySchoolof Medicine, Wake Forest UniversityMedical Center at Winston-Salem,North Carolina. Requests for reprints shouldbe addressedto MichaelH. Hines, MD, Departmentof Surgery,BowmanGraySchoolof Medicine,300 SouthHawthorneRoad,Winston-Salem,NorthCarolina27103. ManuscriptsubmittedJuly 19, 1989,and acceptedSeptember 19, 1989.
Carolina
modification, a guide-wire is placed retrograde and a thin tube changer is inserted over it to gain access to and effectively separate the cords, allowing passage of an endotracheal tube over the tube changer. TECHNIQUE While the patient receives ventilation through a mask, the neck is quickly prepared with povidone-iodine and draped with sterile towels. We use a commercially available, prepackaged central venous access kit containing a large-bore needle and a flexible J wire. The needle is inserted in a cephalad direction through the cricothyroid membrane into the tracheal lumen at a 45-degree angle (Figure 1A). The J wire is then passed through the needle upward into the trachea and between the cords into the oropharynx, where the assistant giving ventilation can grasp it with McGill forceps and bring it out through the mouth. The needle is then removed from the skin and pulled off the wire (Figure 1B). The patient again receives oxygen by mask ventilation for a few minutes. Then, a commercially available, 29-inch pliable plastic endotracheal tube changer is passed from above over the wire and down toward the cords (Figure 1C). It is carefully guided between the cords under direct laryngoscopic visualization, with the wire being kept under moderate tension to direct the tube changer between the cords. Once the tube changer has passed through the cords, it will stop along the anterior trachea at the site where the wire enters (Figure 1C). The wire is removed, and the tube changer is passed distally to the carina. The endotracheal tube is then placed over the tube changer and advanced carefully to and through the cords (Figure 1D), under direct visualization when possible. Once the endotracheal tube is in the proper position, the tube changer is removed (Figure 1E), the cuff is inflated, the patient receives ventilation, and the tube is secured. Radiographic confirmation of tube placement is obtained. COMMENTS This technique offers a fast, effective way to replace an endotracheal tube in the patient with edematous vocal cords; the airway is secured, while the hazards and time required for emergency bedside tracheostomy are avoided. The technique will usually allow placement of a tube large enough to continue bronchoscopic evaluation through the tube and to provide access via bronchoscopy for good pulmonary cleansing. Unlike previously described retrograde intubation techniques intended for patients with cervical spine injuries, cervical spine deformities, or poorly visualized cords, this technique is for use in patients with burned airways and tight swollen cords [110], in whom passage of an endotracheal tube, even under ideal visualization, is difficult, and patients in whom bronchoscopic intubation is impossible because of poor
THE AMERICANJOURNALOF SURGERY VOLUME159 JUNE 1990 597
HINES AND MEREDITH
A
B
Cricothyroid
I
Epiglottis
Vocal Cords
E
Figure 1. A, the needle is inserted while the patient is being ventilatedwith a mask. B, the wire is placed through the needle and through the cords into the oropharynx (1) where it will be grasped by the McGill forceps (2) and brought out through the mouth; the needle is then removed (3). C, the tube changer is inserted over the wire (1) and the wire is removed (2). D, the tube changer is advanced to the carina (1) and the endotracheal tube is inserted over it (2). E, the endotracheal tube is advanced to the proper position, and the tube changer is removed (1); the tube is connected to the oxygen source (2). visualization and tightness of the cords. It is especially useful in patients with upper chest and neck burns, because it can be performed through the burn site, thereby avoiding a tracheostomy incision. It can also be performed easily during cardiopulmonary resuscitation. We believe that this technique causes less vocal cord damage than forceful attempts to place an endotracheal
598
tube between swollen cords in the absence of wire guidance. We use the tube changer over the wire to gain access to the cords and to dilate the opening between them before inserting the endotracheal tube. We use a wire instead of a catheter because it is much less likely to kink, it is longer and easier to work with, and it can be held under tension. It is required for use with the tube
THE AMERICAN JOURNAL OF SURGERY VOLUME159 JUNE 1990
EDITORIALCOMMENT
changer because the catheters are much too short. We emphasize, however, that this technique requires the ability to give the patient ventilation with a mask during the procedure. A patient with dislodgment of an endotracheal tube who has a totally obstructed airway secondary to edema still requires immediate airway access and is a candidate for emergency needle cricothyroidotomy. In two instances, we have successfully replaced dislodged endotracheal tubes between edematous vocal cords using this modified technique of retrograde wire guidance. The method is simple, quick, and safe; it uses routine equipment available in all intensive care units; and it avoids the hazards of emergency tracheostomy in patients with neck and upper chest burns. Although retrograde intubation is described in the anesthesia and emergency medicine literature [1-3,5,8-10], this modification is particularly applicable to the patient with thermal injury to the airway. We report it now in order to explain its advantages and to bring it to the attention of surgeons caring for burn patients.
