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Oral endotracheal intubation via direct laryngoscopy or video-assisted laryngoscopy remains the “gold standard” of airway management. Difficult situations arise in which oral endotracheal intubation is impossible, is contraindicated, or fails. Retrograde guidewire intubation is an alternative airway management technique. The American Society of Anesthesiology difficult airway algorithm describes retrograde intubation as an alternative airway in the nonemergent pathway when mask ventilation is adequate but multiple intubation attempts are not successful. The technique should be familiar to those involved with emergency airway management.1,2

Retrograde intubation was first described in 1960 by Butler and Carillo as a way to remove a tracheostomy tube in neck surgery.3 In 1963, Waters described insertion of an epidural catheter through a cricothyroid puncture as an alternative means of establishing an airway.4 Powell and Odzil reported a series of patients in whom retrograde intubation was employed without complications using a plastic catheter rather than an epidural catheter as a guide.5 The current technique of retrograde intubation varies little from these original descriptions.

Retrograde intubation represents one of several alternative maneuvers for securing the difficult airway. The technique can be used in awake, sedated, or obtunded patients who have either an anticipated or unanticipated difficult airway.6 The technique can be performed despite presence of secretions or blood in the oropharynx. Retrograde intubation has proven to be an effective method used by Emergency Physicians to establish a definitive airway.

The success rate of retrograde intubation is variable.7 Completion times for retrograde intubation vary based on physician experience. The mean length of time to intubation was 71 ± 4 seconds among health care professionals who had no prior experience with the technique but who had just completed a mannequin-aided training course.8 The completion of retrograde intubation within 150 seconds with a mean intubation time of 56 ± 6 seconds was seen in resident physicians after a brief instruction course.9


The American Society of Anesthesiologists defines a difficult airway “as the clinical situation in which a conventionally trained anesthesiologist experiences difficulty with mask ventilation, difficulty with tracheal intubation, or both.”1 Consider performing retrograde intubation in any patient in whom endotracheal intubation may be difficult, is contraindicated, or has failed.10-16 The technique can be used in awake, sedated, or obtunded patients who have either an anticipated or unanticipated difficult airway.6 It is potentially indicated when airway control is required and less invasive methods have failed. Maxillofacial trauma and cervical spine fractures represent the most common etiologies of a difficult airway.17 Retrograde intubation was successful on the first attempt in these patients. Ankylosing spondylitis, rheumatoid arthritis, trismus, and congenital anomalies represent another group of challenging airway situations where retrograde intubation could be considered. It is also useful when bleeding obstructs visualization of the glottis or as an alternative in situations where a ...

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