In the Nick of Time-Emergency Front-of-Neck Airway Access

Emergency front-of-neck access refers to all techniques that deliver oxygen into the airway lumen through the anterior neck structures and encompasses access both through the cricothyroid membrane and the tracheal wall. There has yet to be a universal agreement regarding the preferred technique. A surgical incision is currently the most common approach in prehospital and in-hospital care. This review intends to review and summarize the existing clinical, basic science, and societal guidelines for eFONA.

Emergency front-of-neck access in pediatric anesthesia: A narrative review

BACKGROUND AND OBJECTIVES

Children undergoing airway management during general anesthesia may experience airway complications resulting in a rare but life-threatening situation known as "Can't Intubate, Can't Oxygenate". This situation requires immediate recognition, advanced airway management, and ultimately emergency front-of-neck access. The absence of standardized procedures, lack of readily available equipment, inadequate knowledge, and training often lead to failed emergency front-of-neck access, resulting in catastrophic outcomes. In this narrative review, we examined the latest evidence on emergency front-of-neck access in children.

METHODS

A comprehensive literature was performed the use of emergency front-of-neck access (eFONA) in infants and children.

RESULTS

Eighty-six papers were deemed relevant by abstract. Finally, eight studies regarding the eFONA technique and simulations in animal models were included. For all articles, their primary and secondary outcomes, their specific animal model, the experimental design, the target participants, and the equipment were reported.

CONCLUSION

Based on the available evidence, we propose a general approach to the eFONA technique and a guide for implementing local protocols and training. Additionally, we introduce the application of innovative tools such as 3D models, ultrasound, and artificial intelligence, which can improve the precision, safety, and training of this rare but critical procedure.

A case series of the Royal Perth Hospital cannula-first approach in the 'can't intubate, can't oxygenate' scenario

At the Royal Perth Hospital, we have been developing and teaching a can't intubate, can't oxygenate (CICO) rescue algorithm for over 19 years, based on live animal simulation. The algorithm involves a 'cannula-first' approach, with jet oxygenation and progression to scalpel techniques if required in a stepwise fashion. There is little reported experience of this approach to the CICO scenario in humans. We present eight cases in which a cannula-first Royal Perth Hospital approach was successfully implemented during an airway crisis. We recommend that institutions teach and practice this approach; we believe it is effective, safe and minimally invasive when undertaken by clinicians who have been trained in it and have immediate access to the requisite equipment. The equipment is low cost, comprising a 14G Insyte cannula, saline, 5 ml syringe and a Rapid-O2. Training can be provided using low-fidelity manikins or part-task trainers.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Current practice pattern among anaesthesiologists for difficult airway management: A nationwide cross-sectional survey

Background and Aims

The practice patterns for airway management vary among anaesthesiologists, depending on various setups and geographical divides. This survey assessed practice patterns in unanticipated difficult intubation and cannot intubate or cannot ventilate (CICV) situations/complete ventilation failure among Indian anaesthesiologists'.

Methods

A validated questionnaire of 22 items related to practice preferences for airway management among anaesthesiologists was sent to Indian Society of Anaesthesiologists members online through Google Forms and distributed manually to delegates in continuing medical education programme.

Results

A total of 535 responses were obtained and analysed. In unanticipated difficult laryngoscopy and intubation, the order of preference for alternative airway devices was video laryngoscope (VL, 60.1%), intubating laryngeal mask airway/laryngeal mask airway (23.5%), fibreoptic bronchoscope (13.5%) and optical stylets (1.2%). Advanced difficult airway devices were unavailable in most nursing homes and government non-teaching hospitals. Seventy per cent of respondents experienced CICV situations at least once, most during head and neck surgeries. In CICV situations, the order of choice for the front-of-neck airway access was cricothyroidotomy (CT) by narrow bore cannula (48.9%), tracheostomy by the surgeon (30%), Seldinger CT (12.5%), open surgical CT (5.4%) and scalpel bougie CT (3.2%).

