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

Abstract

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.

Clinical recommendations for in-hospital airway management during aerosol-transmitting procedures in the setting of a viral pandemic

“…As in adults, a surgical eFONA with scalpel is recommended: in the absence of an ENT surgeon, rapid sequence surgical tracheostomy should be preferred to access the trachea for emergencies in children under 8 years of age [ 86 ]. For children older than 8 years, we prefer a scalpel bougie technique over a needle technique [ 87 , 88 , 86 ]. There are no other special recommendations for changes in technique in children with aerosol-transmitted viral disease.…”

Success and Time to Oxygen Delivery for Scalpel-Finger-Cannula and Scalpel-Finger-Bougie Front-of-Neck Access: A Randomized Crossover Study With a Simulated “Can’t Intubate, Can’t Oxygenate” Scenario in a Manikin Model With Impalpable Neck Anatomy

“…Another study conducted by Rees et al 11 on palpable neck anatomy in ovine models yielded similar results, in which the cannula technique was quicker and more successful than the scalpel-bougie technique. Conversely, Umek et al 12 found no difference in success and time between cannula and scalpel-bougie cricothyrotomy in porcine models. However, the study participants made a transverse skin incision followed by 2-finger blunt tissue dissection before making a transverse stab through the cricothyroid membrane for the scalpel-bougie technique.…”

“…Another study conducted by Rees et al 11 on palpable neck anatomy in ovine models yielded similar results, in which the cannula technique was quicker and more successful than the scalpel-bougie technique. Conversely, Umek et al 12 found no difference in success and time between cannula and scalpel-bougie cricothyrotomy Data are presented as number (proportion) and 95% CI. Comparison of the success rates using a mixed-effects logistic regression.…”

A Proposed Guideline for Performance of Emergency Surgical Airways in Small Animals: Analysis of Five Unsuccessfully Managed Cannot Intubate, Cannot Oxygenate Cases

“…In human clinical practice, this technique has a very high failure rate [18] and is not the primary option recommended for CICO as surgical techniques are superior [2]. An experimental study in pigs found only a 20% success rate at delivering rescue oxygenation, citing frequent kinking or displacement of the catheter as reasons for failure [19]. This may explain the outcome of both cases that underwent CPA with a cannula tracheostomy in place (cases 1 and 3).…”