Guest Post: More from Minh Le Cong on Needle Cricothyrotomy

Minh Le Cong is a frequent guest and commenter on EMCrit. I have asked him, whenever inspiration strikes, to write guest posts on the blog. Minh is an airway guru and can share the unique perspective of a doc doing prehospital retrieval and care. Here’s Minh:

Needle Cricothyrotomy

Oxygenation with a needle cricothyrotomy based technique:

I want to provide a host of reference articles for you to decide for yourself the science and the practicality in the cannot intubate/cannot oxygenate  scenario. The astute reader will note the crucial difference between total upper airway obstruction model of research and the partially obstructed or unobstructed airway model. High pressure, high flow via a needle catheter carries a low safety index with the margin between safe oxygenation and lethal barotraumas being narrow. Short inspiratory times and long expiratory times ( ratio of more than 1:4 and ideally 1: 9) appear to be safest. In the more common situation of a partially obstructed or unobstructed airway but a failed intubation, failed BVM oxygenation and critical hypoxia, high flow oxygenation via a 14 G needle cannula is practical and much safer as pressure is released via the upper airway.

In his article, Patel describes successful repeat intubation in more than half of the rescue oxygenated patients using the needle cricothyroidotomy technique, avoiding the open surgical technique completely. Low flow transtracheal insufflations of oxygen at 2 l/min as demonstrated by the research Black, Janus and Grothwohl is even safer yet capable in their animal model of rescue oxygenating successfully for at least 1 hr. There are multiple case reports in the literature of human patients being successfully rescued using the needle catheter technique with a variety of improvised as well as dedicated transtracheal oxygenation setups. The reader must decide for themselves but it needs to be pointed out that the needle catheter technique is the only one that is most applicable across all age groups, with open surgical technique in children being even less practiced than in adults!

References compiled by Dr. Minh Le Cong, Jan 2012-01-02:

Patel RG. Percutaneous transtracheal jet ventilation: a safe, quick, and temporary way to provide oxygenation and ventilation when conventional methods are unsuccessful. Chest. 1999 Dec; vol. 116(6) pp. 1689-94. PMID: 10593796

Based on the subsequent insertion of an endotracheal tube into the trachea, there were two important benefits in the patients who underwent PTJV successfully. First, PTJV provided effective oxygenation, while allowing adequate time for upper airway visualization and possible suctioning of oropharyngeal secretions. Second, tracheal intubation was subsequently easier, possibly because the high tracheal pressure from the gas insufflation opened the collapsed glottis, making visualization of the glottic aperture better. PTJV is safe and quick in providing immediate oxygenation, and therefore should be considered as an alternative to insistent, multiple intubation attempts, when neither bag-mask-valve ventilation nor endotracheal intubation is feasible in providing adequate gas exchange.

 


Black IH, Janus SA, Grathwohl KW. Low-flow transtracheal rescue insufflation of oxygen after profound desaturation. PMID: 16294073

 

Low-flow TRIO rescued animals from profound hypoxia and maintained oxygenation for at least 1 hour. Low-flow TRIO did not prevent hypercarbia with its subsequent sympathetic activation.


Ayoub IM, Brown DJ, Gazmuri RJ. Transtracheal oxygenation : an alternative to endotracheal intubation during cardiac arrest. Chest. 2001 Nov; vol. 120(5) pp. 1663-70  PMID: 11713151

 

TTO was as effective as conventional positive-pressure ventilation with 100% O(2) for securing oxygenation, resuscitation, and short-term survival and more effective than O(2) delivered through a mask.


Jawan B, Cheung HK, Chong ZK, Poon YY, Cheng YF, Chen HS, Huang CJ, Lee JH. Aspiration in transtracheal oxygen insufflation with different insufflation flow rates during cardiopulmonary resuscitation in dogs. Anesth. Analg. 2000 Dec; vol. 91(6) pp. 1431-5

PMID: 11093994

 

We investigated whether transtracheal insufflation of oxygen with different insufflation flow rates protects against aspiration of gastric contents during cardiopulmonary resuscitation (CPR). Its ventilation and oxygenation effects were also evaluated. Cardiac arrest was induced in anesthetized and paralyzed 18 mongrel dogs. Chest compression using an automatic thumper was performed while the dogs randomly received no mechanical ventilation (Group I, n = 6) or were transtracheally insufflated with 4 L/min oxygen (Group II, n = 6) or 10 L/min oxygen (Group III, n = 6). Blood samples were drawn every 5 min for 20 min for blood gas analysis. the mouths of the dogs were then filled with 70 mL mixed barium, and 10 min after chest compression, chest radiographs were taken to evaluate the incidence of pulmonary aspiration. Results showed that pulmonary aspiration occurred in all dogs of Group I and three of the six dogs in Group II, whereas dogs in Group III were free from pulmonary aspiration. Both transtracheal oxygen insufflation groups maintained oxygen saturation significantly better than Group I, but mild hypercapnia was observed in all groups after 20 min of CPR. We conclude that transtracheal oxygen insufflation, but not chest compression alone, was able to maintain oxygenation for 20 min during CPR in dogs with cardiac arrest. Mild hypercapnia was noted in all groups. Chest compression alone caused pulmonary aspiration, whereas insufflation of 10 L O(2)/min provided better protection against pulmonary aspiration than that of 4 L O(2)/min.


