Clinical Communications: Adults
Retrograde Intubation with an Extraglottic Device in Place

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Abstract

Background

The intubating laryngeal mask airway (ILMA) is an extraglottic device with a high rate of successful ventilation and oxygenation. Most modern airway algorithms suggest using an extraglottic device as the first-line rescue technique for a failed airway in emergency airway management. Eventually, a more secure airway is needed if the extraglottic temporizing device is working well. Retrograde intubation is a surgical airway management technique that is effective but relatively slow, making it most useful when ventilation can be maintained during the procedure.

Case Report

We report 2 cases of difficult emergency airway management with an ILMA used initially and retrograde intubation later used to establish a more secure airway.

Why Should an Emergency Physician Be Aware of This?

Retrograde incubation can be performed with an LMA in place for complicated airway management.

Introduction

The intubating laryngeal mask airway (ILMA) is an extraglottic airway device that is an important tool for airway management in the emergency department (ED) because its versatility enables it to be used both as a standard ventilatory device and as a rescue device after failed rapid sequence intubation 1, 2, 3, 4, 5, 6, 7, 8, 9, 10. The ILMA is blindly placed in the oropharynx and is wedged into the laryngopharynx to achieve ventilation. It can be placed with little difficulty even by an inexperienced user, and previous reports have documented successful use of the ILMA in the ED 1, 2, 3, 9, 11. Multiple reports indicate that ILMA can be properly placed to achieve satisfactory ventilation on the first attempt in >95% of cases, making it a useful temporizing device after a failed airway attempt during emergency airway management 12, 13, 14, 15. Most modern airway algorithms suggest using an extraglottic device as the first-line rescue technique for a failed airway in emergency airway management.

Because ILMA is a short-term solution to the problem of decreased ventilation, a more permanent airway must eventually be established. In addition to working as a ventilatory device, the ILMA also possesses an epiglottic-elevating bar to place the epiglottis in an anterior position to enable the device to be used as a conduit for endotracheal intubation. The standard method for this process is blind anterograde intubation of an endotracheal tube (ETT) through the ILMA (11). If blind intubation is unsuccessful, a bronchoscope can be used through the ILMA to place the ETT.

In retrograde intubation, a needle is used to puncture the trachea at the level of the cricothyroid membrane. Aspiration of air from the trachea is used to confirm that the needle has punctured the trachea before proceeding with retrograde placement of a guidewire which is passed up and out of the mouth (16). After placement of the guidewire, an obturator is placed anterograde over the guidewire, and an ETT is placed over the obturator through either a blind method or with fiber optic assistance (16). The vocal cords in the larynx do not need to be seen in retrograde intubation because the use of a guidewire helps to ensure that the ETT remains in the midline of the pharynx and is placed anteriorly into the trachea (17).

Section snippets

Case 1: Airway Trauma

A 24-year-old man presented to the ED after he was struck with a piece of lumber in an assault. Paramedics found him sitting on a curb; his face was bleeding and he was in respiratory distress. During ambulance transport, he had increasing stridor and respiratory distress with worsening subcutaneous emphysema in his neck. Upon arrival in the ED, he was unable to talk but was able to follow commands. He was spitting large quantities of blood but appeared to be keeping his airway clear. He

Discussion

In both cases described here, standard endotracheal intubation by rapid sequence intubation failed because of abnormal pharyngeal anatomy. An extraglottic device was placed to ventilate the patient, but there was difficulty passing the ETT through the ILMA during subsequent attempts to place a secure airway. Therefore, the decision was made to use retrograde intubation. In both cases, retrograde intubation proceeded with little difficulty and ventilation was maintained throughout the procedure

Why Should an Emergency Physician Be Aware of This?

The use of an extraglottic device as a temporizing airway followed by retrograde intubation facilitated these complex airway procedures. This combination of techniques may help emergency airway providers establish secure airways in patients who require rescue with an extraglottic device and are difficult to intubate.

Reprints are not available from the authors.

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