Percutaneous vs surgical emergency cricothyroidotomy: An experimental randomized crossover study on an animal-larynx model

Favour the best in case of emergency cricothyroidotomy-a randomized cross-over trial on manikin focused training and simulation of common devices

Background

Performing an emergency cricothyroidotomy (EC) is extremely challenging, the devices used should be easy to handle and the selected technique reliable. However, there is still an ongoing debate concerning the most superior technique.

Methods

Three different techniques were compared using a standardized, simulated scenario regarding handling, performing, training and decision making: The scalpel-bougie technique (SBT), the surgical anatomical preparation technique (SAPT) and the Seldinger technique (ST). First, anaesthesia residents and trainees, paramedics and medical students (each group n = 50) performed a cricothyroidotomy randomly assigned with each of the three devices on a simulator manikin. The time needed for successful cricothyroidotomy was the primary endpoint. Secondary endpoints included first-attempt success rate, number of attempts and user-satisfaction. The second part of the study investigated the impact of prior hands-on training on both material selection for EC and on time to decision-making in a simulated "cannot intubate cannot ventilate" situation.

Results

The simulated scenario revealed that SBT and SAPT were significantly faster than percutaneous EC with ST (p < 0.0001). Success rate was 100% for the first attempt with SBT and SAPT. Significant differences were found with regard to user-satisfaction between individual techniques (p < 0.0001). In terms of user-friendliness, SBT was predominantly assessed as easy (87%). Prior training had a large impact regarding choice of devises (p < 0.05), and time to decision making (p = 0.05; 180 s vs. 233 s).

Conclusion

This study supports the use of a surgical technique for EC and also a regular training to create familiarity with the materials and the process itself.The trial was registered before study start on 11.11.2018 at ClinicalTrials.gov (NCT: 2018-13819) with Nicole Didion as the principal investigator.

Video Versus Nonvideo in a Rabbit Training Model for Establishing an Emergency Front of Neck Airway in Children: A Prospective Trial

OBJECTIVES

Simulating a realistic "cannot intubate, cannot oxygenate" (CICO) situation to train an "emergency front of neck airway" is difficult. It further remains unclear if provision of regular technical refreshers improves performance in the setting of a real CICO situation. The purpose of this prospective study on an established surgical rabbit cadaver tracheostomy model was to evaluate the benefit of viewing training material shortly before performing "emergency front of neck airway."

METHODS

Previously trained participants were randomized into 2 groups. The control group (video) was allowed to watch an instructional video before performing a tracheotomy on the training model, while the study group (nonvideo) was not. Queried outcomes included success rate, performance time, and severe secondary airway injuries between the 2 groups.

RESULTS

In 29 tracheotomies performed by 29 participants, the overall success rate was 86% (92% video; 81% nonvideo, P = 0.4). Performance time was not different between the 2 groups (video: 80 s [IQR25-75: 53-86], nonvideo 64 s [IQR25-75: 47-102]; P = 0.93). Only in the nonvideo group, the performance time and the time between the workshops correlated positively (P = 0.048). Severe secondary injuries were noted in 4 of 29 rabbit cadavers, 2 in each group. Watching a refresher video before performing an emergency surgical tracheostomy in an infant training model did not influence the success rate and the performance time in previously trained anesthetists.

CONCLUSIONS

These results highlight the ease of learning, memorization, and recall of this emergency surgical tracheostomy technique and may demonstrate its applicability in a real infant CICO situation.

[Ultrasound supported identification of the ligamentum conicum in teaching head and neck sonography]

OBJECTIVE

Upper airway obstructions are usually acute emergencies. Coniotomy is the last option to secure the airway and can be supported by sonography. The aim of this study was to establish a training program to teach these skills.

MATERIAL AND METHODS

The training consisted of theoretical training with an additional video presentation (10 minutes each) and practical training (45 minutes). Evaluations were completed before (T1) and after (T2) the training to measure prior experience and satisfaction with the training as well as subjective and objective competence levels. At T2, a practical test was also completed by n=113 participants. A standardized evaluation form was used to document the results of the practical test.

RESULTS

A large proportion of the participants had neither seen a coniotomy (64.6%) nor performed one independently (79.6%). Significant improvement (T1 to T2) was measured with regard to the subjective assessment of competence (p<0.001). The training received positive ratings for all items tested (scale ranges 1-2). During practical tests, the participants achieved an average of 89.2% of the possible points and needed a mean of 101 ±23 seconds to identify the conic ligament.

