Comparison of Open Dilatational Tracheostomy with Conventional Pediatric Tracheostomy in a Growing Animal Model

Emergency front-of-neck access in infants: A pragmatic crossover randomized control trial comparing two approaches on a simulated rabbit model

BACKGROUND

Rapid-sequence tracheotomy and scalpel-bougie tracheotomy are two published approaches for establishing emergency front-of-neck access in infants. It is unknown whether there is a difference in performance times and success rates between the two approaches.

AIMS

The aim of this cross-over randomized control trial study was to investigate whether the two approaches were equivalent for establishing tracheal access in rabbit cadavers. The underlying hypothesis was that the time to achieve the tracheal access is the same with both techniques.

METHODS

Between May and September 2022, thirty physicians (pediatric anesthesiologists and intensivists) were randomized to perform front-of-neck access using one and then the other technique: rapid-sequence tracheotomy and scalpel-bougie tracheotomy. After watching training videos, each technique was practiced four times followed by a final tracheotomy during which study measurements were obtained. Based on existing data, an equivalence margin was set at ∆ = ±10 s for the duration of the procedure. The primary outcome was defined as the duration until tracheal tube placement was achieved successfully. Secondary outcomes included success rate, structural injuries, and subjective participant self-evaluation.

RESULTS

The median duration of the scalpel-bougie tracheotomy was 48 s (95% CI: 37-57), while the duration of the rapid-sequence tracheotomy was 59 s (95% CI: 49-66, p = .07). The difference in the median duration between the two approaches was 11 s (95% CI: -4.9 to 29). The overall success rate was 93.3% (95% CI: 83.8%-98.2%). The scalpel-bougie tracheotomy resulted in significantly fewer damaged tracheal rings and was preferred among participants.

CONCLUSIONS

The scalpel-bougie tracheotomy was slightly faster than the rapid-sequence tracheotomy and favored by participants, with fewer tracheal injuries. Therefore, we propose the scalpel-bougie tracheostomy as a rescue approach favoring the similarity to the adult approach for small children. The use of a comparable equipment kit for both children and adults facilitates standardization, performance, and logistics.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT05499273.

"Cannot intubate, cannot oxygenate": A novel 2-operator technique for cannula tracheotomy in an infant animal model-a feasibility study

BACKGROUND

Evidence regarding optimal management of the "Cannot Intubate, Cannot Oxygenate" (CICO) scenario in infants is scarce. When inserting a transtracheal cannula for front of neck access direct aspiration to confirm intratracheal location is standard practice. This postmortem "infant airway" animal model study describes a novel technique for cannula tracheotomy.

AIMS

To compare a novel technique of cannula tracheotomy to an accepted technique to assess success and complication rates.

METHODS

Two experienced proceduralists repeatedly performed tracheotomy using an 18-gauge BD InsyteTM cannula (BD, Franklin Lakes, NJ, USA) in 6 postmortem White New Zealand rabbits. Cannulas were attached either directly to a 5ml syringe (Direct Aspiration) or via a 25 cm length minimum volume extension tubing set (TUTA Healthcare Lidcombe, NSW, Australia) (Indirect Aspiration, 2 operator technique). Each technique was attempted a maximum of 12 times per rabbit with an ENT surgeon assessing success and complication rates endoscopically for each attempt.

RESULTS

72 tracheotomy attempts were made in total, 36 for each technique. Initial aspiration through the needle was achieved in 93% (97.2% direct versus 89% indirect). Advancement of the cannula and continued aspiration (success) into the trachea occurred in 67% for direct compared with 64% for indirect aspiration. Direct aspiration was associated with higher rates of lateral (10.3% versus 5.6%) and posterior (19.4% versus 13.9%) wall injury compared with the indirect 2-operator technique.

CONCLUSION

Cannula tracheotomy in infant-sized airways is technically difficult and seems frequently associated with tracheal wall injury. The reduced incidence of injury in the indirect group warrants further investigation in preclinical and clinical trials.

The 'Can't intubate can't oxygenate' scenario in pediatric anesthesia: a comparison of the Melker cricothyroidotomy kit with a scalpel bougie technique

BACKGROUND

While the majority of pediatric intubations are uncomplicated, the 'Can't intubate, Can't Oxygenate' scenario (CICO) does occur. With limited management guidelines available, CICO is still a challenge even to experienced pediatric anesthetists.

OBJECTIVES

To compare the COOK Melker cricothyroidotomy kit (CM) with a scalpel bougie (SB) technique for success rate and complication rate in a tracheotomy on a cadaveric 'infant airway' animal model.

