RETROGRADE

INTUBATION
 Premedication :
1) Antisialagogue ½ hour prior to induction
- Allows better application of local
anesthetic drugs.
- Improves visualization by drying
secretions.
2) Minimal sedation may be given to decrease
anxiety. (Avoid deep sedation)
 Preparation:
 Nasal patency checked.
 Xylometazoline drops put in the
nostrils.
 Adrenaline soaked pack inserted in the same
nostril using forceps. ( causes decongestion and
vasoconstriction hence minimizes bleeding
during intubation.)
 For awake patient airway is anesthetized as in
fibreoptic intubation.
 Airway Anaesthesia
 Oral cavity – 2% Lignocaine viscous

 Nose - 4% Lignocaine + Decongestant

 Nasopharynx - 4%Lignocaine
 Preparation:
Main sensory supply is 5th , 9th and 10th
cranial nerves.
- Nose and nasopharygeal airway anesthetized by
using 4% lignocaine nebulization.
- 10% lignocaine spray instilled through nose or
directly into oropharynx.
- Gargles with 2% lignocaine viscous solution to
achieve anesthesia of oropharynx.
- Glossopharyngeal nerve and superior laryngeal
nerve blocks are given to eliminate gag reflex and
minimize response to intubation.
 Glossopharygeal nerve block
( lingual branch of 9th nerve)

 Tongue gently retracted exposing palatoglossal arch.

The arch is pierced approximately 0.5 cms from the
lateral margin of the rest of the tongue at the point at
which it joins floor of the mouth.

 2ml of 2% lignocaine injected using 25 G spinal needle

on either side. Length of the spinal needle allows the
syringe to be outside the mouth.
Superior laryngeal nerve block

External approach Transoral approach

Using 23 G hypodermic needle Lignocaine soaked pledget
2ml of 2% lignocaine injected kept in pyriform fossa.
on either side at the greater cornu
of hyoid bone.

2 ml 2% lignocaine
 Transtracheal injection :

Trachea is anesthetized by transtracheal

injection. Cough induced by injection produces
excellent spread of drug below vocal cords.

2ml 4% lignocaine
 RETROGRADE INTUBATION:
 Patient is able to open mouth partially just
enough to retrieve catheter by finger.

 Preparation of the airway as discussed.

 Neck is scrubbed.
 Cricothyroid puncture done under LA with 18 G
tuohy needle. Needle is angled cephaled and
directed towards pharynx.
 18 G epidural catheter is inserted into trachea
via needle.
 The catheter retrieved from pharynx either by
patient himself or anesthesiologist.
 Tuohy needle retrieved keeping the catheter in
situ.
 Soft rubber catheter introduced through the
nose and brought out through mouth.
 Epidural catheter and the rubber catheter tied
to each other tightly.
 The epidural catheter is pulled out of the
nose by pulling the suction catheter and the
suction catheter is detached once the
epidural catheter comes out of nose.
 ETT is inserted over the epidural catheter by
keeping the catheter taut.
 Once the tip of the ETT reaches cricothyroid
membrane , epidural catheter cut near the
skin and removed from above and the ETT is
advanced into trachea.
Cricothyroid puncture
Threading of epidural catheter
Railroading of ETT
 SUBMENTAL INTUBATION

 It is the route of intubation used in cases of

maxillofacial surgeries where both nasal and oral
intubation are contraindicated.
 Example: In case of Leforte I & II fractures surgeons
require maxillo-mandibular fixation intraoperatively.
 Oral intubation is obsolete in such cases.

 Nasal intubation is avoided in fear of displacing the

fractures or causing CSF rhinorrhoea or meningitis.
 Initially tracheostomy was the only option available
in such cases but now a days with submental
intubation technique, the morbidity associated with
tracheostomy is avoided.
 Procedure :

 Induction done by conventional method.

 Orotracheal flexometallic tube used for intubation.

Throat packing done.

 Cutaneous incision in the submental region which

is extended intraorally, safegaurding the
submandibular glands duct.
 Laryngoscopy done and the tube disconnected
from circuit. The universal connector
disconnected.

 The proximal end of the tube held with

magills forceps and the end taken out from the
submental incision outside the oral cavity and
reconnected to the circuit. The pilot balloon
also taken out.
 Tube position confirmed with end tidal CO2
monitoring and chest auscultation. Now the
tube doesn’t come in way of interdental
occlusion.

 At the end of surgery the interdental

occlusion released and tube again brought out
from the oral cavity and submental incision
sutured. Patient extubated after reversal.
 COMPLICATIONS
Infections
Orocutaneous fistula

 CONTRAINDICATION
Infection at submental site.
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