CONCLUSION

Structured training for sonographic identification of the conic ligament leads to significant improvement in the subjective assessment of competence and a high objective competence level in a short period of time. This type of training should be standardized in head and neck ultrasound training in the future.

[The correct way to deal with the definitive surgical airway]

Dealing with a difficult airway is familiar to emergency care providers in both the prehospital and clinical settings. In anesthesiology and emergency medical care different algorithms almost equal in their wording have been introduced, indicating that an emergency front of neck airway access (eFONA) has to be established in the case of a cannot ventilate-cannot oxygenate situation. In a survey (Surveymonkey®) data concerning the level of experience with eFONA, devices required, previous training and complications were allocated among acute and emergency care providers of different backgrounds (doctors and paramedics). Furthermore, we asked about individual attitudes to and frequency of previous situations, in which an eFONA was not established despite strong indications. Of the respondents 15% (n = 63) answered that they had experienced this type of situation. eFONA had been performed by 28% of the interviewed (n = 117), reflecting the high number of military and EMT (emergency medical team) physicians participating in the survey. The number of experiences are rarely representative for the civilian setting. Different adjuncts may be helpful to detect the cricothyroid ligament. To use ultrasound seems obvious but it doubles the time for the detection of the cricothyroid ligament. Laryngeal masks can be employed as a supraglottic airway device (SAD) during "plan B". Stabilizing the airway with a SAD almost doubles the success of identifying laryngeal landmarks in females. The crew resource management (CRM) guidelines are more than essential in threatening situations demanding measures like eFONA. Providers should anticipate emerging problems and whenever feasible call for help and finally speak up. Naming a failed airway should be avoided as it implies a failure of the provider or of the entire airway team. In fact, the term non-accessible airway should be introduced. This might help to avoid the implication of a major failure. So far, an ideal simulator to train eFONA has not been introduced but it is mandatory to train procedures and algorithms on different types of simulators and manikins to achieve mastery.

Scalpel cricothyrotomy versus punctured cricothyrotomy in the context of the CICO crisis. A systematic review and Meta-analysis

IMPORTANCE

The preferential use of a scalpel (SCT) or puncture techniques (PCT) for cricothyrotomy remains a controversial topic.

OBJECTIVE

We performed a systematic review and meta-analysis comparing puncture cricothyrotomy with scalpel cricothyrotomy using overall success rate, first-time success rate, and time taken to perform the procedure as the primary outcome together with complications as a secondary outcome.

EVIDENCE REVIEW

Pubmed databases, EMBASE databases, MEDLINE, Google Scholar, and Cochrane Central Register of Controlled Trials, from 1980 to October 2022.

FINDINGS

A total of 32 studies were included in the systematic review and meta-analysis. It also showed that PCT was close to SCT in terms of overall success rate (82.2% vs. 82.6%, Odd Ratios OR = 0.91, [95%CI: 0.52-1.58], p = 0.74) as well as first-performance success rate (62.9% vs. 65.3%, OR = 0.52, [0.22-1.25], p = 0.15). PCT does not compare favorably with SCT in terms of required time for the procedure (the mean time required for PCT versus SCT incision in the intervention groups was 0.34 standard deviations higher (Mean Difference MD = 17.12, [3.37-30.87], p = 0.01) as well as complications (21.4% vs. 15.1%, Relative Risk RR = 1.49, [0.80-2.77], p = 0.21).

CONCLUSIONS AND RELEVANCE

The results show that SCT has an advantage over PCT in terms of time required for the procedure, while there is no difference in overall success rate, first-time success rate after training, and complications. The superiority of SCT may be the result of fewer and more reliable procedural steps. However, the level of evidence is low (GRADE).

Comparison of emergency surgical cricothyroidotomy and percutaneous cricothyroidotomy by experienced airway providers in an obese, in vivo porcine hemorrhage airway model

BACKGROUND

Emergency front-of-neck airway (eFONA) is a life-saving procedure in "cannot intubate, cannot oxygenate" (CICO). The fastest and most reliable method of eFONA has not been determined. We compared two of the most advocated approaches: surgical cricothyroidotomy and percutaneous cricothyroidotomy, in an obese, in vivo porcine hemorrhage model, designed to introduce real-time physiological feedback, relevant and high provider stress. The primary aim was to determine the fastest method to secure airway. Secondary aims were arterial saturation and partial pressure of oxygen, proxy survival and influence of experience.

