Ultrasound identification of the cricothyroid membrane: the new standard in preparing for front-of-neck airway access

Kristensen, Michael Seltz; Teoh, Wendy H.

doi:10.1016/j.bja.2020.10.004

Cited by 29 publications

(24 citation statements)

References 22 publications

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“…Another aspect to enhancing the airway exam in patients with significantly altered anatomy is to identify the location of the cricothyroid membrane (CTM). 22 If visual inspection or palpation fails to identify the CTM location with certainty, it should be identified using ultrasonography and marked, 22 , 23 with the patient’s neck in an extended position. The patient can subsequently be positioned optimally for the intended airway technique; if eFONA is required, the patient can quickly be returned to the neck-extended position to utilize the previously made marking.…”

Section: Prediction Of Difficulty With Airway Managementmentioning

confidence: 99%

“…21 Another aspect to enhancing the airway exam in patients with significantly altered anatomy is to identify the location of the cricothyroid membrane (CTM). 22 If visual inspection or palpation fails to identify the CTM location with certainty, it should be identified using ultrasonography and marked, 22,23 with the patient's neck in an extended position. The patient can subsequently be positioned Table 1 Published predictors of difficult tracheal intubation using direct laryngoscopy Predictors of difficult laryngoscopy and tracheal intubation using direct laryngoscopy [11][12][13]16,[25][26][27][28][29][30][31] • Age [ 46 yr…”

Section: The Enhanced Airway Evaluationmentioning

confidence: 99%

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Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

Law

Duggan

Asselin

et al. 2021

Can J Anesth/J Can Anesth

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Purpose Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the published airway management literature has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This second of two articles addresses airway evaluation, decision-making, and safe implementation of an airway management strategy when difficulty is anticipated. Source Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence is lacking, statements are based on group consensus. Findings and key recommendations Prior to airway management, a documented strategy should be formulated for every patient, based on airway evaluation. Bedside examination should seek predictors of difficulty with face-mask ventilation (FMV), tracheal intubation using video- or direct laryngoscopy (VL or DL), supraglottic airway use, as well as emergency front of neck airway access. Patient physiology and contextual issues should also be assessed. Predicted difficulty should prompt careful decision-making on how most safely to proceed with airway management. Awake tracheal intubation may provide an extra margin of safety when impossible VL or DL is predicted, when difficulty is predicted with more than one mode of airway management (e.g., tracheal intubation and FMV), or when predicted difficulty coincides with significant physiologic or contextual issues. If managing the patient after the induction of general anesthesia despite predicted difficulty, team briefing should include triggers for moving from one technique to the next, expert assistance should be sourced, and required equipment should be present. Unanticipated difficulty with airway management can always occur, so the airway manager should have a strategy for difficulty occurring in every patient, and the institution must make difficult airway equipment readily available. Tracheal extubation of the at-risk patient must also be carefully planned, including assessment of the patient’s tolerance for withdrawal of airway support and whether re-intubation might be difficult.

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Section: Prediction Of Difficulty With Airway Managementmentioning

confidence: 99%

Section: The Enhanced Airway Evaluationmentioning

confidence: 99%

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

Law

Duggan

Asselin

et al. 2021

Can J Anesth/J Can Anesth

View full text Add to dashboard Cite

show abstract

“…e patient should be placed in an upright sitting position and supplementary oxygen should be administered. e cricothyroid membrane should be identified and properly marked if necessary, with the aid of ultrasound [4,5,28].…”

Section: Discussionmentioning

confidence: 99%

“…is should be avoided at all costs since it has demonstrated a failure rate of more than 50% when performed by anesthesiologists on acute (nonobstetric) patients [6]. Preanesthetic identification and marking of the cricothyroid membrane is likely to enhance the success rate of cricothyrotomy [28] and should always be performed in at-risk patients before any airway troubles arise [4,28].…”

Section: Discussionmentioning

confidence: 99%

Managing Known Difficult Airways in Obstetric Patients Using a Flexible Bronchoscope and IRRIS: A Case-Illustrated Guide for Nonexpert Anesthesiologists, without Surgical Backup

Hannig

Hauritz

Jessen

et al. 2021

Case Reports in Anesthesiology

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Pregnancy is associated with anatomical and physiological changes leading to potential difficult airway management. Some pregnant women have known difficult airways and cannot be intubated even with a hyperangulated videolaryngoscope. If neuraxial techniques are also impossible, awake tracheal intubation with a flexible bronchoscope may be one of the few available options to avoid more invasive techniques. The Infrared Red Intubation System (IRRIS) may help nonexpert anesthesiologists in such situations and may enhance the chance of successful intubation increasing safety for the mother and the fetus, especially in hospitals without the ear, nose, and throat surgical backup.

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“…These studies justified adding this measurement to our study, finding that the BCT exceeded the level of the cricoid cartilage in 5 patients, of which 2 patients presented BCT anterior to the cricothyroid membrane reaching even the thyroid cartilage. This low frequency can support the safety of cricothyroidotomy on tracheotomy in emergency access to the respiratory tract, however, we emphasize the importance of accurately identifying the cricothyroid membrane and a careful dissection by the surgeon, as well as the use of imaging studies, when available to properly assess the anatomy [ 33 , 34 ].…”

Section: Discussionmentioning

confidence: 99%

Anatomical and positional variants of the brachiocephalic trunk in a Mexican population

et al. 2021

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Background Brachiocephalic trunk (BCT) variants may have a clinical impact during surgical procedures, some of which could be fatal. The objective of this study was to classify height positions of the BCT and report their prevalence in a Mexican population. Methods Patients: A retrospective, descriptive, observational, and cross-sectional was performed using computed tomography angiography (CTA) of adult (> 18 years of age) patients, without gender distinction, of Mexican origin. Measuring techniques were standardized using the suprasternal notch to analyze linear and maximum heights, linear and curved lengths, and the vertebral origin and bifurcation levels of the BCT. Results A total of 270 CTA were obtained (66.7% men and 33.3% women). A high position of BCT was present in 64.81% (n 175/270). The mean linear medial height was 0.58 ± 1.91 cm, the maximum height of the free edge was 3.85 ± 2.04 cm, side length of the midline at the maximum height of the free edge was 1.46 ± 2.59, linear length 3.72 ± 0.70, and a curve length 3.99 ± 0.79. The BCT origin was most predominant at the T3 (57.9%) and T4 (27.0%) vertebral levels, with the bifurcation at T2 (57.9%) and T1 (36.2%). Conclusions There is a high prevalence of high position BCT in our population. Patients should be assessed before any procedures in the area, due to the potential risk of complications.

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Ultrasound identification of the cricothyroid membrane: the new standard in preparing for front-of-neck airway access

Cited by 29 publications

References 22 publications

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

Managing Known Difficult Airways in Obstetric Patients Using a Flexible Bronchoscope and IRRIS: A Case-Illustrated Guide for Nonexpert Anesthesiologists, without Surgical Backup

Anatomical and positional variants of the brachiocephalic trunk in a Mexican population

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