Palpation Versus Ultrasonography for Identifying the Cricothyroid Membrane in Case of a Laterally Deviated Larynx: A Randomized Trial.

BACKGROUND: Large neck circumference and displacement of the trachea due to pathology increase the risk of failed identification of the cricothyroid membrane and cricothyroidotomy. We investigated whether ultrasound aids in the successful identification of the cricothyroid membrane in a model of an obese neck with midline deviation of the trachea. METHODS: We developed silicone neck models that were suitable for both palpation and ultrasonography and where the trachea deviated laterally from the midline to either side. After reading a book chapter and participating in a 25-minute lecture and a 15- to 23-minute hands-on demonstration and rehearsal of ultrasonography for identification of the cricothyroid membrane, anesthesiologists and anesthesiology residents randomly performed identification with either ultrasound or palpation on 1 of 2 neck models. RESULTS: We included 57 participants, of whom 29 and 28 were randomized to palpation and ultrasound, respectively. Correct identification of the cricothyroid membrane was achieved by 21 (75.0%) vs 1 (3.5%) of participants in the ultrasound versus palpation groups (risk ratio [RR], 21.8 [95% confidence interval {CI}, 3.1-151.0]). The tracheal midline position in the sagittal plane was identified correctly by 24 (85.7%) vs 16 (55.2%) of participants in the ultrasound versus palpation groups (RR, 1.6 [95% CI, 1.1-2.2]). CONCLUSIONS: Identification of the cricothyroid membrane in a model of an obese neck with midline deviation of the trachea was more often successful with ultrasound compared to palpation. Our study supports the potential use of ultrasound before induction of anesthesia and airway management in this group of patients, and it may even be applied in emergency situations when ultrasound is readily available. Further studies in human subjects should be conducted.

Tube tip in pharynx-a conduit for awake oral intubation in patients with extremely restricted mouth opening.

PURPOSE: Awake flexible bronchoscope-guided intubation is challenging in patients with extremely limited mouth opening (when there is inadequate space for an oropharyngeal airway), especially when nasal access is unavailable. Alternatives include awake front of neck access, which is an invasive procedure and not suitable for elective surgery. We present a novel technique to facilitate flexible bronchoscope-guided oral intubation in these patients. CLINICAL FEATURES: Tube tip in pharynx (TTIP) is a technique for establishing a patent airway if ventilation is difficult or has failed using a face mask, supraglottic airway, or endotracheal tube. The technique involves placing the tip of the endotracheal tube in the pharynx, 10-14 cm past the teeth, filling the cuff with air, closing the mouth and nose of the patient, and then initiating ventilation. The TTIP method thus combines the function of an oropharyngeal airway and a face mask akin to a supraglottic airway device, but is more flexible with regard to insertion depth and cuff inflation and demands only minimal mouth opening. We have adapted the TTIP technique for awake flexible bronchoscope-guided oral intubation and report the technique illustrated with three cases where mouth opening was so restricted that it precluded insertion of an oropharyngeal airway. CONCLUSION: By placing an endotracheal tube with the tip in the pharynx, TTIP can establish a conduit for awake oral flexible bronchoscope-guided intubation in patients with extremely limited mouth opening and unavailable nasal access. This technique requires equipment that is readily available and may help avoid unnecessary awake tracheostomy.

RéSUMé: OBJECTIF: L'intubation éveillée guidée par bronchoscope flexible est un défi chez les patients présentant une ouverture buccale extrêmement restreinte (lorsqu'il n'y a pas suffisamment d'espace pour une canule oropharyngée), et tout particulièrement lorsqu'un accès nasal est non disponible. Les alternatives incluent l'accès antérieur du cou chez patient éveillé, une procédure invasive qui ne convient pas pour la chirurgie élective. Nous présentons une technique innovante pour faciliter l'intubation orale guidée par bronchoscope flexible chez ces patients. CARACTéRISTIQUES CLINIQUES: La technique TTIP (de l'anglais Tube Tip In Pharynx) permet d'établir un accès aux voies aériennes si la ventilation est difficile ou a échoué à l'aide d'un masque, d'un dispositif supraglottique ou d'un tube endotrachéal. La technique consiste à placer l'extrémité du tube endotrachéal dans le pharynx, à 10-14 cm au-delà des dents, à remplir le ballonnet d'air, à fermer la bouche et le nez du patient, puis à amorcer la ventilation. La méthode TTIP combine ainsi la fonction d'une canule oropharyngée et d'un masque facial, de façon similaire à un dispositif supraglottique, mais est plus flexible en ce qui concerne la profondeur d'insertion et le gonflage du ballonnet et ne nécessite qu'une ouverture minimale de la bouche. Nous avons adapté la technique TTIP pour l'intubation orale éveillée guidée par bronchoscope flexible et rapportons la technique en l'illustrant par trois cas où l'ouverture de la bouche était si restreinte qu'elle empêchait l'insertion d'une canule oropharyngée. CONCLUSION: En plaçant l'extrémité d'un tube endotrachéal dans le pharynx, la technique TTIP peut établir un passage pour l'intubation orale éveillée guidée par bronchoscope flexible chez les patients ayant une ouverture de la bouche extrêmement limitée et un accès nasal indisponible. Cette technique nécessite du matériel facilement disponible et peut contribuer à éviter une trachéotomie non nécessaire chez patient éveillé.

Managing and securing the bleeding upper airway: a narrative review.

Failure to manage bleeding in the airway is an important cause of airway-related death. The purpose of this narrative review is to identify techniques and strategies that can be employed when severe bleeding in the upper airway may render traditional airway management (e.g., facemask ventilation, intubation via direct/video laryngoscopy, flexible bronchoscopy) impossible because of impeded vision. An extensive literature search was conducted of bibliographic databases, guidelines, and textbooks using search terms related to airway management and bleeding. We identified techniques that establish a definitive airway, even in cases of impeded visibility resulting from severe bleeding in the airway. These include flexible video-/optical- scope-guided intubation via a supraglottic airway device; cricothyroidotomy or tracheotomy; and retrograde-, blind nasal-, oral-digital-, light-, and ultrasound-guided intubation. We provide a structured approach to managing bleeding in the airway that accounts for the source of bleeding and the estimated risk of failure to intubate using direct laryngoscopy or to achieve a front-of-neck access for surgical airway rescue. In situations where these techniques are predicted to be successful, the recommended approach is to identify the cricothyroid membrane (in preparation for rescue cricothyroidotomy), followed by rapid sequence induction. In situations where traditional management of the airway is likely to fail, we recommend an awake approach with one of the aforementioned techniques.

Postoperative Upper Airway Blood Clot After Tonsillectomy Requiring a Suction Catheter Without Side Holes for Removal: A Case Report.

We present a case of acute dyspnea due to postoperative oral bleeding after tonsillectomy, wherein a blood clot obscured the laryngeal structures to such an extent that no recognizable structures could be identified. A larger-bore suction catheter without side holes proved necessary to solve the problem. The case illustrates how a gradually forming blood clot can remain asymptomatic until reaching a size where it poses an airway threat and highlights the necessity for readily available larger-bore suction devices without side holes. We consider this as an important reminder of the unpredictable nature of blood clot formation and its management.

Use of the flexible bronchoscope and Infrared Red Intubation System in a known difficult airway in the intensive care unit.

This case report describes a patient in the ICU in need of urgent intubation, for whom video laryngoscope-guided intubation had previously failed. The Infrared Red Intubation System (IRRIS) may enhance the chance of successful flexible bronchoscope intubation, especially when performed by non-expert anesthesiologists.