Authors: Sugiyama D et al.
Anesthesiology 144(4):965–966, April 2026
Summary:
This brief clinical report revisits retrograde intubation as a critical rescue airway technique, emphasizing its continued relevance despite the widespread adoption of video laryngoscopy. While modern airway tools have significantly improved visualization, the authors highlight that certain scenarios—such as airway tumors, severe distortion, or bleeding—can render even advanced devices ineffective.
The article presents a case of a patient with maxillary gingival carcinoma in whom conventional intubation was not feasible. A hybrid technique was used, combining retrograde guidewire placement through the cricothyroid membrane with flexible bronchoscopy. This approach allowed controlled, visually guided advancement of the endotracheal tube while maintaining spontaneous ventilation—an important consideration in difficult airway cases.
The technique involves passing a guidewire cephalad through the trachea and retrieving it orally, then using it to guide a bronchoscope-mounted endotracheal tube into the trachea. The addition of bronchoscopy improves upon traditional blind retrograde intubation by allowing direct visualization of the wire crossing the vocal cords, reducing trauma and increasing success.
The authors argue that although rarely used today, retrograde intubation remains an indispensable skill, particularly in “can’t see” airways where both direct and video laryngoscopy fail. Integrating it with modern tools enhances both safety and practicality.
Key Points:
- Retrograde intubation remains a valuable rescue technique in difficult airways
- Particularly useful when visualization is impossible (tumors, bleeding, distortion)
- Hybrid approach with bronchoscopy improves safety and success
- Allows maintenance of spontaneous ventilation during airway management
- Should remain part of the anesthesiologist’s skill set despite modern devices
What You Should Know:
This is one of those techniques you hope you never need—but when you do, nothing else works. Video laryngoscopy doesn’t solve every airway. Keeping retrograde intubation in your toolbox can be the difference between control and chaos in a true difficult airway.
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