Conclusion

The VL was the most preferred airway rescue device in unanticipated difficult intubation, and intravenous catheter cricothyroidotomy was the most selected technique in CICV situations.

Design and Implementation of Airway Response Teams to Improve the Practice of Emergency Airway Management

Emergency airway management (EAM) is a commonly performed procedure in the critical care setting. Despite clinical advances that help practitioners identify patients at risk for having a difficult airway, improved airway management tools, and algorithms that guide clinical decision-making, the practice of EAM is associated with significant morbidity and mortality. Evidence suggests that a dedicated airway response team (ART) can help mitigate the risks associated with EAM and provide a framework for airway management in acute settings. We review the risks and challenges related to EAM and describe strategies to improve patient care and outcomes via implementation of an ART.

2021 Update on airway management from the Anaesthesia Continuing Education Airway Management Special Interest Group

Airway Management is the key for anaesthetists dealing with patients undergoing diagnostic procedures and surgical interventions. The present coronavirus pandemic underpins even more how important safe airway management is. It also highlights the need to apply stringent precautions to avoid infection and ongoing transmission to patients, anaesthetists and other healthcare workers (HCWs). In light of this extraordinary global situation the aim of this article is to update the reader on the varied aspects of the ever-changing tasks anaesthetists are involved in and highlight the equipment, devices and techniques that have evolved in response to changing technology and unique patient and surgical requirements.

Complications of cricothyroidotomy versus tracheostomy in emergency surgical airway management: a systematic review

Background

Airway guidelines recommend an emergency surgical airway as a potential life-saving treatment in a “Can’t Intubate, Can’t Oxygenate” (CICO) situation. Surgical airways can be achieved either through a cricothyroidotomy or tracheostomy. The current literature has limited data regarding complications of cricothyroidotomy and tracheostomy in an emergency situation. The objective of this systematic review is to analyze complications following cricothyroidotomy and tracheostomy in airway emergencies.

Methods

This synthesis of literature was exempt from ethics approval. Eight databases were searched from inception to October 2018, using a comprehensive search strategy. Studies were included if they were randomized controlled trials or observational studies reporting complications following emergency surgical airway. Complications were classified as minor (evolving to spontaneous remission or not requiring intervention or not persisting chronically), major (requiring intervention or persisting chronically), early (from the start of the procedure up to 7 days) and late (beyond 7 days of the procedure).

Results

We retrieved 2659 references from our search criteria. Following the removal of duplicates, title and abstract review, 33 articles were selected for full-text reading. Twenty-one articles were finally included in the systematic review. We found no differences in minor, major or early complications between the two techniques. However, late complications were significantly more frequent in the tracheostomy group [OR (95% CI) 0.21 (0.20–0.22), p < 0.0001].

Conclusions

Our results demonstrate that cricothyroidotomies performed in emergent situations resulted in fewer late complications than tracheostomies. This finding supports the recommendations from the latest Difficult Airway Society (DAS) guidelines regarding using cricothyroidotomy as the technique of choice for emergency surgical airway. However, emergency cricothyroidotomies should be converted to tracheostomies in a timely fashion as there is insufficient evidence to suggest that emergency cricothyrotomies are long term airways.

A pilot study evaluating the utility of a novel tube cricothyrotomy technique in providing ventilation in small animals using a live porcine model

Background

Tube cricothyrotomy has been suggested as a first-choice for emergency surgical airway access in small animals, rather than the more commonly accepted procedures of tracheotomy and needle cricothyrotomy.

Methods

A small pilot study of tube cricothyrotomy in a live porcine model was conducted to evaluate this method. The technique was modified to permit the use of commonly available equipment and ease of application. Following ethics approval, a tube cricothyrotomy was performed on 9 live pigs. The endpoints were the efficacy of ventilation through the tube as measured by end-tidal carbon dioxide, successful placement of the tube and the time taken for placement.

