Surgical intervention during a Can't Intubate Can't Oxygenate (<scp>CICO</scp>) event: Emergency Front‐of‐neck Airway (<scp>FONA</scp>)?

Pracy, J.P.; Brennan, Linda; Cook, Tim; Hartle, Andrew; Marks, R. J.; McGrath, Brendan A.; Narula, A.; Patel, Anil

doi:10.1111/coa.12669

Cited by 36 publications

(46 citation statements)

References 10 publications

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“…Options at this point include: ●Further attempts or advanced or assisted intubation of the upper airway or stoma by more experienced responders using specialised equipment ○Intubation endoscopes (e.g. Bonfils TM , Bambrink TM ) ○Hopkins rod lens‐telescope ○Flexible fiberoptic endoscopes ●Attempted cricothyroidotomy ●Emergency surgical exploration of the stoma and attempts at percutaneous or surgical tracheostomy ●Extracorporeal membrane oxygenation may be possible in some units …”

Section: Resultsmentioning

confidence: 99%

Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies

et al. 2018

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Summary Temporary and permanent tracheostomies are required in children to manage actual or anticipated long‐term ventilatory support, to aid secretion management or to manage fixed upper airway obstruction. Tracheostomies may be required from the first few moments of life, with the majority performed in children < 4 years of age. Although similarities with adult tracheostomies are apparent, there are key differences when managing the routine and emergency care of children with tracheostomies. The National Tracheostomy Safety Project identified the need for structured guidelines to aid multidisciplinary clinical decision making during paediatric tracheostomy emergencies. These guidelines describe the development of a bespoke emergency management algorithm and supporting resources. Our aim is to reduce the frequency, nature and severity of paediatric tracheostomy emergencies through preparation and education of staff, parents, carers and patients.

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Section: Resultsmentioning

confidence: 99%

Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies

et al. 2018

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“…Hence, it is crucial for anaesthetists to be trained in cricothyroidotomy with equipment that is readily available and familiar – a key criticism of small‐bore or wide‐bore cannula techniques. The DAS 2015 guidelines for a scalpel cricothyroidotomy technique have also been disseminated to our surgical colleagues, who may be involved in emergency airway management . However, this introducer represents an additional step, and requires adjustment of the depth guard before performing cricothyroidotomy.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of a novel cricothyroidotomy introducer in a simulated obese porcine model: a randomised crossover comparison with scalpel cricothyroidotomy

et al. 2018

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The Difficult Airway Society 2015 guidelines for management of unanticipated difficulties in tracheal intubation in adults have generated much discussion regarding Plan D: emergency front-of-neck access with a scalpel-bougie cricothyroidotomy technique. There is concern that this technique may not provide an adequate pathway for the bougie and subsequently the tracheal tube, especially in obese patients with deeper airway structures. This could lead to the formation of a false passage, trauma and failure. A novel cricothyroidotomy introducer, 8 mm wide and 170 mm long, with a sharp leading edge and guiding channel to pass a bougie into the trachea, has been designed to complement the scalpel cricothyroidotomy technique. A comparison study of the use of this novel introducer with the scalpel technique in a simulated obese porcine laryngeal model demonstrated shorter insertion times (median (IQR [range]) 85 (65-123 [48-224]) s vs. 84 (72-184 [46-377]) s, p = 0.030). All 26 (100%) participants successfully performed cricothyroidotomy in the introducer group, whereas only 24 (92%) participants were successful in the scalpel group. The introducer group required fewer attempts to access the trachea compared with the scalpel group (p = 0.046). False passages occurred eight (31%) times in the introducer group compared with 17 (65%) times in the scalpel group (p = 0.022). There were no statistical differences in tracheal trauma (p = 0.490), ease of use (p = 0.220) and device preference (p = 0.240). This novel cricothyroidotomy introducer has shown promising results in securing the airway in an emergency front-of-neck access situation. With robust training, this introducer could potentially be complementary to the scalpel-bougie cricothyroidotomy technique.

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“…Recently an editorial written for United Kingdom airway professionals was published in both an otolaryngology and anesthesiology journal, underlining the importance of disseminating new guidelines on difficult airway management amongst all relevant specialties.…”

Section: Discussionmentioning

confidence: 99%

“…Recently an editorial 15 written for United Kingdom airway professionals was published in both an (N) number of respondents trained or not trained or with or without clinical experience in urgent or emergency FONA in one year Self-efficacy scores (0 no confidence-10 maximal confidence) are given as mean (SD) 95% CI gives the 95% confidence interval for the difference in mean self-efficacy scores ("yes" minus "no") PDT = Percutaneous Dilatational Tracheostomy otolaryngology and anesthesiology journal, underlining the importance of disseminating new guidelines on difficult airway management amongst all relevant specialties.…”

Section: Materials and Protocolsmentioning

confidence: 99%

Emergency front‐of‐neck airway by ENT surgeons and residents: A dutch national survey

Bruijstens

Titulaer

Scheffer

et al. 2018

Laryngoscope Investig Oto

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ObjectivesENT surgeons and anesthesiologists work closely together in managing challenging airway cases. Sharing knowledge, experiences, and expectations interdisciplinary is essential in order to facilitate decision‐making and adequate management in emergency front‐of‐neck airway cases.MethodsA survey was performed, to analyze level of experience, technique of preference, training, knowledge of material and protocols, and self‐efficacy scores of Dutch ENT surgeons and residents in performing an urgent or emergency front‐of‐neck airway.ResultsWithin one year (January 2014–2015), 25.7% of the 257 respondents had performed an urgent or emergency front‐of‐neck airway. Of all reported emergency front‐of‐neck airways (N = 30), 80% were managed by tracheotomy. In future emergency front‐of‐neck airway cases, 74% stated cricothyrotomy would be their technique of preference. The majority would choose an uncuffed large‐bore cannula technique. Post‐academic hands‐on training was attended by 42% of respondents. Self‐efficacy scores were highest for surgical tracheotomy, and higher when trained or experienced. In case of an emergency scenario, 8.6% would not perform a front‐of‐neck airway themselves. The main reasons for reluctance to start in general were lack of experience and lack of training. Reported items for improvement were mainly the development of a protocol and training.ConclusionThe chance of encountering an airway emergency scenario requiring front‐of‐neck airway is realistic. There is inconsistency between advised technique, technique of preference and technique actually performed by ENT surgeons. This study shows that there is both a need and desire for improvement in training and organization of care. Interdisciplinary guidelines and education is needed and could eventually safe lives.Level of evidence5

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Surgical intervention during a Can't Intubate Can't Oxygenate (CICO) event: Emergency Front‐of‐neck Airway (FONA)?

Cited by 36 publications

References 10 publications

Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies

Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies

Evaluation of a novel cricothyroidotomy introducer in a simulated obese porcine model: a randomised crossover comparison with scalpel cricothyroidotomy

Emergency front‐of‐neck airway by ENT surgeons and residents: A dutch national survey

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