"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.

The 'Can't intubate can't oxygenate' scenario in pediatric anesthesia: a comparison of the Melker cricothyroidotomy kit with a scalpel bougie technique.

BACKGROUND: While the majority of pediatric intubations are uncomplicated, the 'Can't intubate, Can't Oxygenate' scenario (CICO) does occur. With limited management guidelines available, CICO is still a challenge even to experienced pediatric anesthetists. OBJECTIVES: To compare the COOK Melker cricothyroidotomy kit (CM) with a scalpel bougie (SB) technique for success rate and complication rate in a tracheotomy on a cadaveric 'infant airway' animal model. METHODS: Two experienced proceduralists repeatedly attempted tracheotomy in eight rabbits, alternately using CM and SB (4 fr) technique. The first attempt was performed at the level of the first tracheal cartilage with subsequent experimental trials of insertion progressively more caudad. Success was defined as intratracheal placement of cannula as seen on bronchoscope. Complications were assessed both by bronchoscopic and macropathological appearance. RESULTS: 32 attempts were made at tracheotomy. CM had an overall success rate of 100% compared to a 75% success rate for SB. Success rate for the first attempt was dependent on the level of the tracheotomy (Level 1 100%, level 2 62.5% and level 3 & 4 25%). While CM was associated with lateral and/or posterior wall damage on bronchoscopy/macropathology in 6% of 19% and 25% of 50% respectively, the damage observed was greater and more frequent with SB (19%/44% and 31%/50%, respectively). CONCLUSIONS: At level 1, the first attempt success rate was 100% for both devices. Overall CM showed a better success rate than SB; however, both techniques were associated with significant complication rates, which were more pronounced following the scalpel bougie technique.

The 'Can't Intubate Can't Oxygenate' scenario in Pediatric Anesthesia: a comparison of different devices for needle cricothyroidotomy.

BACKGROUND: Little evidence exists to guide the management of the 'Can't Intubate, Can't Oxygenate' (CICO) scenario in pediatric anesthesia. OBJECTIVES: To compare two intravenous cannulae for ease of use, success rate and complication rate in needle tracheotomy in a postmortem animal model of the infant airway, and trial a commercially available device using the same model. METHODS: Two experienced proceduralists repeatedly attempted cannula tracheotomy in five postmortem rabbits, alternately using 18-gauge (18G) and 14-gauge (14G) BD Insyte(™) cannulae (BD, Franklin Lakes, NJ, USA). Attempts began at the first tracheal cartilage, with subsequent attempts progressively more caudad. Success was defined as intratracheal cannula placement. In each rabbit, an attempt was then made by each proceduralist to perform a cannula tracheotomy using the Quicktrach Child(™) device (VBM Medizintechnik GmbH, Sulz am Neckar, Germany). RESULTS: The rabbit tracheas were of similar dimensions to a human infant. 60 attempts were made at cannula tracheotomy, yielding a 60% success rate. There was no significant difference in success rate, ease of use, or complication rate between cannulae of different gauge. Successful aspiration was highly predictive (positive predictive value 97%) and both sensitive (89%) and specific (96%) for tracheal cannulation. The posterior tracheal wall was perforated in 42% of tracheal punctures. None of 13 attempts using the Quicktrach Child(™) were successful. CONCLUSION: Cannula tracheotomy in a model comparable to the infant airway is difficult and not without complication. Cannulae of 14- and 18-gauge appear to offer similar performance. Successful aspiration is the key predictor of appropriate cannula placement. The Quicktrach Child was not used successfully in this model. Further work is required to compare possible management strategies for the CICO scenario.

Updated guideline on equipment to manage difficult airways: Australian and New Zealand College of Anaesthetists.

The Australian and New Zealand College of Anaesthetists (ANZCA) recently reviewed and updated the guideline on equipment to manage a difficult airway. An ANZCA-established document development group, which included representatives from the Australasian College for Emergency Medicine and the College of Intensive Care Medicine of Australia and New Zealand, performed the review, which is based on expert consensus, an extensive literature review, and bi-nationwide consultation. The guideline (PG56(A) 2021, https://www.anzca.edu.au/getattachment/02fe1a4c-14f0-4ad1-8337-c281d26bfa17/PS56-Guideline-on-equipment-to-manage-difficult-airways) is accompanied by a detailed background paper (PG56(A)BP 2021, https://www.anzca.edu.au/getattachment/9ef4cd97-2f02-47fe-a63a-9f74fa7c68ac/PG56(A)BP-Guideline-on-equipment-to-manage-difficult-airways-Background-Paper), from which the current recommendations are reproduced on behalf of, and with the permission of, ANZCA. The updated 2021 guideline replaces the 2012 version and aims to provide an updated, objective, informed, transparent, and evidence-based review of equipment to manage difficult airways.

2021 Update on airway management from the Anaesthesia Continuing Education Airway Management Special Interest Group.

Airway Management is the key for anaesthetists dealing with patients undergoing diagnostic procedures and surgical interventions. The present coronavirus pandemic underpins even more how important safe airway management is. It also highlights the need to apply stringent precautions to avoid infection and ongoing transmission to patients, anaesthetists and other healthcare workers (HCWs). In light of this extraordinary global situation the aim of this article is to update the reader on the varied aspects of the ever-changing tasks anaesthetists are involved in and highlight the equipment, devices and techniques that have evolved in response to changing technology and unique patient and surgical requirements.