REFERENCES 1. Butler FS, Cirillo AA. Retrograde tracheal intubation. Anesth Analg 1960; 39: 333-8. 2. Waters DJ. Guided blind endotracheal intubation for patients with deformitiesof the upper airway. Anaesthesia 1963; 18: 15862. 3. PowellWF, Ozdil T. A translaryngealguide for tracheal intubation. Anesth Analg 1967; 46: 231-4. 4. Manchester GH, Mani MM, Masters FW. A simplemethod for emergencyorotracheal intubation. Plast Reconstr Surg 1972; 49: 312-5. 5. Bourke D, LevesquePR. Modification of retrograde guide for endotracheal intubation. Anesth Analg 1974; 53: 1013-4. 6. Salem MR, Mathrubhutham M, Bennett EJ. Difficult intubation. N Engl J Med 1976; 295: 879-81. 7. Linscott MS, Horton WC. Management of upper airway obstruction. Otolaryngol Clin North Am 1979; 12: 351-73. 8. Roberts JR, Hedges JR, Clinicalproceduresin emergencymedicine. Philadelphia: WB Saunders, 1985: 22-4. 9. Miller RD. Anesthesia. 2nd ed. New York: Churchill Livingstone, 1986: 539. 10. Rosen P, Baker FJ. Emergencymedicine:conceptsand clinical practice. 2nd ed. St. Louis: CV Mosby, 1988: 60.
EDITORIAL COMMENT Eleanor Asher, MD, Louisville,Kentucky All physicians are interested in simple but effective techniques to add to our repertoire of methods for situations when securing an airway is difficult and dangerous. The technique described in the previous paper by Hines and Meredith has merit in se-
Fromthe Departmentof Anesthesiology,Universityof LouisvilleSchoolof Medicine,Louisville, Kentucky.
lected cases. In using a tube changer to replace oral or nasal endotracheal tubes with defective cuffs, the endotracheal tube frequently lodges against the epiglottis or other pharyngeal structures and will not pass through the vocal cords without twisting the tube or using the laryngoscope to visualize and bypass the obstructing tissue. This same problem is known to occur when using retrograde intubation. In a patient
with edematous burns or with actual burn damage to the airway, this could be quite traumatic. I am unable to obtain any statistics on the m o r b i d i t y associated with tube changers, but since they are used only in adverse situations, it is logical to believe the risk-benefit ratio to be favorable. As the authors stated, the alternative to this technique could be tracheostomy, which can be problematic in a burn patient.
__~ EDITORIAL COMMENT Benjamin M. Rigor, MD, Louisville,Kentucky This modification of a retrograde intubation technique is very similar to that reported by Bogod et al [I], the only difference being that in that study, the authors used an epidural needle and an epidural catheter instead of a central venous access kit with a large-bore needle and J wire. Bogod et al used their technique with Fromthe Departmentof Anesthesiology,Universityof LouisvilleSchoolof Medicine,Louisville, Kentucky.
routine difficult intubations, whereas Hines and Meredith used it in two patients with burns of the neck and thorax and laryngeal edema. If the tip of the J wire is grasped with McGill forceps, is this method really less traumatic than direct laryngoscopy with small endotracheal tube intubation, or the use of a pediatric flexible bronchoscope and a small diameter endotracheal tube? If the J wire is too soft and flimsy, it might be difficult to direct it upward
toward the mouth. Can the use of the tube changer, which is more rigid and firm, also add to trauma in a patient with pre-existing laryngeal edema? This method is not new, and it is questionable whether it is less traumatic than other methods of endotracheal intubation. 1. Bogod D, Vaughan R, Latto P. Retrograde intubation. Presented at the World Congress of Anesthesia, May 27, 1988; Washington, DC.
THE AMERICAN JOURNAL OF SURGERY VOLUME 159 JUNE 1990 599
