Can’t Intubate, Can’t Oxygenate

Untitled-108_Can’t-intubate,-Can’t-ventilate

This Skill Station covers:

-Cannula cricothyroidotomy

-Seldinger cricothyroidotomy

-Surgical cricothyroidotomy

-The indications, contraindications and complications of cricothyroidotomy and its role within the DAS guidelines and the Vortex approach

The Equipment

BD Insite cannula
VBM Ravussin cannula
Cook Melker kit
Rapid-O2 device
VBM Manujet
Scalpel/bougie
Tracheal hook
Tracheal dilators
Cook cricothyroidotomy kit

The Essentials

Cricothyroidotomy forms part of the DAS guidelines in the “can’t intubate, can’t oxygenate” (CICO) scenario once oxygen saturations have fallen below 90% on FiO2 of 1.0 (Plan D), and in the Vortex approach, when optimal attempts have been made at the three non-surgical airway techniques.

There are three basic methods to achieve trans-tracheal oxygenation:1

-Small cannula techniques (2-3 mm) plus a high-pressure gas source. These techniques rely on a patent airway for exhalation. However, inability to inflate the lungs with positive pressure ventilation via a facemask does not mean that the airway will be obstructed in expiration, when positive intraluminal pressure tends to expand and open the upper airway. In one series, 86% of patients with CICV retained a patent expiratory route.2 Gas entrainment is also a feature of these techniques if the upper airway is not obstructed.

-Large cannula techniques (≥4 mm). These enable oxygenation and ventilation with a lower pressure gas source but require either a cuffed cannula or obstruction of the upper airway to achieve adequate driving pressure for prolonged ventilation.

-Surgical technique. This enables placement of a size 6.0 to 7.0 tube and conventional ventilation.

As cricothyroidotomy is performed so rarely in clinical practice, evidence for the superiority of one technique over another is confined to studies in manikins, cadavers, case series and audits. Manikin studies consistently show high success rates, with mean times to successful oxygenation ranging between 23-123 seconds for various methods.3-5 The manikins used in these studies have slim necks the material which needs to be breached to perform a cricothyroidotomy has a limited resemblance to human tissue. A more recent study, in which the manikin was modified with belly pork to simulate a morbidly obese patient, showed a significantly longer median time to successful oxygenation (183.5s), with a low success rate of needle techniques (30%). When the needle technique failed, the majority of participants used a surgical approach as their second choice and succeeded.6

A study in 200 cadavers compared a Seldinger technique with surgical cricothyroidotomy and found similar success rates (84-88%) between the techniques, although mean time to oxygenation was faster with the Seldinger technique (98s vs 119s).7

A group from Western Australia has trained hundreds of anaesthetists to perform needle, Melker™ kit, scalpel-bougie and ‘scalpel-finger-needle’ cricothyroidotomy in anaesthetised sheep.8 The latter technique is advocated in cases of difficult neck anatomy, where the cricothyroid membrane cannot easily be palpated. A long, vertical midline neck incision is made, then the soft tissues blunt-dissected away with the fingers until the neck anatomy can be palpated. The group have reported success rates for these techniques, but unfortunately, only for 10 participants for each technique. As might be expected, cannula cricothyroidotomy performed poorly in difficult neck anatomy (40% success rate). Despite this, the algorithm that the group has produced (and which has been adopted by the Australia and New Zealand College of Anaesthetists), advocates a needle cricothyroidotomy as a first-line intervention in all patients, with palpation of neck anatomy only in the event of failure.8

The largest study of airway emergencies in hospitalised patients is the UK National Audit Project 4 (NAP4), conducted by the Royal College of Anaesthetists and the Difficult Airway Society.9,10 In this audit, the anaesthetist attempted to rescue the airway on 25 occasions. In 19 cases, they chose needle techniques, and notably, these failed in the majority of cases (12/19 = 63%). In Emergency Departments (EDs) and Intensive Care Units (ICUs), needle techniques were chosen less often, as the patients more often had facial trauma or known airway pathology. In the ED, there were four attempts at needle cricothyroidotomy, all of which failed, and in the ICU, a needle technique was used only once, successfully. By contrast, in NAP 4, surgical techniques were consistently successful when performed by surgeons, emergency physicians and anaesthetists alike, although not always with a good patient outcome.

