Effect of palpable vs. impalpable cricothyroid membranes in a simulated emergency front‐of‐neck access scenario

Pairaudeau, C.; Mendonca, Cyprian; Hillermann, C.; Qazi, Ilyas; Baker, Paul; Hodgson, RE; Radhakrishna, S.

doi:10.1111/anae.14218

Cited by 21 publications

(15 citation statements)

References 18 publications

(22 reference statements)

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“…17 Psychological barriers can lead to delay in eFONA being performed or to not being performed at all. 18 A more recent study by Pairaudeau and colleagues 19 demonstrated that anaesthetists with limited experience in eFONA could perform the techniques recommended by the DAS guidelines in a timely manner and to a high level of competence after a structured training programme. Reluctance may stem from a scalpel technique being the sole recommended approach, the intimidation of using a scalpel itself, or the potential associated bleeding and trauma.…”

Section: Discussionmentioning

confidence: 99%

Emergency cricothyroidotomy: an observational study to estimate optimal incision position and length

Fennessy

Drew

Husarova

et al. 2019

British Journal of Anaesthesia

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Background: A vertical incision is recommended for cricothyroidotomy when the anatomy is impalpable, but no evidence-based guideline exists regarding optimum site or length. The Difficult Airway Society guidelines, which are based on expert opinion, recommend an 80e100 mm vertical caudad to cephalad incision in the extended neck position. However, the guidelines do not advise the incision commencement point. We sought to determine the minimum incision length and commencement point above the suprasternal notch required to ensure that the cricothyroid membrane would be accessible within its margins. Methods: We measured using ultrasound, in 80 subjects (40 males and 40 females) without airway pathology, the distance between the suprasternal notch and the cricothyroid membrane, in the neutral and extended neck positions. We assessed the inclusion of the cricothyroid membrane within theoretical incisions of 0e100 mm in length made at 10 mm intervals above the suprasternal notch. Results: In the 80 subjects, the distance ranged from 27 to 105 mm. Movement of the cricothyroid membrane on transition from the neutral to extended neck position varied from 15 mm caudad to 27 mm cephalad. The minimum incision required in the extended position was 70 mm in males and 80 mm in females, commencing 30 mm above the suprasternal notch. Conclusions: An 80 mm incision commencing 30 mm above the suprasternal notch would include all cricothyroid membrane locations in the extended position in patients without airway pathology, which is in keeping with the Difficult Airway Society guidelines recommended incision length.

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Section: Discussionmentioning

confidence: 99%

Emergency cricothyroidotomy: an observational study to estimate optimal incision position and length

Fennessy

Drew

Husarova

et al. 2019

British Journal of Anaesthesia

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“…However, the factors of individual stress combined with potential technical issues connected to the ultrasound machine itself, make the use of ultrasound during emergency airway management less convenient [34]. A recent manikin-based study demonstrated the positive effect of training on the scalpel-bougie eFONA performance when the cricothyroid membrane was not palpable [35]. Consequently, there is a possibility that complications associated with the scalpel-bougie technique in our study could be avoided if regular wet lab or manikin training was implemented.…”

Section: Plos Onementioning

confidence: 99%

Rescue oxygenation success by cannula or scalpel-bougie emergency front-of-neck access in an anaesthetised porcine model

et al. 2020

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In the obese, the evidence for the choice of the optimal emergency front-of-neck access technique is very limited and conflicting. We compared cannula and scalpel-bougie emergency front-of-neck access techniques in an anaesthetised porcine model with thick pretracheal tissue. Cannula and scalpel-bougie cricothyroidotomy techniques were performed in 11 and 12 anaesthetised pigs, respectively. Following successful tracheal access, oxygenation was commenced and continued for 5 min using Rapid-O2 device for cannula and circle breathing system for scalpel-bougie study groups. The primary outcome was a successful rescue oxygenation determined by maintenance of arterial oxygen saturation >90% 5 min after the beginning of oxygenation. Secondary outcomes included success rate of airway device placement, time to successful airway device placement, and trauma to the neck and airway. The success rate of rescue oxygenation was 18% after cannula, and 83% after scalpel-bougie technique (P = 0.003). The success rate of airway device placement was 73% with cannula and 92% with scalpel-bougie technique (P = 0.317). Median (inter-quartilerange) times to successful airway device placement were 108 (30-256) and 90 (63-188) seconds (P = 0.762) for cannula and scalpel-bougie emergency front-of-neck access, respectively. Proportion of animals with iatrogenic trauma additional to the procedure itself was 27% for cannula and 75% for scalpel-bougie technique (P = 0.039). Thus, in the porcine model of obesity, the scalpel-bougie technique was more successful in establishing and maintaining rescue oxygenation than cannula-based technique; however, it was associated with a higher risk of severe trauma.

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“…Performing an emergency front of neck airway (eFONA) in this situation can be life‐saving but is associated with a significant failure rate . This has prompted discussion on methods of improving eFONA training; simulation training improves adherence to CICO algorithms and eFONA technical skills . The 2015 Difficult Airway Society (DAS) guidelines advocate a scalpel‐based technique and recommended regular training, whereas the 4th National Audit Project of the Royal College of Anaesthetists (NAP4) and the DAS recommended that “ all anaesthetists must be trained in emergency cricothyroidotomy and keep their skills up to date ” .…”

Section: Introductionmentioning

confidence: 99%

A trial comparing emergency front of neck airway performance in a novel obese‐synthetic neck, meat‐modified obese neck and conventional slim manikin

et al. 2019

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Conventional emergency front of neck airway training manikins mimic slim patients and are associated with unrealistic procedural ease. We have described previously a pork belly-modified manikin that more realistically simulated an obese patient's neck. In this study, we compared a novel obese-synthetic manikin (obese-synthetic manikin) with a pork belly-modified manikin (obese-meat manikin) and a conventional slim manikin (slim manikin). Thirty-three experienced anaesthetists undertook simulated emergency front of neck airway procedures on each manikin (total 99 procedures). Time to ventilation was longer on both obese manikins compared with the slim manikin (median (IQR [range]) time to intubation 159 (126-243 [73-647]) s in the obese-synthetic, 105 (72-138 [43-279]) s in the obese-meat and 58 (47-74 [30-370]) s in the slim manikin; p < 0.001 between each manikin). Cricothyroidotomy success rate was similar in the both obese manikins but lower when compared with the slim manikin (15/33 obese-synthetic vs. 14/33 obese-meat vs. 27/33 slim manikin). Participant feedback indicated performance difficulty was similar between both obese manikins, which were both more difficult than the slim manikin. The tissues of the obese-meat manikin were judged more realistic than those of either other manikin. Overall, the obese-synthetic manikin performed broadly similarly to the obese-meat manikin and was technically more difficult than the conventional slim manikin. The novel obese-synthetic manikin maybe useful for training and research in front of neck airway procedures.

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Effect of palpable vs. impalpable cricothyroid membranes in a simulated emergency front‐of‐neck access scenario

Cited by 21 publications

References 18 publications

Emergency cricothyroidotomy: an observational study to estimate optimal incision position and length

Emergency cricothyroidotomy: an observational study to estimate optimal incision position and length

Rescue oxygenation success by cannula or scalpel-bougie emergency front-of-neck access in an anaesthetised porcine model

A trial comparing emergency front of neck airway performance in a novel obese‐synthetic neck, meat‐modified obese neck and conventional slim manikin

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