Equivalence of the top-down manoeuvre and bottom-up manoeuvre in speed and accuracy of identifying the cricothyroid membrane: a prospective randomised cross-over study

Abstract

Background Accurate identification of the cricothyroid membrane is crucial for successful cricothyrotomy; however, a manoeuvre that helps identify it both accurately and quickly remains unclear. The effectiveness of the so-called ‘bottom-up manoeuvre’ has never been investigated. This study aimed to examine whether the bottom-up manoeuvre is as rapid and accurate as the conventional ‘top-down manoeuvre’ at identifying the cricothyroid membrane. Methods This study was a prospective randomised cross-over trial conducted at an academic medical centre between 2018 and 2019. Fifth-year medical students participated. The students were trained in the use of either the top-down manoeuvre or the bottom-up manoeuvre first. Each student subsequently performed the technique once on a volunteer. The students were then taught and practiced the other manoeuvre as well. The accuracy of cricothyroid membrane identification and the time taken by successful participants only were measured and compared between the manoeuvres using equivalence tests with two one-sided tests. Results A total of 102 medical students participated in this study and there was no missing data. The accuracy of identification and time required for success were similar between the top-down manoeuvre and the bottom-up manoeuvre (65.7% vs. 70.6%, taking 13.8 s [interquartile range (IQR): 9.4–17.5] vs. 15.5 s [IQR: 11.5–19.9], respectively). The success rate was statistically equivalent (rate difference, 4.9%; 90% confidence interval [CI], -5.8 to 15.6; equivalence margin, -20.0 to 20.0). The time required for success was also statistically equivalent (median difference, 1.7 s; 90% CI, -0.2 to 3.3; equivalence margin, -4.0 to 4.0). Conclusion Among students first trained in both manoeuvres for identifying the cricothyroid membrane, the speed and accuracy of identification were similar between those using the bottom-up manoeuvre and those using the top-down manoeuvre.