Cuffed versus uncuffed tracheal tubes in a rabbit training model for establishing an emergency front-of-neck airway in infants: a prospective trial.

BACKGROUND: There is a paucity of evidence regarding the optimal type of tracheal tube to be advanced over a Frova catheter when performing a 'bougie' emergency front-of-neck airway (eFONA) technique in infants during a 'cannot intubate, cannot oxygenate' situation. METHODS: A prospective non-inferiority trial in a rabbit cadaver surgical tracheotomy model to assess the performance of the eFONA technique with an uncuffed 3.5 mm ID tracheal tube vs a cuffed 3.0 mm ID tracheal tube. Queried outcomes include success rate, performance time, and severe secondary airway injuries among tracheal tube types. RESULTS: In 60 tracheostomies performed by 30 participants, the overall success rate was 98%. Performance time was independent from tracheal tube choice (uncuffed: 61 s [95% confidence interval (CI), 52-76], cuffed: 64 s [95% CI, 55-79]; P = 0.82). No tracheal tube type was preferred in terms of usability by participants. The cuffed tracheal tube required increased force to be advanced over the Frova catheter and was associated with a risk ratio of 2.5 (95% CI, 0.53-11.9; number needed to harm, 10) for severe secondary airway injuries when compared with the uncuffed tracheal tube. CONCLUSION: In performing eFONA in the rabbit cadaver model, an ID 3.5 uncuffed is non-inferior to an ID 3.0 cuffed tracheal tube regarding performance time and preference by the operator. Greater force application to advance the cuffed tube over the Frova catheter and more severe airway injuries may argue for the standardised performance of the eFONA technique with a uncuffed tracheal tube in infants.

Rabbit training model for establishing an emergency front of neck airway in children.

BACKGROUND: A 'cannot intubate, cannot oxygenate' (CICO) situation is rare in paediatric anaesthesia, but can always occur in children under certain emergency situations. There is a paucity of literature on specific procedures for securing an emergency invasive airway in children younger than 6 yr. A modified emergency front of neck access (eFONA) technique using a rabbit cadaver model was developed to teach invasive airway protection in a CICO situation in children. METHODS: After watching an instructional video of our eFONA technique (tracheotomy, intubation with Frova catheter over which a tracheal tube is inserted), 29 anaesthesiologists performed two separate attempts on rabbit cadavers. The primary outcome was the success rate and the performance time overall and in subgroups of trained and untrained participants. RESULTS: The overall success rate across 58 tracheotomies was 95% and the median performance time was 67 s (95% confidence interval [CI], 56-76). Performance time decreased from the first to the second attempt from 72 s (95% CI, 57-81) to 61 s (95% CI, 50-81). Performance time was 59 s (95% CI, 49-79) for untrained participants and 72 s (95% CI, 62-81) for trained participants. Clinical experience and age of the participants was not correlated with performance time, whereas the length of the tracheotomy incision showed a significant correlation (P=0.006). CONCLUSION: This eFONA training model for children facilitates rapid skill acquisition under realistic anatomical conditions to perform an emergency invasive airway in children younger than 2 yr.

"Cannot intubate, cannot oxygenate": A novel 2-operator technique for cannula tracheotomy in an infant animal model-a feasibility study.

BACKGROUND: Evidence regarding optimal management of the "Cannot Intubate, Cannot Oxygenate" (CICO) scenario in infants is scarce. When inserting a transtracheal cannula for front of neck access direct aspiration to confirm intratracheal location is standard practice. This postmortem "infant airway" animal model study describes a novel technique for cannula tracheotomy. AIMS: To compare a novel technique of cannula tracheotomy to an accepted technique to assess success and complication rates. METHODS: Two experienced proceduralists repeatedly performed tracheotomy using an 18-gauge BD InsyteTM cannula (BD, Franklin Lakes, NJ, USA) in 6 postmortem White New Zealand rabbits. Cannulas were attached either directly to a 5ml syringe (Direct Aspiration) or via a 25 cm length minimum volume extension tubing set (TUTA Healthcare Lidcombe, NSW, Australia) (Indirect Aspiration, 2 operator technique). Each technique was attempted a maximum of 12 times per rabbit with an ENT surgeon assessing success and complication rates endoscopically for each attempt. RESULTS: 72 tracheotomy attempts were made in total, 36 for each technique. Initial aspiration through the needle was achieved in 93% (97.2% direct versus 89% indirect). Advancement of the cannula and continued aspiration (success) into the trachea occurred in 67% for direct compared with 64% for indirect aspiration. Direct aspiration was associated with higher rates of lateral (10.3% versus 5.6%) and posterior (19.4% versus 13.9%) wall injury compared with the indirect 2-operator technique. CONCLUSION: Cannula tracheotomy in infant-sized airways is technically difficult and seems frequently associated with tracheal wall injury. The reduced incidence of injury in the indirect group warrants further investigation in preclinical and clinical trials.

