Abstract
Background
Emergency front of neck access (eFONA) is a critical step in oxygenation in cases of unrelieved airway obstruction. Multiple techniques are used in clinical practice without agreement regarding the optimal approach. We evaluated a novel device, the Cric-Guide (CG), a channelled bougie introducer that enters the airway in a single action and compared it with a scalpel-bougie-tube (SBT) technique in laboratory benchtop model.
Methods
Seven anaesthesiologists attempted eFONA on both obese and non-obese models using both techniques in randomized order on an excised porcine trachea with an intact larynx with variable subcutaneous tissue depth. The primary outcome was successful tracheal cannulation. Secondary outcomes included false passage rate, time and tissue injury.
Results
Anaesthesiologists performed 4 cricothyroidotomies on each model with each device. The CG was more successful in airway cannulation (47/56 [89.4%] vs. 33/56 [58.9%], P = 0.007). This difference was observed in the obese model only. The CG was associated with fewer false passages than the standard technique in the obese model (8/56 [14.3%] vs. 23/56 [41.1%], P = 0.006). There were no significant differences in time to completion or injury patterns between the techniques in the obese model, but the SBT was faster in the non-obese model. There was no difference in the proportion of specimens injured.
Conclusion
The Cric-Guide device was more successful than the standard SBT technique in airway cannulation in an obese neck model and with equivalent frequency and distribution of injury but performed equivalently in the non-obese model.
Similar content being viewed by others
References
Cook TM, Woodall N, Frerk C, Fourth National Audit P (2011) 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. Br J Anaesth 106 (5):617–631.https://doi.org/10.1093/bja/aer058
Fennessy P, Aslani A, Campbell M et al (2018) Theoretical optimal cricothyroidotomy incision length in female subjects, following identification of the cricothyroid membrane by digital palpation. Int J Obstet Anesth 36: 42-48
Fennessy P, Drew T, Husarova V et al (2019) Emergency cricothyroidotomy: an observational study to estimate optimal incision position and length. Br J Anaesth 122(2):263–268. https://doi.org/10.1016/j.bja.2018.10.003
Salah N, Mhuircheartaigh RN, Hayes N, McCaul C (2010) A comparison of four techniques of emergency transcricoid oxygenation in a manikin. Anesth Analg 110(4):1083–1085. https://doi.org/10.1213/ANE.0b013e3181d27eb2
Duggan L, Ballantyne Scott B, Law J et al (2016) Transtracheal jet ventilation in the ‘can’t intubate can’t oxygenate’emergency: a systematic review. BJA: British Journal of Anaesthesia 117 (suppl_1):i28-i38
Baker P, O'sullivan E, Kristensen M, Lockey D (2016) The great airway debate: is the scalpel mightier than the cannula? Br J Anaesthesia 117(Issue suppl_1), Pages i17–i19. https://doi.org/10.1093/bja/aew219
Dimitriadis J, Paoloni R (2008) Emergency cricothyroidotomy: a randomised crossover study of four methods. Anesth 63(11):1204–1208
Eisenburger P, Laczika K, List M et al (2000) Comparison of conventional surgical versus Seldinger technique emergency cricothyrotomy performed by inexperienced clinicians. Anesthesiol 92(3):687–690. https://doi.org/10.1097/00000542-200003000-00012
Helm M, Hossfeld B, Jost C et al (2013) Emergency cricothyroidotomy performed by inexperienced clinicians—surgical technique versus indicator-guided puncture technique. Emerg Med J 30(8):646–649
Apfelbaum JL, Hagberg CA, Caplan RA et al (2013) American Society of Anesthesiologists Task Force on Management of the Difficult A Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiol 118(2):251–270. https://doi.org/10.1097/ALN.0b013e31827773b2
Frerk C, Mitchell VS, McNarry AF et al (2015) Difficult Airway Society intubation guidelines working Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth 115(6):827–848. https://doi.org/10.1093/bja/aev371
Fennessy P, Aslani A, Campbell M et al (2018) Theoretical optimal cricothyroidotomy incision length in female subjects, following identification of the cricothyroid membrane by digital palpation. Int J Obstet Anesth 36:42–48. https://doi.org/10.1016/j.ijoa.2018.06.003
Kristensen MS, Teoh WH (2020) Ultrasound identification of the cricothyroid membrane: the new standard in preparing for front-of-neck airway access. Br J Anaesth 126(1):22–27
Drew T, McCaul CL (2018) Laryngeal handshake technique in locating the cricothyroid membrane: a non-randomised comparative study. Br J Anaesth 121(5):1173–1178. https://doi.org/10.1016/j.bja.2018.07.034