In pre-hospital medicine, surgical techniques are chosen more often than needle techniques, and appear to be more successful. One meta-analysis showed success rates of 66% (27 patients) and 90% (485 patients) for needle and surgical techniques, respectively.11 In a British study of 7256 pre-hospital intubations, surgical cricothyroidotomy was performed in 48 patients with a 100% success rate.12 By contrast, a paramedic study, which included 1332 needle and surgical cricothyroidotomies, had a success rate of 34%.13

Complications from attempts at needle cricothyroidotomy and trans-tracheal jet ventilation can be severe, and appear to be commonplace. A 2005 American Society of Anesthesiologists closed claims analysis showed that, in 26 needle cricothyroidotomies, all had a poor outcome, and pneumothorax, pneumomediastinum or subcutaneous emphysema occurred in 89%.14

A 2006 systematic review came to the conclusion that surgical cricothyroidotomy should replace needle techniques as the intervention of choice for the CICO scenario.15 The authors maintained that the surgical technique is easily taught, allows for sustained, adequate ventilation and has relatively fewer complications than needle cricothyroidotomy.

A recent editorial came to the same conclusion, recommending not only that all anaesthetists should be able to perform a surgical technique, but that it should be considered the default technique.16 They have produced an algorithm which can be found in the paper. The Difficult Airway Society CICO algorithm also now advocates that the default technique should be surgical, with cannula techniques reserved for experts only.17 The CCAM CICO Algorithm is based on these two resources, and is shown below. The CCAM approach advocates a long vertical incision and blunt dissection in cases where the cricothyroid membrane cannot be easily identified.16 This is followed by a stab incision through the membrane, then the insertion of a gloved finger to dilate the orifice.18 This allows for controlled dilatation, and provides tactile feedback: the inferior surface of the thyroid cartilage and the superior surface of the cricoid arch should be palpable on the sides of the finger, and the hard anterior surface of the cricoid lamina should be palpable with the fingertip. Finger dilatation should then allow for a tracheal tube to be inserted under direct vision. Alternatively, a digitally guided bougie can be inserted first, followed by a tracheal tube.

In small-bore needle techniques, a high-pressure gas source must be used.1,15 There are two methods available: a specialised jet ventilator, such as the Manujet™, or a wall or cylinder oxygen supply connected via a system in which there is the capacity to vent gas, such as the Rapid-O2™ device. Ventilation is not possible with bag-valve devices or via the common gas outlet of an anaesthetic machine, which is limited by a 40 KPa pressure valve.

When using a wall or cylinder oxygen flowmeter, it has been found that the flow through a trans-tracheal catheter is almost three times higher and the pressure just before the catheter four times higher when the flowmeter is fully opened than when it is opened to the 15 l.min-1 mark.19 Care should therefore be taken when fully opening the flowmeter, just as care is taken to gradually increase the pressure when using the Manujet™.

No formal evaluation of the Melker™ and Rapid-O2™ devices has been undertaken. The developers of the Rapid-O2™ device suggest that is provides better tactile feedback about obstruction to flow, and the large bore vent in the system acts as a safety valve, preventing the dangerous build up of pressure that can occur with a Manujet™.20

If a small bore cannula technique is not chosen, different practitioners may opt for either a large bore cannula or a surgical technique. With the advent of cuffed Seldinger based kits (such as the Melker™), practitioners (especially those familiar with dilational percutaneous tracheostomy) may opt for these techniques.

The Laryngeal Handshake

For all techniques, a good way to identify the anatomical landmarks is to perform a ‘laryngeal handshake’ (described by Levitan):17

CCAM CICO Algorithm

Top Tips

-Perform a ‘laryngeal handshake’ to identify the anatomical landmarks

-You should be familiar with small cannula, Seldinger large cannula and surgical techniques.

-Be aware of the equipment available in the clinical areas where you work.

-If you choose a small cannula technique, be aware that the failure rate for this technique is high. Be prepared to abandon early in favour of another technique.

-If you use a high-pressure oxygen source, the Rapid-O2™ device may give better tactile feedback of obstruction and better protection from barotrauma than the Manujet™.

-If you use a high-pressure oxygen source, allow plenty of time for expiration and be vigilant for potential gas delivery into tissues (failure of chest rise, tactile feel of obstructed flow, surgical emphysema).

-If you prefer a Seldinger technique, a cuffed cannula will give far superior ventilation than an uncuffed device.

-For surgical cricothyroidotomy, the scalpel-finger (+/- bougie) technique has a high success rate and has the advantage of tactile feedback.