Front-of-neck airway rescue with impalpable anatomy during a simulated cannot intubate, cannot oxygenate scenario: scalpel-finger-cannula versus scalpel-finger-bougie in a sheep model.

BACKGROUND: Front-of-neck airway rescue in a cannot intubate, cannot oxygenate (CICO) scenario with impalpable anatomy is particularly challenging. Several techniques have been described based on a midline vertical neck incision with subsequent finger dissection, followed by either a cannula or scalpel puncture of the now palpated airway. We explored whether the speed of rescue oxygenation differs between these techniques. METHODS: In a high-fidelity simulation of a CICO scenario in anaesthetised Merino sheep with impalpable front-of-neck anatomy, 35 consecutive eligible participants undergoing airway training performed scalpel-finger-cannula and scalpel-finger-bougie in a random order. The primary outcome was time from airway palpation to first oxygen delivery. Data, were analysed with Cox proportional hazards. RESULTS: Scalpel-finger-cannula was associated with shorter time to first oxygen delivery on univariate (hazard ratio [HR]=11.37; 95% confidence interval [CI], 5.14-25.13; P<0.001) and multivariate (HR=8.87; 95% CI, 4.31-18.18; P<0.001) analyses. In the multivariable model, consultant grade was also associated with quicker first oxygen delivery compared with registrar grade (HR=3.28; 95% CI, 1.36-7.95; P=0.008). With scalpel-finger-cannula, successful oxygen delivery within 3 min of CICO declaration and ≤2 attempts was more frequent; 97% vs 63%, P<0.001. In analyses of successful cases only, scalpel-finger-cannula resulted in earlier improvement in arterial oxygen saturations (-25 s; 95% CI, -35 to -15; P<0.001), but a longer time to first capnography reading (+89 s; 95% CI, 69 to 110; P<0.001). No major complications occurred in either arm. CONCLUSIONS: The scalpel-finger-cannula technique was associated with superior oxygen delivery performance during a simulated CICO scenario in sheep with impalpable front-of-neck anatomy.

Lost in transition: the challenges of getting airway clinicians to move from the upper airway to the neck during an airway crisis.

Technical and psychological factors make performance of an emergency front-of-neck airway (eFONA) a challenging procedure for clinical teams involved in airway management. When 'cannot intubate, cannot oxygenate' (CICO) emergencies occur, eFONA is frequently performed too late or not at all. The concept of transition to eFONA comprises simultaneous efforts to prevent and prepare for eFONA before a declaration of CICO in an effort to facilitate its timely and effective implementation. Although such a transition represents an appealing idea, attention to many aspects of airway practice is required for it to become an effective intervention.

Performance of emergency surgical front of neck airway access by head and neck surgeons, general surgeons, or anaesthetists: an in situ simulation study.

