Retrograde intubation

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partydoc

partydoc

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Had a potential difficult airway come up in the ICU (didn't end up having to intubate the guy thankfully) and while discussing with the fellow and attending rescue airway techniques- retrograde wire came up. I understand that there are retrograde kits available, but those are not readily on hand.

For those of you that have done these before, what type of needle and wire did you use?
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It's been a while. I have a handful under my belt. Always fiberoptically assisted. So I always made sure the wire fit through the fiber optic scope before I started.

You can make your own kit pretty easily.
 
You don't have a difficult airway cart/box? Major fail for your department if not. As you note, there are kits, my department carries a Cook retrograde wire kit with angiocath, 15mm airway adapter, cannulated exchange catheter and wire. Some other adapter in there as well, probably for jet vent...havn't looked at it for a while. Not something to cobble together in a pinch. The wire is longer than any vascular access wire you could grab in an emergency. Just buy one.
 
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sevoflurane said:
It's been a while. I have a handful under my belt. Always fiberoptically assisted. So I always made sure the wire fit through the fiber optic scope before I started.

You can make your own kit pretty easily.
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I've never done a retrograde, but how does the wire fit into the fiber optic scope?
 
I did one on a difficult intubation in an unstable c-spine in residency. The bronchoscopes were locked in a new Pyxis machine and nobody's code worked. I was moonlighting on a weekend and we couldn't intubate this pt after trying various permutations of glide scope, bougie, nasal etc. It was a young guy and he wasn't an aspiration risk so we just kept mask ventilating between attempts. I suggested a retrograde wire to my attending since I had practiced on a cadaver a few weeks prior. So she ran and got an epidural kit and we did it using the epidural catheter. It worked well. Only problem was getting the tube hung up on the arytenoid cartilage which resolved when I twisted the tube counter or clockwise while watching it with the glidescope.
 
Ronin786 said:
I've never done a retrograde, but how does the wire fit into the fiber optic scope?
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Through the side port where you flush saline during bronchs. You can also use a wire and a bronchoscope to help position bronchial blockers. As Sevo mentioned you need a long wire, at least 120 cm IIRC.
 
Epidural kit. Poke cricothyroid lig with bevel facing upwards. Aspirate air, thread catheter through needle. Magill forceps retrieve in pharynx. Thread tube over the catheter. Turn 90 degrees anti clockwise when it hangs up on larynx. Leave catheter in et tube until tube secured and placement confirmed and checked that cuff is not busted.
 
Alternatively, you can thread the cath through the murphy eye of the ETT and slide it down that way. Another slightly more wacky way is to actually tie the cath to the ETT via the murphy eye so you can pull it down.
 
kazuma said:
I did one on a difficult intubation in an unstable c-spine in residency. The bronchoscopes were locked in a new Pyxis machine and nobody's code worked. I was moonlighting on a weekend and we couldn't intubate this pt after trying various permutations of glide scope, bougie, nasal etc. It was a young guy and he wasn't an aspiration risk so we just kept mask ventilating between attempts. I suggested a retrograde wire to my attending since I had practiced on a cadaver a few weeks prior. So she ran and got an epidural kit and we did it using the epidural catheter. It worked well. Only problem was getting the tube hung up on the arytenoid cartilage which resolved when I twisted the tube counter or clockwise while watching it with the glidescope.
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Epidural catheter? That's new. Pretty cool that it worked. I'd imagine that it would be too floppy.
 
Yes, as SaltyDog mentioned, this is the only time I can think of that the stiff Braun catheters are useful. I looped the catheter around the Murphys eye once then up through the center of the ETT and pinched the catheter between the tube and the connector stem to secure it. Once the tube is in, I removed the connector stem and pulled the catheter thru the cricothyroid membrane. If you are concerned about extubation you could just leave the catheter in place for the procedure.
 
