Retrograde nasal intubation using nasogastric tube saves the day.

Sir,

A 26-year-old, 40 kg weight, female patient was posted for the release of postburn contracture neck followed by skin grafting. Airway assessment revealed a thick contracture on the neck and chest with no neck mobility and flexion deformity. Mouth opening was less than one finger breadth [Figure 1]. Cervical spine X-ray showed the deviation of trachea toward the right. Awake fiber optic nasotracheal intubation was planned. The patient was informed about details of the procedure, routine monitors attached, vitals checked to be within normal limits and intravenous (i.v.) access secured. Patient was given (injection) glycopyrrolate 0.2 mg intramuscularly, (injection) ranitidine 50 mg i.v. (injection) ondansetron 6 mg i.v., and xylometazoline nasal drops. Upper airway was anesthetized using nasal pledgets, mouth gargles, and nebulization of lignocaine. (Injection) midazolam 1 mg i.v. and (injection) fentanyl 80 µg i.v. were administered. Fiber optic intubation was unsuccessful due to distorted laryngeal anatomy and secretions obstructing a clear view. Tracheostomy consent was taken, but in order to make it possible, the contracture was released partly after local skin infiltration with 10 ml of 0.25% bupivacaine.

Figure 1

Patient with postburn contracture and difficult airway

Since tracheostomy would have interfered in the surgical field, we decided to try retrograde nasal intubation with a standby tracheostomy arrangement. Cricothyroid membrane was punctured with 14 gauge cannula used for central venous cannulation. To worsen the situation and complicate the scenario, the guide wire fell down while being handed over. The unexpected situation prompted us to use a nasogastric tube (NGT) (Romsons® Scientific and Surgical Industries Private Limited, Agra, India.) as an alternative to guide wire. The cannula was removed and the distal end of 14 French gauges NGT introduced through the puncture site facing cephalad and advanced slowly till it emerged out from the right nostril [Figure 2]. A cuffed flexometallic endotracheal tube (ETT) size 7.0 was railroaded over it after removing its connector. Once ETT was 24 cm in and palpable at the puncture site, the cuff was inflated, NGT withdrawn, ETT tube connector reattached, bilateral lungs air entry checked, and reconfirmed with capnography. The procedure took about 110 seconds. The patient was comfortable, sedated, breathing spontaneously, and maintaining normal vital signs. She was then given general anesthesia as per the standard guidelines. After completion of the surgery, anesthesia was reversed, and trachea extubated successfully.

Figure 2

The nasogastric tube emerging through right nostril

Retrograde tracheal intubation was first described by Butler and Cirillo[1] in 1960. While it may never have the popularity of other airway management techniques, it is an useful alternative in some difficult intubation situations where ventilation is secured, such as trauma, upper airway masses, bleeding, secretions or anatomical anomalies.[2] Recent advances including the combination of retrograde intubation and fiber optic bronchoscopy,[3] using ultrasound guidance,[4] and Cook® Retrograde Intubation Sets have renewed interest in this old technique.

Though the procedure has many complications and a variable success rate,[5] our purpose was served successfully in a “cannot intubate” scenario where tracheostomy seemed avoidable. NGT served as a viable alternative to guide wire in a difficult situation as it was sterile, had adequate length and had a blunt (atraumatic) but stiff (because of lead balls) distal end. Thus, with wise decision making in a crisis situation and timely intervention, any prolonged morbidity to the patient was averted: aptly said – drowning man will clutch at a straw.