BACKGROUND: The 'cannot intubate cannot oxygenate' (CICO) emergency requires urgent front of neck airway (FONA) access to prevent death. In cases reported to the 4th National Audit Project, the most successful FONA was a surgical technique, almost all of which were performed by surgeons. Subsequently, UK guidelines adopted surgical cricothyroidotomy as the preferred emergency surgical FONA technique. Despite regular skills-based training, anaesthetists may still be unwilling to perform an emergency surgical FONA. Consultant anaesthetists, head and neck surgeons, and general surgeons were compared in a high-fidelity simulated emergency. We hypothesised that head and neck surgeons would successfully execute emergency surgical FONA faster than anaesthetists and general surgeons. METHODS: We recruited 15 consultants from each specialty (total of 45) at a single tertiary care hospital in the UK. All agreed to participate in an in situ high-fidelity simulation of an 'anaesthetic emergency'. Participants were not told in advance that this would be a CICO scenario. RESULTS: There were no significant differences in total time to successful ventilation between anaesthetists, head and neck surgeons and general surgeons (median 86 vs 98 vs 126 s, respectively, P=0.078). Anaesthetists completed the emergency surgical FONA procedure significantly faster than general surgeons (median 50 vs 86 s, P=0.018). Despite this strong performance, qualitative data suggested some anaesthetists still believed 'surgeons' best placed to perform emergency surgical FONA in a genuine CICO situation. CONCLUSION: Anaesthetists regularly trained in emergency surgical FONA function at levels comparable with head and neck surgeons and should feel empowered to lead this procedure in the event of a CICO emergency.

Can't intubate, can't oxygenate? What is the preferred surgical strategy? A retrospective analysis.

INTRODUCTION: Cricothyrotomy (CTM) is currently recommended as the preferred method due to its ease, speed, and safety in life-threatening airway emergencies where standard tracheal intubation and mask ventilation fail. MATERIAL AND METHODS: This retrospective study analyzed 33 cases of "can't intubate, can't oxygenate or ventilate" (CICOV): 12 of percutaneous dilatational tracheostomy (PDT) and 21 of CTM. The CTM group was younger (median age 44) and mainly consisted of trauma patients. The PDT group was more diverse and procedures were performed by anesthesia and critical care consultants. RESULTS: Initial success rates were 100% for PDT (12/12) and 86% for CTM (18/21), with one conversion from CTM to PDT. No perioperative complications occurred in the PDT group, while the CTM group experienced two cases of false tracts requiring re-do and three cases of bleeding. Immediate mortality within 24 hours was reported in 5/19 CTM patients and none in the PDT group. Successful liberation from mechanical ventilation at hospital discharge was achieved in 6/12 PDT patients and 11/21 CTM patients. Among the 21 CTM cases, all 16 survivors underwent subsequent tracheostomy. Tracheal decannulation occurred in 4/12 PDT patients and 10/21 CTM patients. Favorable immediate neurological outcomes (GCS ≥ 11T) were observed in 8/12 PDT patients and 8/21 CTM patients, while 3 PDT patients remained anesthetized until death and 7 CTM patients died within the first 72 hours without recovery attempts. CONCLUSIONS: In experienced hands, PDT could be a legitimate clinical option for the surgical airway in cases of CICOV. CTM may be more suitable for practitioners who encounter CICOV infrequently.

Implementation of a Spaced Learning Program for Educating CRNAs on a Scalpel-Bougie Cricothyrotomy Procedure for Emergency Front of Neck Access.

Certified registered nurse anesthetists (CRNAs) who are responsible for airway management, may lack adequate continuing education for emergency front of neck access (EFONA), an advanced skill necessary in situations when a patient cannot be intubated and cannot be oxygenated (CICO). The purpose of this study was to improve CRNA knowledge and confidence when performing a scalpel-bougie cricothyrotomy for EFONA in a CICO event through the implementation of a spaced learning intervention. Thirteen CRNAs at a 160-bed community hospital participated in a 3-week educational intervention. Week 1: online preintervention survey followed by an educational video. Week 2: video review and skills component practiced on a cricothyrotomy trainer. Week 3: skills component practiced on a cricothyrotomy trainer followed by postintervention survey. This was a single-arm study and Wilcoxon sign ranked tests and a paired t-test were utilized to monitor for change in CRNA knowledge, confidence, and skill in performing EFONA. Implementation of a 3-week spaced learning program for educating CRNAs to perform a scalpel-bougie cricothyrotomy significantly increased CRNA knowledge, confidence, and skill when performing EFONA. Utilizing a spaced learning program may therefore improve provider skills, resulting in optimized patient care during a CICO event, leading to improved patient safety and outcomes.

