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Retrograde-Assisted Fiberoptic Intubation: An Unusual But Useful Use Of Flexible Fiberoptic Endoscope

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Altaf Hussain MBBS, DA, MCPS, FCPS
Department Of Anaesthesiology (41)
King Khalid University Hospital

Nauman Ahmad FCPS
Consultant Anaesthesiologist
King Khalid University Hospital

Amir B. Channa FFARCS
Professor Of Anaesthesiology
King Khalid University Hospital

Citation: A. Hussain, N. Ahmad & A. B. Channa : Retrograde-Assisted Fiberoptic Intubation: An Unusual But Useful Use Of Flexible Fiberoptic Endoscope . The Internet Journal of Anesthesiology. 2004 Volume 8 Number 2

Keywords: Flexible Fiberoptic Endoscope | Retrograde Technique | and Difficult Airway

Case Report
Pre-operative Assessment
Presenting complaint:
Past Medical History:
Past Surgical History:
Physical Examination:
Airway Assessment:
X-ray cervical spine:
Premedication:
Airway Management:
Discussion
Acknowledgements
Correspondence to

Abstract

The flexible fiberoptic endoscope is invaluable equipment used in the practice of anaesthesiology and intensive care medicine. Its basic use is as an aid to difficult intubation either by the oral or nasotracheal route. A few numbers of cases of Retrograde-Assisted Fiberoptic Intubation have been reported in the literature. We report a similar case.

Case Report

A 42-year-old male patient was scheduled for elective right total hip replacement.

Pre-operative Assessment

Presenting complaint:

Inability to move right lower limb for the last few years.

Past Medical History:

Known case of ankylosing spondilitis for the last 24 years.
No history of taking steroids or NSAIDs for the last one year.
No history of diabetes mellitus, hypertension, COPD or allergies etc.

Past Surgical History:

Left total hip replacement done under epidural anaesthesia.
Perioperative course remained uneventful.

Physical Examination:

The patient was of short stature.
His height was 156 cm and weight 68 kg.
There was no pallor, cyanosis, jaundice or edema.
He was lying on the bed with two big pillows under the head.
Respiration was abdominal and chest movements were seemed to be restricted on either side.
The examination of all other systems was unremarkable.

Airway Assessment:

Short neck
Mouth opening 3.4 cms.
Thyromental distance 4.5 cms.
All teeth present with good oral hygiene
Unable to flex, extend or rotate his neck on either side at all.
Unable to protrude his lower incisors in front of upper incisors.
MalIampatti Class III

X-ray cervical spine:

Figure 1: Lateral view of cervical spine is showing extensive vertebral ankylosis involving the apophyseal joints with disc calcification.

Figure 2: X-ray lumbosacral spine. Lateral view showing bamboo appearance

Premedication:

Tablet Lorazepam 2 mg po 2 hours before operation
Tablet ranitidine 150 mg po 2 hours before operation
Tablet Metoclopramide 10 mg po 2 hours before operation

Airway Management:

After failed epidural block and awake intubation with the conventional method of endotracheal tube insertion under topical anaesthesia by the use of a flexible fiberoptic bronchoscope (Olympus BF 3c 10), a retrograde assisted fiberoptic intubation was considered. The cricothyroid membrane was identified and 5.0 ml of Xylocaine 2% was given through this route. A 16 G intravenous canula was successfully passed into the trachea at the injection site. Stainless steel safety guide wire with a fixed core straight flexible tip (0.97mm x 100cm) was passed through the intravenous canula and retrieved from the oral cavity. A well-lubricated 8 mm ID cuffed endotracheal tube was passed over the endoscope. The oral end of the guide wire was passed through the suction port of endoscope in retrograde direction while the other end was clamped with artery forceps at cricothyriod membrane. The bronchoscope was introduced into trachea as shown in the Figure 3.

Figure 3: The guide is passed in the trachea via the cricothyriod membrane. The distal end is held with artery forceps at the cricothyriod membrane and the proximal end after retrieving from mouth or nose is passed through the suction port of the fiberscope. The fiberscope already mounted with endotracheal tube is passed through the vocal cord into the trachea.

Tracheal rings were identified, the guide wire removed and the endotracheal tube rail-roaded over the bronchoscope and then the bronchoscope was removed. Correct placement of endotracheal tube was confirmed with the use of an Et CO₂ detector device.

