“Cannot intubate, cannot oxygenate”: A novel 2‐operator technique for cannula tracheotomy in an infant animal model—a feasibility study

Abstract

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.

Emergency front‐of‐neck access in pediatric anesthesia: A narrative review

“…If this approach fails, the last resource is a surgical cricothyroidotomy 5 . Although the Association for Pediatric Anesthesia of Great Britain and Ireland (APAGBI) recommend percutaneous needle cricothyroidotomy 5,14 the 100% success rate in animals reported by Prunty et al 24 . is in contrast to the 43% success rate reported in real life CICO‐situations in adults 11 and to two pediatric case reports that describe unsuccessful percutaneous cricothyroidotomy which was rescued by surgical tracheostomy 13,14 .…”

“…Often, only two physician conduct eFONA procedures on a restricted number of animal subjects, using them for multiple interventions. [21][22][23][24] This homogeneity may lead to modifications in the structure of the trachea due to repeated punctures, potentially compromising the reliability of subsequent attempts. 21,24 More recently, four studies involved rabbit cadaver models and standardized settings to simulate a more realistic scenario of eFONA in infants.…”

“…[21][22][23][24] This homogeneity may lead to modifications in the structure of the trachea due to repeated punctures, potentially compromising the reliability of subsequent attempts. 21,24 More recently, four studies involved rabbit cadaver models and standardized settings to simulate a more realistic scenario of eFONA in infants. [25][26][27][28] Rabbit cadavers weighing 2.5-3.5 kg were used in these studies with the aim to better simulate the size of a small infant's trachea.…”

“…Prunty S.L. et al 21 Stacey J. et al 22 Metterlein T. et al 23 Prunty S. L. et al 24 Ulmer F. et al 25 Both C.P. et al 26 Thomas J. et al 27…”

“…Second, a significant issue regarding representativeness arises from the small sample sizes typically employed and from the reduced number of study partecipants. Often, only two physician conduct eFONA procedures on a restricted number of animal subjects, using them for multiple interventions 21–24 . This homogeneity may lead to modifications in the structure of the trachea due to repeated punctures, potentially compromising the reliability of subsequent attempts 21,24 …”