Background. Retrograde intubation is useful for obtaining endotracheal access when direct laryngoscopy proves difficult. The technique is a practical option in the “cannot intubate / can ventilate” scenario. However, it is equally useful as an elective technique in awake patients with anticipated difficult airways. Many practitioners report difficulty successfully advancing the endotracheal tube due to anatomical obstructions and the acute angle of the anterograde guide. The purpose of this study was to test whether a more caudal tracheal puncture would increase the success rate. Methods. Twenty-four anesthesiology residents were randomly assigned to either a cricothyroid or a cricotracheal puncture group. Each was instructed how to perform the technique and then attempted it on a manikin at their assigned site. Data collection included whether the trachea was intubated, the number of attempts required, and the total time. Results. Both groups displayed a high degree of success. While the group assigned to the cricotracheal site required significantly more time to perform the procedure, they accomplished it in fewer attempts than the cricothyroid group. Conclusion. Retrograde intubation performed via a cricotracheal puncture site, while more time consuming, resulted in fewer attempts to advance the endotracheal tube and may reduce in vivo laryngeal trauma. 1. Introduction Retrograde intubation of the trachea (RI) is an established airway management technique that can be used to place an endotracheal tube (ETT) when more conventional methods (e.g., direct laryngoscopy) have failed. The American Society of Anesthesiologists (ASA) difficult airway algorithm groups RI with other techniques (laryngeal mask airway (LMA), fiberoptic intubation, light wand, etc.) in the nonemergency limb of the pathway (i.e., cannot intubate but can ventilate the patient with either a mask or an LMA [1]). RI also has a role in the elective management of the difficult airway, where its chief strength is that it requires no visualization of the glottic structures. Hence, it can be performed in an airway that is soiled with blood or secretions—conditions that could make a fiberoptic intubation difficult or impossible [2]. It can be performed under general anesthesia with spontaneous or assisted ventilation but can also be performed under MAC or solely with the application of topical anesthesia to the airway. RI has been documented in pediatric patients as young as 5 months old [3]. The elective use of RI has been well documented in patients with angioedema [4], deep neck
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