Discussion

In 1960, Butler and Cirilo¹ first described passing the guide wire via a tracheotomy stoma. This was given the name of retrograde intubation. Waters² who passed the epidural catheter with the help of Thoughy needle via the cricothyriod membrane to assist tracheal intubation presented the concept of percutaneous guide wire insertion in 1963. We do not know exactly who first described the Retrograde Fiberoptic Assisted Intubation. Tobias et al ³ described the method of Retrograde Fiberoptic Assisted Intubation with guide wire but they passed the bronchoscope along side of the guide wire. Audenaert et al ⁴ and Bissinger et al ⁵ reported cases of retrograde fiberscope assisted intubation through the working channel of a flexible fiberscope. S. Rao Mallampati⁶ has suggested the use of suction port of fiberscope for retrograde intubation.

Acknowledgements

We are very thankful to our anaesthesia technicians for assisting with this procedure.

Correspondence to

Dr. Altaf Hussain MBBS; DA; MCPS; FCPS.
Department Of Anaesthesiology (41)
King Khalid University Hospital
Post Box No.7805
Al-Riyadh 11472
Saudia Arabia
E-mail: [altafdoa@hotmail.com]

References

1. Butler FS, Cirillo AA. Retrograde tracheal intubation. Anesth Analg1960; 39; 333-38. (s)

2. Waters DJ. Guided blind endotracheal intubation. Anesthesia 1963; 18:158-162 (s)

3. Tobias R. Increased success with retrograde guide for endotracheal intubation. Anesth Analg 1983; 62:366-7 (s)

4. Audenaeert SM, Montgomery CI, Stone B et al. Retrograde -assisted Fiberoptic tracheal intubation in children with difficult airways. Anesth Analg1991; 73:660-664 (s)

5. Bissinger U, Guggenberger H, Lenz G. Retrograde -guided Fiberoptic intubation in patients with laryngeal carcinoma. Anesth Analg 1995; 81:408-410 (s)

