Successful Retrograde Intubation After Failed Fiberoptic Intubation and Percutaneous Cricothyrotomy

An obstructive neck lesion presents an airway challenge for any emergency physician. Retrograde intubation is an infrequently used airway alternative that can be employed in the difficult airway algorithm that requires little training and is less invasive than surgical cricothyrotomy.

We report a case of a 31-year-old male patient who presented with respiratory distress progressing to respiratory failure from upper airway obstruction. The patient had significant tracheal thickening at the level of the thyroid gland based on a computed tomography report from 3 weeks prior to his presentation. Awake upright fiberoptic intubation and subsequent percutaneous cricothyrotomy were unsuccessful secondary to obstructive neck mass. We performed a retrograde intubation via tracheal approach and secured the airway via manipulation of a small-diameter endotracheal tube over the guidewire using visualization with video laryngoscopy. This case describes a combination of difficult airway techniques utilizing retrograde intubation with a Glidescope (Verathon Inc., Bothell, WA) as a rescue maneuver for a difficult airway secondary to a tracheal obstruction and supraglottic and subglottic stenosis. Follow-up confirmed the patient's diagnosis as granulomatosis with polyangiitis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In cases of supraglottic and subglottic narrowing or mass lesions, retrograde intubation can be a life-saving technique that is an important consideration in the difficult airway algorithm. This technique may be combined with other difficult airway techniques and is especially relevant and potentially life-saving for patients in whom an open cricothyrotomy is undesirable, such as patients with a potentially vascular neck mass, subglottic stenosis, localized neck trauma, or morbid obesity.