Retrograde Intubation vs. Crichotyrotomy

sandman1 · Sep 12, 2005

The benefit would be if you successfully complete a retrograde intubation then you have a controlled airway that you can ventilate adequately with. A cric is a temporary fix until you can establish another airway. IT is my understanding that you can't really ventilate through a cric, but it is a way to get large amts of oxygen to the lungs with jet ventilation etc. Someone will be sure to correct my if I am mistaken.

In addition, retrograde wire intubation will normally take about 5 minutes(according to Barash) while a cric takes only 15-30 seconds so the cric seems like the way to go (between these two options) in an emergent/hypoxic patient. For that reason, I think retrogrades are MORE OFTEN but not exclusively used in non-emergent situations.

What is the benefit of retrograde intubation as an emergency airway versus crichothyotomy? I was reading an article on retrograde intubation the other day and I've never seen one performed in our ER, but I have seen a crich or two. I was just wondering if there is a benefit of one or the other. It seems to me that retrograde intubation also involves cutting the crichothyroid membrane, although i guess a needle insertion to pass a guidewire is less invasive than placing the airway there. Is that it?
Just curious.
bryan

jewelcutt · Sep 12, 2005

I think you could do a retrograde once you have done a cric and oxygenated the patient. Dome people probably have other favorite modes to manage difficult airways though (FOB), so perhaps that is why the numbers aren't that high.

yoga crna · Sep 13, 2005

I agree with Sandman--it is a matter of time. You can do a crico very fast and are able to oxgenate the patient. We have a crico kit that enables you to connect up an ambu bag or anesthesia circuit. I have had to do one in my career in radiology after a bilateral carotid angiogram (years ago) when both carotids leaked and obstructed the airway. It worked until we found a surgeon to do a tracheostomy. That is one of the reasons I like working with REAL surgeons who know how to do a tracheostomy.

yoga crna

PS. Take the time to practice using different blades, intubating LMA and combitube whenever you can--in easy cases. It saves a lot of cardiac spasm (yours) to be comfortable with these techniques when you have the inevitable difficult intubation.

mwbeah · Sep 13, 2005

I had to perform a retrograde intubation in Iraq, it took some time because we didn't have a special "kit" so I used what I had:

18g angiocath

central line wire

I think it took so long for two reasons, first it was a nasal intubation on a healthy soldier (facial trauma) who didn't not have a plate fracture and was cleared by both the OMFS and GS. The OMFS had to repair this guy's face after a tank turret spun around (after a vehicle hit it) and hit him square (tore up his mandible). Myself and 2 other colleagues tried Blind Nasal, DL, FOB all without success, but the OMFS had to have a NETT for what she needed to do. We had a controlled situation and had time so I proceeded to try a wire. The central line wire was chosen because I felt it had the flexibility to manuever around the nasopharynx and through the nare (which it did thankfully). But because it was flexible, it developed "memory" in the wire when trying to pass the ETT (placed over the wire in the right nare). It took roughly 15-20 minutes to figure out a way to manuever the wire to get the ETT over and into the trachea. A colleague there suggested pulling the wire and creating a slight tension to remove the wire "memory" it work and we passed the tube.

Bottom line, we had an awake patient who was sedated and had solid airway blocks (transtracheal, bilat SLN, and Bilat Glossopharygeal) so we had the time. If you never have performed one in a controlled situation, I would offer that an emergency be the first. Its a great technique but like was stated by Yogi, you have to become adept in several techniques concerning airway control.

Hope this helps,

Mike

FlyingSquirrel · Sep 16, 2005

As stated, the benefits of a retrograde are that it is less invasive, and results in a much more definitive airway.

I've never personally done one on a patient, but we practice the technique regularly on manikins and/or cadavers. A couple of the other medics I work with have done quite a few of them and have gotten so proficient with it that they can usually do one in about a minute or so...thats about how long it take me on a manikin. One of them actually uses it as his first line back-up technique, as far as I know he's never missed one.

5 minutes sounds very pessimistic to me. It shouldn't take much longer to do a retrograde than a cric, as long a you practice it occasionally and have the right equipment handy. Our "kit" just consists of a central line guidewire and a 16g angio that we keep in a ziploc bag with the rest of our surgical airway equipment.

The primary disadvantage of the retrograde is simply that it's not a "sure thing", whereas a surgical cric pretty much is.

mwbeah · Sep 16, 2005

As stated, the benefits of a retrograde are that it is less invasive, and results in a much more definitive airway.
I've never personally done one on a patient, but we practice the technique regularly on manikins and/or cadavers. A couple of the other medics I work with have done quite a few of them and have gotten so proficient with it that they can usually do one in about a minute or so...thats about how long it take me on a manikin. One of them actually uses it as his first line back-up technique, as far as I know he's never missed one.
5 minutes sounds very pessimistic to me. It shouldn't take much longer to do a retrograde than a cric, as long a you practice it occasionally and have the right equipment handy. Our "kit" just consists of a central line guidewire and a 16g angio that we keep in a ziploc bag with the rest of our surgical airway equipment.
The primary disadvantage of the retrograde is simply that it's not a "sure thing", whereas a surgical cric pretty much is.