METHODS

Two experienced proceduralists repeatedly attempted tracheotomy in eight rabbits, alternately using CM and SB (4 fr) technique. The first attempt was performed at the level of the first tracheal cartilage with subsequent experimental trials of insertion progressively more caudad. Success was defined as intratracheal placement of cannula as seen on bronchoscope. Complications were assessed both by bronchoscopic and macropathological appearance.

RESULTS

32 attempts were made at tracheotomy. CM had an overall success rate of 100% compared to a 75% success rate for SB. Success rate for the first attempt was dependent on the level of the tracheotomy (Level 1 100%, level 2 62.5% and level 3 & 4 25%). While CM was associated with lateral and/or posterior wall damage on bronchoscopy/macropathology in 6% of 19% and 25% of 50% respectively, the damage observed was greater and more frequent with SB (19%/44% and 31%/50%, respectively).

CONCLUSIONS

At level 1, the first attempt success rate was 100% for both devices. Overall CM showed a better success rate than SB; however, both techniques were associated with significant complication rates, which were more pronounced following the scalpel bougie technique.

Tubeless tracheotomy for survival airway surgery in the leporine model

OBJECTIVES/HYPOTHESIS

The ideal animal experimental tracheostomy technique is one that is 1) safe and easy to perform, 2) requires no tracheostomy tube, and 3) requires minimal cleaning or suctioning to maintain patency. The leporine model for airway injury has been well established and offers an inexpensive and practical animal model for experimental evaluation. However, previous research has demonstrated a high mortality rate with survival airway surgery in rabbits. This study demonstrates the feasibility of airway management in the leporine model using a simple maturing suture tracheostomy that avoids a tracheostomy tube.

STUDY DESIGN

Tracheostomy was performed in six New Zealand white rabbits in the setting of survival surgery over a 2-week study period.

METHODS

A vertical tracheal incision was made from the second to the sixth tracheal ring. The anterior portion of the tracheal rings was removed and the skin surrounding the stoma was sutured down to the tracheal wall. The lateral tracheal wall was then suspended to the soft tissue in the lateral neck.

RESULTS

All six rabbits survived the study period with minimal care and maintained stoma patency until sacrifice. Granulation tissue and edema were noted during the first week and largely resolved by the second week. An average of 5-mm-diameter stoma was measured 14 days after surgery without intraluminal stenosis or laryngeal edema.

CONCLUSIONS

This method meets the defined criteria for the ideal experimental tracheostomy, demonstrating potential benefit in a laryngotracheal stenosis model and a rabbit model of evoked phonation.

The 'Can't Intubate Can't Oxygenate' scenario in Pediatric Anesthesia: a comparison of different devices for needle cricothyroidotomy

BACKGROUND

Little evidence exists to guide the management of the 'Can't Intubate, Can't Oxygenate' (CICO) scenario in pediatric anesthesia.

OBJECTIVES

To compare two intravenous cannulae for ease of use, success rate and complication rate in needle tracheotomy in a postmortem animal model of the infant airway, and trial a commercially available device using the same model.

METHODS

Two experienced proceduralists repeatedly attempted cannula tracheotomy in five postmortem rabbits, alternately using 18-gauge (18G) and 14-gauge (14G) BD Insyte(™) cannulae (BD, Franklin Lakes, NJ, USA). Attempts began at the first tracheal cartilage, with subsequent attempts progressively more caudad. Success was defined as intratracheal cannula placement. In each rabbit, an attempt was then made by each proceduralist to perform a cannula tracheotomy using the Quicktrach Child(™) device (VBM Medizintechnik GmbH, Sulz am Neckar, Germany).

RESULTS

The rabbit tracheas were of similar dimensions to a human infant. 60 attempts were made at cannula tracheotomy, yielding a 60% success rate. There was no significant difference in success rate, ease of use, or complication rate between cannulae of different gauge. Successful aspiration was highly predictive (positive predictive value 97%) and both sensitive (89%) and specific (96%) for tracheal cannulation. The posterior tracheal wall was perforated in 42% of tracheal punctures. None of 13 attempts using the Quicktrach Child(™) were successful.

CONCLUSION

Cannula tracheotomy in a model comparable to the infant airway is difficult and not without complication. Cannulae of 14- and 18-gauge appear to offer similar performance. Successful aspiration is the key predictor of appropriate cannula placement. The Quicktrach Child was not used successfully in this model. Further work is required to compare possible management strategies for the CICO scenario.