6. S.Rao Mallampati. In Clinical Anesthesia 3rd edition. Philadelphia 1996.Paul G. Barash et al (Editors); 592 (s)

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	The Internet Journal of Anesthesiology™ ISSN: 1092-406X \| Home \| Editors \| Current Issue \| Archives \| Instructions for Authors \| Disclaimer \| Share with others \| Retrograde-Assisted Fiberoptic Intubation: An Unusual But Useful Use Of Flexible Fiberoptic Endoscope Read printer friendly Subscribe in a reader Share with others Altaf Hussain MBBS, DA, MCPS, FCPS Department Of Anaesthesiology (41) King Khalid University Hospital Nauman Ahmad FCPS Consultant Anaesthesiologist King Khalid University Hospital Amir B. Channa FFARCS Professor Of Anaesthesiology King Khalid University Hospital Citation: A. Hussain, N. Ahmad & A. B. Channa : Retrograde-Assisted Fiberoptic Intubation: An Unusual But Useful Use Of Flexible Fiberoptic Endoscope . The Internet Journal of Anesthesiology. 2004 Volume 8 Number 2 Keywords: Flexible Fiberoptic Endoscope \| Retrograde Technique \| and Difficult Airway Table of Contents Case Report Pre-operative Assessment Presenting complaint: Past Medical History: Past Surgical History: Physical Examination: Airway Assessment: X-ray cervical spine: Premedication: Airway Management: Discussion Acknowledgements Correspondence to Abstract The flexible fiberoptic endoscope is invaluable equipment used in the practice of anaesthesiology and intensive care medicine. Its basic use is as an aid to difficult intubation either by the oral or nasotracheal route. A few numbers of cases of Retrograde-Assisted Fiberoptic Intubation have been reported in the literature. We report a similar case. Case Report A 42-year-old male patient was scheduled for elective right total hip replacement. Pre-operative Assessment Presenting complaint: Inability to move right lower limb for the last few years. Past Medical History: Known case of ankylosing spondilitis for the last 24 years. No history of taking steroids or NSAIDs for the last one year. No history of diabetes mellitus, hypertension, COPD or allergies etc. Past Surgical History: Left total hip replacement done under epidural anaesthesia. Perioperative course remained uneventful. Physical Examination: The patient was of short stature. His height was 156 cm and weight 68 kg. There was no pallor, cyanosis, jaundice or edema. He was lying on the bed with two big pillows under the head. Respiration was abdominal and chest movements were seemed to be restricted on either side. The examination of all other systems was unremarkable. Airway Assessment: Short neck Mouth opening 3.4 cms. Thyromental distance 4.5 cms. All teeth present with good oral hygiene Unable to flex, extend or rotate his neck on either side at all. Unable to protrude his lower incisors in front of upper incisors. MalIampatti Class III X-ray cervical spine: Figure 1: Lateral view of cervical spine is showing extensive vertebral ankylosis involving the apophyseal joints with disc calcification. Figure 2: X-ray lumbosacral spine. Lateral view showing bamboo appearance Premedication: Tablet Lorazepam 2 mg po 2 hours before operation Tablet ranitidine 150 mg po 2 hours before operation Tablet Metoclopramide 10 mg po 2 hours before operation Airway Management: After failed epidural block and awake intubation with the conventional method of endotracheal tube insertion under topical anaesthesia by the use of a flexible fiberoptic bronchoscope (Olympus BF 3c 10), a retrograde assisted fiberoptic intubation was considered. The cricothyroid membrane was identified and 5.0 ml of Xylocaine 2% was given through this route. A 16 G intravenous canula was successfully passed into the trachea at the injection site. Stainless steel safety guide wire with a fixed core straight flexible tip (0.97mm x 100cm) was passed through the intravenous canula and retrieved from the oral cavity. A well-lubricated 8 mm ID cuffed endotracheal tube was passed over the endoscope. The oral end of the guide wire was passed through the suction port of endoscope in retrograde direction while the other end was clamped with artery forceps at cricothyriod membrane. The bronchoscope was introduced into trachea as shown in the Figure 3. Figure 3: The guide is passed in the trachea via the cricothyriod membrane. The distal end is held with artery forceps at the cricothyriod membrane and the proximal end after retrieving from mouth or nose is passed through the suction port of the fiberscope. The fiberscope already mounted with endotracheal tube is passed through the vocal cord into the trachea. Tracheal rings were identified, the guide wire removed and the endotracheal tube rail-roaded over the bronchoscope and then the bronchoscope was removed. Correct placement of endotracheal tube was confirmed with the use of an Et CO₂ detector device. Discussion In 1960, Butler and Cirilo¹ first described passing the guide wire via a tracheotomy stoma. This was given the name of retrograde intubation. Waters² who passed the epidural catheter with the help of Thoughy needle via the cricothyriod membrane to assist tracheal intubation presented the concept of percutaneous guide wire insertion in 1963. We do not know exactly who first described the Retrograde Fiberoptic Assisted Intubation. Tobias et al ³ described the method of Retrograde Fiberoptic Assisted Intubation with guide wire but they passed the bronchoscope along side of the guide wire. Audenaert et al ⁴ and Bissinger et al ⁵ reported cases of retrograde fiberscope assisted intubation through the working channel of a flexible fiberscope. S. Rao Mallampati⁶ has suggested the use of suction port of fiberscope for retrograde intubation. Acknowledgements We are very thankful to our anaesthesia technicians for assisting with this procedure. Correspondence to Dr. Altaf Hussain MBBS; DA; MCPS; FCPS. Department Of Anaesthesiology (41) King Khalid University Hospital Post Box No.7805 Al-Riyadh 11472 Saudia Arabia E-mail: [altafdoa@hotmail.com] References 1. Butler FS, Cirillo AA. Retrograde tracheal intubation. Anesth Analg1960; 39; 333-38. (s) 2. Waters DJ. Guided blind endotracheal intubation. Anesthesia 1963; 18:158-162 (s) 3. Tobias R. Increased success with retrograde guide for endotracheal intubation. Anesth Analg 1983; 62:366-7 (s) 4. Audenaeert SM, Montgomery CI, Stone B et al. Retrograde -assisted Fiberoptic tracheal intubation in children with difficult airways. Anesth Analg1991; 73:660-664 (s) 5. Bissinger U, Guggenberger H, Lenz G. Retrograde -guided Fiberoptic intubation in patients with laryngeal carcinoma. Anesth Analg 1995; 81:408-410 (s) 6. S.Rao Mallampati. In Clinical Anesthesia 3rd edition. Philadelphia 1996.Paul G. Barash et al (Editors); 592 (s) This article was last modified on Fri, 13 Feb 09 13:13:43 -0600 This page was generated on Sun, 21 Mar 10 03:44:58 -0500, and may be cached.
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