I would disagree, once you have the wire, pass the ETT, perform a 5 point placement verification.....it most definitely is a sure thing and much less intruding with respect to the patient's homeostatic mechanisms.

A retrograde wire technique is meant to be performed in a controlled environment and I would hate to be the patient that it took "5 minutes" to do....thats not even long enough for your anxiolytics to take effect, let alone whatever airway block technique you choose. That is an unrealistic timeframe. If you are performing this technique as first line in emergency transport, I would argue it is an inappropriate technique for transport. First responders should have advanced airway skills but I don't believe that the appropriate training is provided to First Responders if a complication secondary to utilizing techique in the field if it were to arise. Sounds like a poor choice is being made.

Mike

FlyingSquirrel · Sep 17, 2005

"I would argue it is an inappropriate technique for transport. First responders should have advanced airway skills but I don't believe that the appropriate training is provided to First Responders if a complication secondary to utilizing techique in the field if it were to arise. Sounds like a poor choice is being made."
I realize that this is a CRNA forum and not a transport forum, but if you would, please expound on why you feel this is an innapropriate technique for the transport environment? What is inherent in the hospital environment that makes this an appropriate tool for there, but not the field? What kind of "appropriate training" do we need that we dont get? I can tell you that we spend ALOT of time training on airway management.

chadash · Sep 17, 2005

Dear MWbeah: Just had to say your quote {A sucking chest wound is Nature's way of telling you to slow down} made my day. I must be very tired.

mwbeah · Sep 18, 2005

"i would argue it is an inappropriate technique for transport. first responders should have advanced airway skills but i don't believe that the appropriate training is provided to first responders if a complication secondary to utilizing techique in the field if it were to arise. sounds like a poor choice is being made."
i realize that this is a crna forum and not a transport forum, but if you would, please expound on why you feel this is an innapropriate technique for the transport environment? what is inherent in the hospital environment that makes this an appropriate tool for there, but not the field? what kind of "appropriate training" do we need that we dont get? i can tell you that we spend alot of time training on airway management.
i have no idea of your experience with airway management. i do not believe that first responders are the appropriate personnel to perform invasive airway maneuvers as a first line technique (there are many other less invasive strategies) with the exception of a traumatized airway to the point of there being no other alternative (i.e. gcs 3 with massive facial trauma and pretty much at this time nothing else you could do to this patient would make a difference........no need to worry about plate fracture the patient is pretty much a goner). i stand behind my statement:
1) 5 minutes is unrealistic when performing a retrograde in an unsedated and probably uncooperative and possibly combative patient.
2) inserting a cutting point angiocatheter in less than optimal conditions is risky, especially in an awake, unanesthetized patient who may buck upon insertion of the needle and create an unpleasant situation. the anatomical structures that could be punctured are very vascular and could create a situation where even if you had successfully gained airway management, in that environment you probably would not be able to assess if there was activel bleeding into the tracheobronchial tree or that there is subcutaneous emphysema.
3) mannequins are different than patients and the don't become compromised, reactions to a real situations with decompensating human patients makes people react in different ways
4) being a veteran of several medevac flights in iraq, i just can't imaging attempting a maneuver such as this while in the air or for that matter on the back of a ground ambulance. the airway should be secure far before transporting the patient.
5) another point, if the patient has an injury within the facial region, how can you be sure the patient doesn't have a plate fracture and then you inadvertently thread the guidewire into cerebral tissue?
6) the american journal of emergency medication conducted a review and found that a retrograde wire intubation was only attempted .006% of the time in a hospital setting and was successful only in half of those attempts.
do i need to say more? this attempt is not for a first responder.
mike

FlyingSquirrel · Sep 18, 2005

Mike,

First, I want to tell you that I truly appreciate your input and the time that folks like you often take to reply to questions from folks like me. I come to forums like this primarily to learn from people who I know are much more knowledgeable than myself in their areas of expertise, but I also like to take the opportunity, when it arises, to educate other health care professionals about the challenges that critical care transport clinicians face, as well as the capabilities that many of them have. At any rate, I realize that before I can expect any more input from the members of this forum, I owe a bit of background.

I am a flight paramedic/RN with a civilian helicopter EMS (HEMS) program that covers approximately 22 rural and semi-rural counties. Like most HEMS programs, we typically staff with a crew that consists of a critical care nurse and a critical care paramedic. In order to even interview for a position with us one must have, at a minimum, ACLS, BTLS, and PALS, along with several years of experience in your respective field. Most succesful candidates have multiple "extra" credentials and/or have backgrounds as instructiors in one or more pertinent areas. Our mission is to provide critical care transport throughout our service area by helicopter, a job which frequently involves stabilization of the ABC's at the scene of the accident or in the rural hospital ED. (We are not "first responders". A first responder is a person who is minimally trained to provide the most basic level of emergency medical care, such as CPR, splinting, oxygen administration via non-rebreather mask, etc. This level of EMS certification is designed for folks such as firefighters and police officers, who need fundamental ABC management skills but whose primary job is not to provide medical care.)