SaltyDog said:
The stiff Braun monofilament ones. Not the floppy spring wound kind.
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You see. I have touted how much better the stiffer Braun catheters are than those floppy pieces of crap for years. Finally, you guys are catching on. <sarcasm>
 
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Ok, apparently I'm slow.... Explain how the wire up the bronch port works exactly? If I had a FOB I'm pretty sure I'd just do an awake FOB. Why puncture cric and risk injury, blood, etc only to use a bronch as a wire guided ETT delivery system instead of an optically guided one? (Unless trauma/blood had already made video techniques worthless I guess).
 
Its essentially the same exact procedure except that you end up seeing the tracheal rings as a last bit of confirmation b4 you place the loaded ETT in the trachea


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Ronin786 said:
I've never done a retrograde, but how does the wire fit into the fiber optic scope?
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Why do you need an FOB? A retrograde wire techniques is usually done with a cricoid stick, threading the wire up, grabbing it with Magill forceps, then using the wire to guide the ETT. You could feed the wire up the FOB, but that seems like a time-consuming step when most of these are done emergently. That being said - I've never done one or seen one done. Never had the need.
 
jwk said:
Why do you need an FOB? A retrograde wire techniques is usually done with a cricoid stick, threading the wire up, grabbing it with Magill forceps, then using the wire to guide the ETT. You could feed the wire up the FOB, but that seems like a time-consuming step when most of these are done emergently. That being said - I've never done one or seen one done. Never had the need.
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Bronch scope is bigger and acts better as a stylet than a wire. Wire will bend and kink easily and sometimes your tube will get caught up by those kinks. A bronchoscope fixes that problem and may allow visualization of trachea at end if not too bloody.

Just sticking a bronch into a bloody mouth after a couple intubation attempt is rarely easy or successful. Hence the retrograde bronch technique.
 
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That's what I think. I can conceivably see how it may help you get past arytenoids/cords with the tube (Parker flex ftw otherwise), but if you got the wire out of the mouth to manually load into the FOB I'd think you'd be home free without that step. Though I agree it does allow confirmation of tracheal placement and a mashed oropharynx with blood/vomitus makes standard FOB use difficult.
 
jwk said:
Why do you need an FOB? A retrograde wire techniques is usually done with a cricoid stick, threading the wire up, grabbing it with Magill forceps, then using the wire to guide the ETT. You could feed the wire up the FOB, but that seems like a time-consuming step when most of these are done emergently. That being said - I've never done one or seen one done. Never had the need.
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You are missing a step. Typically a cook exchanger/obturator is railroaded over the wire. Then, the ETT is placed over the obturator. With the fiberoptic approach, the obturator is replaced by the fiberoptic scope which now turns a blind procedure into a procedure on a video screen/tower. Navigation around tumors is further enhanced with a flexible tip that is controlled by the fiberoptic scope. My preferred method.

If it's a bad enough emergent airway I'm going straight to trach. No time for a retro.
 
Chloroform4Life said:
Bronch scope is bigger and acts better as a stylet than a wire. Wire will bend and kink easily and sometimes your tube will get caught up by those kinks. A bronchoscope fixes that problem and may allow visualization of trachea at end if not too bloody.

Just sticking a bronch into a bloody mouth after a couple intubation attempt is rarely easy or successful. Hence the retrograde bronch technique.
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Yes. 👍
 
Robotic Wis-Hipple said:
Ok, apparently I'm slow.... Explain how the wire up the bronch port works exactly? If I had a FOB I'm pretty sure I'd just do an awake FOB. Why puncture cric and risk injury, blood, etc only to use a bronch as a wire guided ETT delivery system instead of an optically guided one? (Unless trauma/blood had already made video techniques worthless I guess).
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Just as a side note. I have done many transtracheal injections and even passed angiocath's and have never had one bleed, not in the least.
 
Wiscoblue said:
Epidural kit. Poke cricothyroid lig with bevel facing upwards. Aspirate air, thread catheter through needle. Magill forceps retrieve in pharynx. Thread tube over the catheter. Turn 90 degrees anti clockwise when it hangs up on larynx. Leave catheter in et tube until tube secured and placement confirmed and checked that cuff is not busted.
Click to expand...

That's what I was looking for, thanks guys.

Is a central line wire too flimsy?
 
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