Results

Of the nine pigs, eight had a tube placed successfully, with the median procedure time being 111.5 seconds (range: 35–240 seconds). After 10 mins, the mean end-tidal carbon dioxide was 58.3 mmHg (95% CI: 55.2–61.3 mmHg), with a range of 54–64 mmHg. Tube cricothyrotomy holds promise as a means of rapidly obtaining tracheal access in small animals and temporarily sustaining ventilation in an emergency.

Conclusion

Further detailed investigation is warranted to assess the use of this technique in the small animal emergency setting.

Transtracheal jet oxygenation: Comparing the efficacy and safety of two self-made Y-connector devices with the ENK oxygen flow modulator™ in an infant animal model

BACKGROUND

Self-made Y-connector jet-oxygenation devices with wide-bore expiratory port have been described but not evaluated in infant models. Little is known about the effect of oxygen flow rates on jet oxygenation via transtracheal cannula.

AIMS

The aim of this study was to compare two self-made Y-connector jet-oxygenation devices against the ENK oxygen flow modulator™, and the effects of three different oxygen flow rates based on body weight, in both unobstructed and obstructed airways, on the time to re-oxygenate in a rabbit infant model. The aim was also to assess the effectiveness of an oxygen flow rate of 1 L/min, for re-oxygenation using ENK oxygen flow modulator™.

METHODS

Nine rabbits were grouped in threes: Group 1 had a Y-connector attached to an intravenous infusion tubing, Group 2 the same Y-connector attached to a perfusion oxygenator tubing and Group 3, ENK oxygen flow modulator™. From oxygen saturations of 75%, the rabbits were jet oxygenated using their assigned device for 10 minutes at each flow rate of 1 L/kg/min, 1.5 L/kg/min and 2 L/kg/min with their airways unobstructed and later, obstructed. Group 3 had additional experiments involving an absolute oxygen flow rate of 1 L/min.

RESULTS

All devices resulted in rapid re-oxygenation within 40 seconds at flow rates of 1 L/kg/min. Oxygen flow rates beyond 1 L/kg/min in obstructed airways resulted in high airway pressures. All rabbits in Group 3 with obstructed airways died from barotrauma when jet oxygenated at a flow rate of 1.5 L/kg/min. When an oxygen flow rate of 1 L/min was used in Group 3, there was a failure to re-oxygenate to SpO₂ 90% within 120 seconds in some rabbits.

CONCLUSION

Our animal model results suggest that self-made Y-connector jet-oxygenation devices with wide-bore expiratory port are efficacious and perhaps safer than ENK oxygen flow modulator™ in obstructed airways, and jet oxygenation with minimal oxygen flow rates starting at 1 L/kg/min or (age [years] + 4) L/min, whichever lower, should be considered.

Use of a trans-tracheal rapid insufflation of oxygen device in a "cannot intubate, cannot oxygenate" scenario in a parturient -a case report

Background

The trans-tracheal rapid insufflation of oxygen (TRIO) device is less commonly used and is an alternative to trans-tracheal jet ventilation for maintaining oxygenation in a "cannot intubate, cannot oxygenate" (CICO) scenario.

Case

We report the successful use of this device to maintain oxygenation after jet ventilator failure in a parturient who presented with the CICO scenario during the procedure for excision of laryngeal papilloma.

Conclusions

A stepwise approach to the airway plan and preparation for an event of failure is essential for good materno-fetal outcomes. The TRIO device may result in inadequate ventilation that can lead to hypercarbia and respiratory acidosis. Hence, it should only be used as a temporizing measure before a definitive airway can be secured.

Management of the airway in maxillofacial surgery: part 1

In part 1 of this review of management of the airway in maxillofacial surgery we discuss preoperative assessment of the airway, and the practical means to deal with difficulties. We review the evidence for videolaryngoscopy and flexible indirect laryngoscopy, together with surgical access to the airway including tracheostomy, cricothyroidotomy, and submental intubation.