Though we market ourselves as a "critical care transport" agency and do have that capability, our bread-and-butter is really the rapid stabilization and transport of acutely ill people, mostly trauma patients. About 60% of our calls are "scene calls", probably 30% are transports from rural ED's to tertiary facilities, with about 10% being critical care transports of ICU patients.

Management of the ABC's - specifically securing of the airway - is the primary focus of our care standards and our initial and ongoing training. Though I can't quote too many stats and percentages off the top of my head, a recent review of medication usage revealed that we induce chemical paralysis on about 30% of our scene flights, and I know that roughly 90% of the patients we intubate are intubated on the first attempt at laryngoscopy and are described as either "easy" or "mildly difficult" by the intubator. Most of our intubations in the field involve the somewhat "prophylactic" intubation of a patient who is breathing adequately, but in whom we suspect a significant brain injury. Many of these patients are intoxicated. Most of these patients are pretty easy to intubate with etomidate, sux, and standard endotracheal technique, but we definitely run into our share of difficult airways as well. The difficult ones are normally due to some significant facial/neck/chest trauma, which is compounded by the need to maintain in-line cervical stabilization and the generally uncontrolled environment (strange positioning, very high- or low-light conditions, suction won't work, patient has a belly full of beer and pizza, has been mask ventilated by ground EMS for 10 minutes before our arrival, is hypoxic and/or hypotensive, etc).

Our formulary includes etomidate, propofol, versed, valium, ativan, fentanyl, morphine, succinylcholine, rocuronium, and vecuronium, in addition to a full complement of ACLS and vasoactive drugs. Our airway skills repertoire includes standard ETI, nasotracheal ETI (very rarely done), bougie assisted ETI, digital intubation, combitube placement, needle cric w/ jet insuflation, retrograde intubation, and standard surgical cricothyrotomy. We used to carry LMA's but really didn't use them at all. We train on these meds, skills, and the associated clinical decision making extensively upon initial hire, and regularly after that. Our standards of care allow for any appropriate combination of the aforementioned drugs and techniques; we do not have a rigid algorithm-type protocol to follow. We use the Univent EAGLE transport ventilators, usually in the control mode.

So, in response to your comment on how difficult it would be to do a retrograde on someone who is awake and combative....they never are awake. And in response to your comment on how difficult it would be to do a retrograde in the field....yeah, airway management in the field can be tough, but sometimes - even more often then in the hospital, I'm sure - less invasive techniques simply don't work for a variety of reasons. Generally, if we are at a point in managing a difficult airway where we're starting to think about having to do something invasive, we really only have two option: a retrograde or a surgical cric. Frankly, we arent too worried about placing a wire in the brain, because what are our options; not intubate the patient and let them almost CERTAINLY develop an anoxic brain injury, just because they MIGHT have a basilar fracture? What is the likelihood of a wire ending up in the base of the skull anyway, before we see it and retrieve it from the pharynx? As far as the low success rates in the hospital, I dare say the operators there probably just aren't experienced and confident with this technique.....the 0.006% tells the whole story. If were an EM doc, and I could call anesthesia or ENT every time I got a tough airway, then I would never do a retrograde either, and I would therefore probably be no good at it. If the hospitals did more retrogrades they would certainly have much higher rates of success. It appears to me that as with so many things, the problem is not with the technique at all, but with the way that it is (not) used.

Just because a given tool isn't frequently used doesn't mean that it couldn't be, especially in a setting and in circumstances that are very different from that which was studied.

Our clinical training and operations are overseen by a panel of 9 medical control physician, all of whom have emergency medicine, surgical, or internal medicine backgrounds. Because we don't have any anesthesia specialists to consult, our quest to find the most updated airway management info often relegates us to studying the literature and the advice provided from resources such as this forum. So thanks for the input and thanks for letting me tell a little about what we do. Sorry for being so long winded.

-Allan

Tenesma · Oct 6, 2005

I have been at a LOT of airway shambles on the streets, in the ER and the OR... Most people who say they can do a quick surgical airway are full of c r a p ...

If you ask the average ENT surgeon how many emergency crics they did during their 5-6 year residency? 3-4 of them

that is close to average exposure for ER guys and General Surgeons... Emergency Crics are far more frequently done in the field by paramedics or in the battle field by paramedics...

And I would say 1/3 to 1/2 of the crics I have seen were total disasters (most of which required significant tracheal repairs as well as esophageal repairs)

Retrograde needs a firm wire... MWBEAH you were lucky you got the J-wire (central line wire) to the oropharynx... About a year ago, i was stuck in the ER doing one w/ the actual kit and the wire never made it into the mouth... I finally had to make a knick with a blade, threaded some of the wire towards the lung (so that i wouldn't lose access to the hole should it start bleeding like stink), then took the ET stylet and advanced that through the cric towards the mouth.... that worked... my perineum was all scrunched up though...