METHODS

Twelve pigs, mean weight (standard deviation, SD) (60.3 ± 4.1) kg, were anesthetized and exposed to 25-35% total blood volume hemorrhage before extubation and randomization to Seldinger technique "percutaneous cricothyroidotomy" (n = 6) or scalpel-bougie-tube technique "surgical cricothyroidotomy" (n = 6). Specialists in anesthesia and intensive care in a tertiary referral hospital performed the eFONA, simulating an actual CICO-situation.

RESULTS

In surgical cricothyroidotomy vs. percutaneous cricothyroidotomy, the median (interquartile range, IQR) times to secure airway were 109 (IQR 71-130) s and 298 (IQR 128-360) s (P = 0.0152), arterial blood saturation (SaO₂) were 74.7 (IQR 46.6-84.2) % and 7.9 (IQR 4.1-15.6) % (P = 0.0167), pO₂ were 7.0 (IQR 4.7-7.7) kPa and 2.0 (IQR 1.1-2.9) kPa (P = 0.0667), and times of cardiac arrest (proxy survival) were 137-233 s, 190 (IQR 143-229), from CICO. All six animals survived surgical cricothyroidotomy, and two of six (33%) animals survived percutaneous cricothyroidotomy. Years in anesthesia, 13.5 (IQR 7.5-21.3), did not influence time to secure airway.

CONCLUSION

eFONA by surgical cricothyroidotomy was faster and had increased oxygenation and survival, when performed under stress by board certified anesthesiologists, and may be an indication of preferred method in situations with hemorrhage and CICO, in obese patients.

Emergency cricothyroidotomy in difficult airway simulation – a national observational study of Air Ambulance crew performance

Background

Advanced prehospital airway management includes complex procedures carried out in challenging environments, necessitating a high level of technical and non-technical skills. We aimed to describe Norwegian Air Ambulance-crews’ performance in a difficult airway scenario simulation, ending with a “cannot intubate, cannot oxygenate”-situation.

Methods

The study describes Air Ambulance crews’ management of a simulated difficult airway scenario. We used video-observation to assess time expenditure according to pre-defined time intervals and technical and non-technical performance was evaluated according to a structured evaluation-form.

Results

Thirty-six crews successfully completed the emergency cricothyroidotomy with mean procedural time 118 (SD: ±70) seconds. There was variation among the crews in terms of completed procedural steps, including preparation of equipment, patient- monitoring and management. The participants demonstrated uniform and appropriate situational awareness, and effective communication and resource utilization within the crews was evident.

Conclusions

We found that Norwegian Air Ambulance crews managed a prehospital “cannot intubate, cannot oxygenate”-situation with an emergency cricothyroidotomy under stressful conditions with effective communication and resource utilization, and within a reasonable timeframe. Some discrepancies between standard operating procedures and performance are observed. Further studies to assess the impact of check lists on procedural aspects of airway management in the prehospital environment are warranted.

Depth to the airway lumen at the level of the cricothyroid membrane measured by ultrasound

BACKGROUND

Knowing the likely depth to the airway before emergency cricothyroidotomy may improve success in cases where it cannot be measured. Our aim was to measure the depth to the airway at the cricothyroid membrane by ultrasound in a large group of adult patients.

METHOD

Prospective, observational study in two centres, Oxford and Gloucester. Patients presenting for a large variety of surgical operations were studied. Patients under 18 years; pregnant; critically ill; had a history of neck surgery were not included. Ultrasound examination was performed pre-operatively while participants lay supine with their head and neck extended, with light transducer pressure. We measured depth to the airway lumen in mm; age; weight; height and sex.

RESULTS

In total 352 patients were studied. We found that depth to the airway lumen strongly correlated with weight (r = 0.855, P < 0.001) and to a lesser extent body mass index (r = 0.781, P < 0.001). Statistical analysis produced an equation to predict upper 95% CI of depth to the airway from the patient's weight: Depth to the airway lumen in mm = (0.13 × weight in kg) + 0.86.

CONCLUSIONS

If ultrasound measurement is not possible before emergency cricothyroidotomy, the clinician could use our results to predict the depth to the airway by using the patient's weight. If the upper 95% CI were used as the depth of incision, it would enter the airway in 39 out of 40 patients of that weight, without damage to posterior structures in those with a shallower airway.