Comparison of a percutaneous device and the bougie-assisted surgical technique for emergency cricothyrotomy: an experimental study on a porcine model performed by air ambulance anaesthesiologists

Abstract

BackgroundA large number of techniques and devices for cricothyroidotomy have been developed. In this study, the Portex™ Cricothyroidotomy Kit (PCK, Smiths Medical Ltd, Hythe, UK) was compared with the bougie assisted emergency surgical cricothyrotomy technique (BACT).MethodsTwenty air ambulance anaesthesiologists performed emergency cricothyrotomy on a cadaveric porcine airway model using both PCK and BACT. Baseline performance and performance after the intensive training package were recorded. Success rate, time to secured airway and tracheal damage were the primary endpoints, and confidence rating was a secondary endpoint.ResultsDuring baseline testing, success rates for PCK and BACT were 60% and 95%, respectively. Tracheal injury rate with PCK was 60% while no such injury was found in BACT. A lecture was given and skills were trained until the participants were able to perform five consecutive successful procedures with both techniques. In the post-training test, all participants were successful with either technique. The mean time to successful insertion was reduced by 15.7 seconds (from 36.3 seconds to 20.6 seconds, p< 0.001) for PCK and by 7.8 seconds (from 44.9 seconds to 37.1 seconds, p=0.021) for BACT. In the post-training scenario, securing the airway with PCK was significantly faster than with BACT (p<0.001). Post-training tracheal laceration occurred in six (30%) of the PCK procedures and in none of the BACT procedures (p=0.028).The self-evaluated confidence level was measured both pre- and post-training using a confidence scale with 10 indicating maximum amount of confidence. The median values increased from 4 to 8 for PCK and from 6.5 to 9.5 for BACT. All participants reported that BACT was their preferred technique.ConclusionsTesting the base-line PCK skills of prehospital anaesthesiologists revealed low confidence, sub-optimal performance and a very high failure rate. The BACT technique demonstrated a significantly higher success rate and no tracheal damage. In spite of PCK being a significantly faster technique in the post-training test, the anaesthesiologists still reported a higher confidence in BACT. Limitations of the cadaveric porcine airway may have influenced this study because the airway did not challenge the clinicians with realistic tissue bleeding.

Effect of palpable vs. impalpable cricothyroid membranes in a simulated emergency front‐of‐neck access scenario

“…Although we showed a difference in speed of securing an airway with a palpable vs. an impalpable membrane, the timings for the latter were still acceptable, demonstrating the positive effect of training. Both sets of times are comparable to those found by other groups investigating broadly similar bougie-assisted cricothyroidotomy techniques [10][11][12][13], with average procedural times of 33-81 s. Our study, however, is probably the first evaluation of the FONA techniques described in the DAS 2015 guidelines in a benchtop study and showed a high first-attempt success rate.…”

Great variation between ICU physicians in the approach to making end‐of‐life decisions.

“…21 Using simulations as a tool to identify different treatment and decision-making strategies is not new. Simulation has been used to test new healthcare facilities and to identify potential flaws, 22 to test procedure competence and 23 and to evaluate protocol and team performance. 24 In the context of our study, the simulation acted as a tool to identify strategies for EOL decisions.…”

Emergency front‐of‐neck airway by ENT surgeons and residents: A dutch national survey

“…Expert opinion, NAP4, and difficult airway society (DAS) guidelines do not recommend small‐bore catheters or uncuffed cannulas in inexperienced hands because of possible serious complications. At the time of the survey there was no gold standard for a cricothyrotomy technique, but surgical FONA was associated with better success rates than percutaneous techniques . The scalpel bougie method might be an interesting alternative to a percutaneous technique for ENT surgeons, since it is based on skills that they are already familiar with.…”

“…At the time of the survey there was no gold standard for a cricothyrotomy technique, 1,8 but surgical FONA was associated with better success rates than percutaneous techniques. 3,9,10 The scalpel bougie method 11,12 might be an interesting alternative to a percutaneous technique for ENT surgeons, since it is based on skills that they are already familiar with. Moreover, this technique uses materials readily available (scalpel, introducing catheter, cuffed tube 6).…”