Evaluation of retrograde intubation in patients with limited mouth opening

Abstract

To the Editor: Tracheal intubation may be difficult due to limited mouth opening or other anatomical abnormalities. Fiberoptic-assisted nasotracheal intubation is the technique of choice in such cases, but a fiberoptic bronchoscope is not always available, especially in hospitals situated in rural areas. We retrospectively investigated the advantages/disadvantages of retrograde intubation in patients with limited mouth opening by evaluating the hospital records of 28 consecutive patients who had undergone retrograde intubation. The success rate, procedure time, number of attempts, and frequency of complications were recorded. A signed consent form was obtained from each patient for all surgical and anesthesia applications. The institutional ethics committee approved the study. In our study, retrograde intubation was performed as described previously [1] in 28 patients (17 male and 11 female, mean age 27 ± 5 years). The mean body mass index was 24 ± 4. Twenty-one patients had temporomandibular joint ankylosis, and seven patients had maxillamandibular fracture. Mean time for retrograde intubation was 3.9 min. Overall success rate was 100 % and success rate of the first attempt was 67.9 %. In three patients, we performed tracheal puncture with a needle on the second attempt. If the guidewire was placed intraorally, it was withdrawn to the oropharanx position and then repositioned to the nasopharanx. In 11 (39.3 %) and 12 (42.9 %) patients, the guidewire was grasped successfully on the first and second attempt, respectively. An endotracheal tube was placed into the trachea on the first attempt in 19 (67.9 %) patients; a second attempt was performed in seven patients. The total procedure time was\5 min in 25 (82.1 %) patients. There was no episode of hypoxemia (pulse oxygen saturation \93 %) during intubation. We found no other evidence of esophagus or airway trauma, nor of serious epistaxis. Minimal bleeding into the trachea was observed in three patients. Additionally, sore throat was present in seven patients on the second-day control after the operation. No other complications were observed during and after the procedures. Retrograde tracheal intubation is a simple and quick procedure when performed by experienced practitioners and may be reliably used in patients with limited mouth opening, including facial trauma and temporomandibular joint ankylosis. Compared to fiberoptic bronchoscope-guided intubation, retrograde tracheal intubation has its advantages and disadvantages. It is a slightly invasive procedure with a number of potential complications, such as tracheoesophageal fistula, vocal cord damage, and bleeding [2]. The advantages of retrograde intubation over fiberoptic bronchoscope-guided intubation include its possible applicability when blood or secretions are present in the upper airway and in patients with an immobilized neck, shorter procedural duration, and a lower risk of subglottic edema and stenosis [3]. In the absence of fiberoptic bronchoscope, blind nasal intubation is another method for endotracheal intubation, but in patients with severe flexion A. Tufek (&) O. Tokgoz F. Celik Department of Anesthesiology, Faculty of Medicine, Dicle University, 21280 Diyarbakir, Turkey e-mail: adnantufek@hotmail.com