Comparing the Scalpel-Bougie-Tube Emergency Front-of-Neck Airway (eFONA) Technique on Conventional Manikins and Ovine Larynges: Evaluating Cost, Realism, and Performance in Anaesthetic Trainees.

Background Emergency front-of-neck airway (eFONA) is a crucial life-saving procedure in "cannot intubate, cannot oxygenate" (CICO) situations. It is essential to teach and maintain eFONA skills for healthcare providers, especially anesthesiologists. This study aims to assess the effectiveness of cost-effective ovine larynx models compared to conventional manikins in teaching eFONA using the scalpel-bougie-tube technique to a group of anaesthesia novices and newly appointed anaesthetic Fellows. Methods and study design The study was conducted at Walsall Manor Hospital, a district general hospital in the Midlands, UK. Participants underwent a pre-survey to assess familiarity with FONA and the ability to perform a laryngeal handshake. After a lecture and demonstration, participants performed two consecutive emergency cricothyrotomies on both ovine models and conventional manikins, followed by a post-survey to assess their confidence in performing eFONA and rate their experience using sheep larynges. Results The training session significantly improved the participants' ability to perform a laryngeal handshake and their confidence in performing eFONA. The majority of participants rated the ovine model higher in terms of realism, difficulty with penetration, difficulty in recognising landmarks, and difficulty in performing the procedure. Additionally, the ovine model was more cost-effective compared to conventional manikins. Conclusion Ovine models provide a more realistic and cost-effective alternative to conventional manikins for teaching eFONA using the scalpel-bougie-tube technique. The use of these models in routine airway teaching enhances the practical skill set of anaesthesia novices and newly appointed anaesthetists, better preparing them for CICO situations. However, further training with objective assessment methods and larger samples is needed to corroborate these findings.

Emergent use of tube tip in pharynx technique in "cannot intubate cannot oxygenate" situation: A case report.

BACKGROUND: A "cannot intubate, cannot oxygenate (CICO)" situation is a life-threatening condition that requires emergent management to establish a route for oxygenation to prevent oxygen desaturation. In this paper, we describe airway management in a patient with an extended parotid tumor that invaded the airways during CICO using the endotracheal tube tip in the pharynx (TTIP) technique. CASE SUMMARY: A 43-year-old man was diagnosed with parotid tumor for > 10 years. Computed tomography and nasopharyngeal fiberoptic examination revealed a substantial mass from the right parotid region with a deep extension through the lateral pharyngeal region to the retropharyngeal region and obliteration of the nasopharynx to the oropharynx. Tumor excision was arranged. However, we encountered CICO during anesthesia induction. An endotracheal tube was used as an emergency supraglottic airway device (TTIP) to ventilate the patient in a CICO situation where other tools such as laryngeal mask airway or mask ventilation were not suitable for this complicated and difficult airway. The patient did not experience desaturation despite sudden loss of definite airway. During tracheostomy, the pulse oximetry remained 100% with our technique of ventilating the patient. The arterial blood gas analysis revealed PaCO2 35.7 mmHg and PaO2 242.5 mmHg upon 50% oxygenation afterward. CONCLUSION: Using an endotracheal tube as a supraglottic airway device, patients may have increased survival without experiencing life-threatening desaturation.

Blind intubation through Laryngeal Mask Airway in a cannot intubate-difficult to ventilate patient with massive hematemesis.

Massive hematemesis could be challenging situation requiring emergency airway control and urgent surgical treatment. We report a case of difficult airway management with blind intubation through Laryngeal Mask Airway in a 56-year-old patient with massive hematemesis. After failed endoscopic attempts to stop bleeding, worsening of hemodynamics called for emergency intubation and surgery. After failed intubation attempts and face-mask ventilation worsening, a classic LMA was used for rescue ventilation and decision was made to intubate through LMA. The airway exchange was aided by a nasogastric tube (NGT) through LMA, confirmed with capnography and surgery was started successfully and uneventfully. Unexpected difficult airway can be extremely challenging situation, especially in emergency settings with no possibility to delay surgery. In those cases, literature suggests different intubating techniques through LMA. Blind intubation through LMA aided by NGT showed to be a suitable option in resources-limited settings, where advanced supraglottic devices and/or optical devices are not available.