-If not using a finger to dilate the orifice, always leave an instrument in the orifice until the airway is established to prevent loss of the tract.

-During a surgical airway, the initial insertion of the bougie or tube should be at 90 degrees to the midline of the neck.

-Don’t be afraid to perform a long, midline neck incision if you can’t feel the anatomy.

-Always keep a tight grip on any device inserted into the cricothyroid membrane, and secure firmly.

The Video

FOAM Resources

References

  1. Cook TM, Nolan JP, Magee PT, Cranshaw JH. Needle cricothyroidotomy. Anaesthesia. 2007;62(3):289-290; author reply 290-281.
  2. Smith RB, Babinski M, Klain M, Pfaeffle H. Percutaneous transtracheal ventilation. Jacep. 1976;5(10):765-770.
  3. Vadodaria BS, Gandhi SD, McIndoe AK. Comparison of four different emergency airway access equipment sets on a human patient simulator. Anaesthesia. 2004;59(1):73-79.
  4. Sulaiman L, Tighe SQ, Nelson RA. Surgical vs wire-guided cricothyroidotomy: a randomised crossover study of cuffed and uncuffed tracheal tube insertion. Anaesthesia. 2006;61(6):565-570.
  5. Wong DT, Prabhu AJ, Coloma M, Imasogie N, Chung FF. What is the minimum training required for successful cricothyroidotomy?: a study in mannequins. Anesthesiology. 2003;98(2):349-353.
  6. Howes TE, Lobo CA, Kelly FE, Cook TM. Rescuing the obese or burned airway: are conventional training manikins adequate? A simulation study. British journal of anaesthesia. 2015;114(1):136-142.
  7. Schaumann N, Lorenz V, Schellongowski P, et al. Evaluation of Seldinger technique emergency cricothyroidotomy versus standard surgical cricothyroidotomy in 200 cadavers. Anesthesiology. 2005;102(1):7-11.
  8. Heard AM, Green RJ, Eakins P. The formulation and introduction of a ‘can’t intubate, can’t ventilate’ algorithm into clinical practice. Anaesthesia. 2009;64(6):601-608.
  9. Cook TM, Woodall N, Frerk C, Fourth National Audit P. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. British journal of anaesthesia. 2011;106(5):617-631.
  10. Cook TM, Woodall N, Harper J, Benger J, Fourth National Audit P. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. British journal of anaesthesia. 2011;106(5):632-642.
  11. Hubble MW, Wilfong DA, Brown LH, Hertelendy A, Benner RW. A meta-analysis of prehospital airway control techniques part II: alternative airway devices and cricothyrotomy success rates. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 2010;14(4):515-530.
  12. Lockey D, Crewdson K, Weaver A, Davies G. Observational study of the success rates of intubation and failed intubation airway rescue techniques in 7256 attempted intubations of trauma patients by pre-hospital physicians. British journal of anaesthesia. 2014;113(2):220-225.
  13. Diggs LA, Yusuf JE, De Leo G. An update on out-of-hospital airway management practices in the United States. Resuscitation. 2014;85(7):885-892.
  14. Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the difficult airway: a closed claims analysis. Anesthesiology. 2005;103(1):33-39.
  15. Scrase I, Woollard M. Needle vs surgical cricothyroidotomy: a short cut to effective ventilation. Anaesthesia. 2006;61(10):962-974.
  16. Kristensen MS, Teoh WH, Baker PA. Percutaneous emergency airway access; prevention, preparation, technique and training. British journal of anaesthesia. 2015;114(3):357-361.
  17. Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. British journal of anaesthesia. 2015;115(6):827-848.
  18. Paix BR, Griggs WM. Emergency surgical cricothyroidotomy: 24 successful cases leading to a simple ‘scalpel-finger-tube’ method. Emergency medicine Australasia : EMA. 2012;24(1):23-30.
  19. Bould MD, Bearfield P. Techniques for emergency ventilation through a needle cricothyroidotomy. Anaesthesia. 2008;63(5):535-539.
  20. Heard AM. Jet Oxygenation (video). Available: https://www.youtube.com/watch?v=QR7ek7VBNiQ.
  21. Gerig HJ, Schnider T, Heidegger T. Prophylactic percutaneous transtracheal catheterisation in the management of patients with anticipated difficult airways: a case series. Anaesthesia. 2005;60(8):801-805.