Retrograde Intubation Over a Flexible Fiber-Optic Bronchoscope

Abstract

Traditional retrograde intubation consists of tracheal intubation performed over a guide wire inserted into the trachea inferior to the vocal cords and then passed transorally or transnasally. This intubation technique is reserved for patients with a difficult airway when other methods such as blind nasal intubation or video laryngoscopy fail. A guide wire passed blindly in a retrograde fashion, however, is not without its own constraints. This case report presents the anesthetic management of a 23-year-old Duchenne muscular dystrophy patient with substantial scarring from a previous tracheostomy stoma and limited mouth opening. The patient underwent a retrograde fiber-optic transnasal intubation without the use of a guide wire for a tracheostomy revision procedure, followed by a second tracheostomy revision and retrograde fiber-optic transoral intubation 7.5 months later. This report demonstrates a novel technique for intubating patients with difficult airways. The use of a flexible fiber-optic bronchoscope for a retrograde intubation mitigates complications that can arise using traditional retrograde intubation over a guide wire and increases the likelihood of successful intubation.

Keywords: Duchenne muscular dystrophy; Fiber-optic bronchoscope; Retrograde intubation; Transnasal intubation; Transoral intubation.

Figure 1.

Intraoral placement of Aintree intubation catheter. An Aintree intubation catheter (Cook Medical) was advanced intraorally into the posterior oropharynx to serve as a visual aid and a potential secondary rescue device.

Figure 2.

Insertion of the scope into the stoma. A flexible fiber-optic bronchoscope (855 mm long, LF-GP, Olympus Medical) was inserted in the patient's tracheostomy stoma and advanced cephalad.

Figure 3.

Successful retrograde advancement of the scope. The scope was successfully advanced through the stoma out the right nares for use as a nasal intubation guide.