From the Department of Anesthesiology, Lehigh Valley Health Network, Allentown, Pennsylvania.
Accepted for publication June 11, 2013.
The author declares no conflicts of interest.
Address correspondence to Michael He, MD, Department of Anesthesiology, Lehigh Valley Health Network, 1245 S. Cedar Crest Blvd., Suite 301, Allentown, PA 18103. Address e-mail to firstname.lastname@example.org.
A 3-year-old girl suffering from Stevens-Johnsons Syndrome with severe sloughing of the oropharyngeal mucosa was brought to the operating room for an emergent tracheostomy after multiple failed attempts to intubate the trachea in the pediatric intensive care unit. However, a retrograde tracheal intubation was successfully performed in the operating room to secure her airway, after which a tracheostomy was performed. Retrograde intubation can be a quick and effective method for securing the difficult airway.
Retrograde tracheal intubation, while still frequently described, is seldom performed since the advent of technologically superior equipment such as the video laryngoscope and fiberoptic bronchoscope. Before this case, having only performed retrograde tracheal intubation in simulations, it was extremely taxing trying to recall the steps and equipment required to perform the procedure. In this case report, I describe a patient with Stevens-Johnson Syndrome in whom retrograde tracheal intubation was performed in a 3-year-old child before tracheostomy.
A 3-year-old girl was being treated in the pediatric intensive care unit (PICU) for medication-induced Stevens-Johnson Syndrome. She had significant mucosal sloughing along her lips and oropharynx, and, although she was experiencing some difficulty in clearing secretions, her vital signs were stable and her hemoglobin oxygen saturation (SpO2) was 98% with no apparent eminent airway obstruction. With the patient in the PICU, a dexmedetomidine infusion was begun for sedation and to maintain spontaneous ventilation. A pediatric Glidescope provided a full view of the larynx, and nasotracheal intubation was attempted because of concern by the PICU team that an oral tracheal tube would be impossible to secure, given the severe degree of sloughing around the mouth and face, leading to an increased risk of inadvertent extubation.
However, despite an adequate view of the vocal cords, the tip of the nasal tube could not be advanced past the cords. At the same time, excessive oral bleeding resulted in decreased SpO2, and while the SpO2 returned to 100% via mask-assisted ventilation, video laryngoscopy was abandoned.
Attempted fiberoptic-assisted intubation was also unsuccessful due to excessive nasal pharyngeal and oropharyngeal bleeding. Laryngospasm developed, and after injections of succinylcholine and atropine, the airway was secured using a Laryngeal Mask Airway (LMA) with return of 100% SpO2. At this time because of gastric distention, a decision to perform a tracheostomy was made, and the patient was brought to the operating room.
The surgeon and I were concerned about performing a tracheostomy on this patient with only a supraglottic airway in place and continued aspiration of blood. However, because the LMA had been inserted without difficulty and could be easily replaced, a decision was made to attempt retrograde tracheal intubation. The tip of an 18G angiocath (with an attached 5 mL syringe filled with saline) was inserted through her cricothyroid membrane, aiming cephalad.
Continuous aspiration was applied during insertion, and advancement was stopped as soon as air was noted in the saline-filled syringe. The catheter was then advanced into the trachea without resistance, and a wire from an arterial catheterization kit inserted through the catheter. Ideally, we should have used a central line wire, but given the patient’s size, it was an appropriate alternative. The LMA was removed, and the wire was seen projecting out of the mouth. A hemostat was placed on the distal end of the wire, so as not to inadvertently pull the wire through the trachea, and with an assistant holding the wire, a 4.0 cuffed endotracheal tube was then inserted over the wire, into the trachea. At this point, the patient’s SpO2 was 71%, but increased to 100% with manual ventilation using 100% oxygen. An orogastric tube was inserted to decompress the stomach. The process took approximately 2 minutes.
The retrograde wire was left in the trachea per surgeon request, and a tracheostomy was performed using the wire as a landmark. After a 4.0-cuffed tracheostomy was successfully placed, the tracheal tube and wire were removed.
Retrograde tracheal intubation has been described as an option for management of the difficult airway and is especially useful when fiberoptic and or video laryngoscopic equipment are not available or their use has not been successful.1,2 However, vascular injury, subcutaneous emphysema, and esophageal perforation are all potential complications if proper technique is not observed. This is especially true in children in whom the structures are smaller and thus the margin for error is reduced.3
In this case, neither the Glidescope nor subsequent fiberoptic-assisted intubation proved useful given the severe degree of oropharyngeal sloughing and bleeding. Retrospectively, a Glidescope attempt with a nasal tube should never have taken place in the PICU. Given the patient’s pathology and tenuous airway, she should be have been brought to the operating room, and while properly sedated, nasal fiberoptic intubation attempted with a otolaryngology surgeon and a tracheostomy kit immediately available. While the LMA did prove to be an essential rescue device, due to the amount of bleeding and abdominal distention, we could not guarantee that the patient would not continuously aspirate blood or develop subsequent laryngospasm during the tracheostomy.
In summary, retrograde wire intubation is a technique that should be considered in difficult airway management.4 As with any invasive technique, simulation practice is a useful training modality, and by mastering this technique in controlled settings, the experienced anesthesiologist would add yet another tool in the management of the patient with a difficult airway.
1. Bagam KR, Murthy SGK, Vikramaditya C, Jagadeesh V. Retrograde intubation: an alternative in difficult airway management in the absence of a fiberoptic laryngoscope. Indian J Anaesth. 2010;54:585
2. Weksler N, Klein M, Weksler D, Sidelnick C, Chorni I, Rozentsveig V, Brill S, Gurman GM, Ovadia L. Retrograde tracheal intubation: beyond fibreoptic endotracheal intubation. Acta Anaesthesiol Scand. 2004;48:412–6
3. Fiadjoe J, Stricker P. Pediatric difficult airway management: current devices and techniques. Anesthesiol Clin. 2009;27:185–95
4. Lehavi A, Weisman A, Katz Y. Retrograde tracheal intubation–an alternative in difficult airway management. Harefuah. 2008;147:59–64, 93