Duggan LV, Lockhart SL, Cook TM et al (2018) The Airway App: exploring the role of smartphone technology to capture emergency front-of-neck airway experiences internationally. Anaesth 73(6):703–710. https://doi.org/10.1111/anae.14247
Salah N, El Saigh I, Hayes N, McCaul C (2009) Airway injury during emergency transcutaneous airway access: a comparison at cricothyroid and tracheal sites. Anesth Analg 109(6):1901–1907. https://doi.org/10.1213/ANE.0b013e3181bdd1ba
Yeow C, Greaney L, Foy C et al (2018) Evaluation of a novel cricothyroidotomy introducer in a simulated obese porcine model: a randomised crossover comparison with scalpel cricothyroidotomy. Anaesth 73(10):1235–1243
Long N, Ng S, Donnelly G et al (2014) Anatomical characterisation of the cricothyroid membrane in females of childbearing age using computed tomography. Int J Obstet Anesth 23(1):29–34. https://doi.org/10.1016/j.ijoa.2013.07.007
Aslani A, Ng SC, Hurley M et al (2012) Accuracy of identification of the cricothyroid membrane in female subjects using palpation: an observational study. Anesth Analg 114(5):987–992. https://doi.org/10.1213/ANE.0b013e31824970ba
Campbell M, Shanahan H, Ash S et al (2014) The accuracy of locating the cricothyroid membrane by palpation - an intergender study. BMC Anesthesiol 14:108. https://doi.org/10.1186/1471-2253-14-108
Siddiqui N, Arzola C, Friedman Z et al (2015) Ultrasound improves cricothyrotomy success in cadavers with poorly defined neck anatomy: a randomized control trial. Anesthesiol 123(5):1033–1041. https://doi.org/10.1097/ALN.0000000000000848
Hossfeld B, Mahler O, Mayer B et al (2019) Necessity to depict difficult neck anatomy for training of cricothyroidotomy: a pilot study evaluating two surgical devices on a new hybrid training model. Eur J Anesthesiol | EJA 36 (7):516–523. doi:https://doi.org/10.1097/eja.0000000000000993
Drew T, Khan W, McCaul C (2019) The effect of i-gel((R)) insertion on the accuracy of cricothyroid membrane identification in adult females: a prospective observational study. Br J Anaesth 123(3):392–398. https://doi.org/10.1016/j.bja.2019.03.012
Howes TE, Lobo CA, Kelly FE, Cook TM (2015) Rescuing the obese or burned airway: are conventional training manikins adequate? A simulation study Br J Anaesth 114(1):136–142. https://doi.org/10.1093/bja/aeu336
McCaul C, Radwan M, Fennessy P et al (2020) Is clinician confidence in localizing the cricothyroid membrane a reasonable basis for cricothyroidotomy strategy. Trends in Anaesth and Critical Care 30:e163
Wong DT, Prabhu AJ, Coloma M et al (2003) What is the minimum training required for successful cricothyroidotomy?: a study in mannequins. Anaesthesiol 98(2):349–353
Fennessy P, Walsh B, Laffey JG et al (2020) Accuracy of pediatric cricothyroid membrane identification by digital palpation and implications for emergency front of neck access. Paediatr Anaesth 30(1):69–77. https://doi.org/10.1111/pan.13773
Walsh B, Fennessy P, Ni Mhuircheartaigh R et al (2019) Accuracy of ultrasound in measurement of the pediatric cricothyroid membrane. Paediatr Anaesth 29(7):744–752. https://doi.org/10.1111/pan.13658
Kelly FE, Cook TM (2017) Front of neck airway: the importance of the correct (obese) models and (trained) participants in study design. Anaesthesiol 126(5):986–987. https://doi.org/10.1097/ALN.0000000000001573
Ezri T, Gewurtz G, Sessler DI et al (2003) Prediction of difficult laryngoscopy in obese patients by ultrasound quantification of anterior neck soft tissue. Anaesth 58(11):1111–1114. https://doi.org/10.1046/j.1365-2044.2003.03412.x
Komatsu R, Sengupta P, Wadhwa A et al (2007) Ultrasound quantification of anterior soft tissue thickness fails to predict difficult laryngoscopy in obese patients. Anaesth Intensive Care 35(1):32–37. https://doi.org/10.1177/0310057X0703500104
Athanassoglou V, Hughes-Jones H, Hadjipavlou G et al (2020) Depth to the airway lumen at the level of the cricothyroid membrane measured by ultrasound. Acta Anaesthesiol Scand 64(1):48–52
Gadd K, Wills K, Harle R, Terblanche N (2018) Relationship between severe obesity and depth to the cricothyroid membrane in third-trimester non-labouring parturients: a prospective observational study. Br J Anaesth 120(5):1033–1039. https://doi.org/10.1016/j.bja.2018.02.010
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Competing interests
No external funding and no competing interests declared. The Cric Guide equipment was supplied by its inventor, Dr Richard Vanner at no cost.
Rights and permissions
About this article
Cite this article
Chauhan, S.K., Monaghan, M. & McCaul, C.L. Evaluation of a novel emergency front of neck access device in a benchtop model of obesity. Ir J Med Sci 191, 413–420 (2022). https://doi.org/10.1007/s11845-021-02530-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11845-021-02530-5