Stothert JC, Stout MJ, Lewis LM, Keltner RM. High pressure percutaneous transtracheal ventilation: the use of large gauge intravenous-type catheters in the totally obstructed airway.Am J Emerg Med. 1990 May; vol. 8(3) pp. 184-9. PMID: 2331256

 

Percutaneous transtracheal ventilation using a large gauge intravenous-type catheter can be used successfully in the setting of complete upper airway obstruction in animals. In this study, using a large animal model, satisfactory oxygenation and ventilation was achieved by inversely varying the catheter size and the inspiration to expiration ratio (I:E). Specifically, 30 to 63 kg ruminants with an obstructed upper airway were resuscitated for 30 minutes from a hypoxic, hypercarbic, and acidotic state using 12- and 14-gauge catheters connected to a 50 psi oxygen source via a two-way valve with an I:E of 1:4 and 1:9 seconds, respectively. Shorter expiratory time or increased inspiratory time with these intravenous catheters resulted in significant hemodynamic compromise, barotrauma, inadequate carbon dioxide elimination, acidemia, and frequent death.

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Comments

  1. Would you change the I:E ratio or flow rate if you were using this during a pedi cric?

  2. Minh Le Cong says:

    Hi Chris. Yes I would. APLS teaches 1L/min/year of age. thats a reasonable rule of thumb. but it really depends overall on what you think you are dealing with. with suspected complete upper airway obstruction, you have to be very careful. the work of Black et al using low flow TRIO in an animal model was compelling. 2L/min rescue oxygenated from critical hypoxia within 30 sec of initiation. in paediatric resuscitation the research is very scant to guide us but overall in an emergency for kids, 2L/min would be reasonable as a starter if you are unsure. You can look for chest wall rise and always increase your flow rate if nothing has happened wihtin30sec. Insp time I would in general keep short with a long exp time, regardless of age. but there is a caveat initially

    • Excellent, thank you! Does guidance exist for the choice in catheter size in peds? Also, would switching to a bevel down approach perhaps be warranted (per the recent literature in switching to this method for IJ cannulation) to reduce the possibility of posterior wall damage?

      • Minh Le Cong says:

        Hi Chris. I am unaware of any research published about using a bevel down approach to reduce injury to posterior tracheal wall. This is of course a recognised complication of the needle cric technique. if the neck skin is tough, it is easy to use excessive force and injurethe posterior tracheal wall. if need be to minimise the risk, making a small skin nick with a blade prior to needle insertion may help. it depends though how critical the situation is. if its a rescue oxygenation situation then it does not matter. if its a situation where you can oxygenate the patient by another rescue method like LMA or BVM and you still want to secure the airway through the neck, then since you have some time on your side, I would take the step to incise the skin, insert the needle and do it seldinger style. or you could do it open technique. in kids I have only done needle crics, never an open surgical airway like a tracheotomy. In adults , you can do it either way. I have only done open surgical airways in adults. Scotts teaching on this is probably the best I have come across in my career

  3. Thank you for an interesting follow-up to the Needle vs. knife-podcast, Minh. As a nurse anesthetist I agree on your recommendations for needle cricothyrotomy as the primary rescue airway in a CI/CV situation. I also agree that in most situations, without any personal experience though, you would probably also get passive expiration through a partially obstructed airway, even in situations where ventilationattempts with BVM/SADs fail, and the airway seems totally obstructed.

    The main problem is then the really totally obstructed airway, and the risk for barotrauma. About a month ago I became aware of a jetventilation-device called Ventrain, which uses Expiratory Ventilatory Assistance (EVA), an application of the Venturi-principle for assisted expiration through a 2,0 mm transtracheal cannula. In short, it “sucks” the insufflated air out, and allows for an I:E-ratio of about 1:1, without the risk of barotrauma.

    Yesterday I made a short video demonstrating the use of it on a 600ml/cc reservoir-bag without resistance and compliance, and it works! You can see it here: http://youtu.be/EZ-785vYvGA More information about the Ventrain: http://www.ventrain.eu/en/

    Is there anyone else who has experience using this device?

    Lars Svarthaug, lecturer, Norway
    Declaration of interests: I have no commercial or personal interests in the Ventrain-product, but I have been provided with one demonstration-device for education purposes in our simulation lab.

    • Minh Le Cong says:

      thanks Lars
      that looks quite novel. I had read about the design of the Ventrain but never seen one used. It seems to address the main problems of emergency needle cricothyrotomy based oxygenation using high flow systems, typically at 15L/min for adults…expiration and build up of excessive pressure, in particular with the near completely obstructed airway. In my experience the manual holding of the oxygen tubing to the catheter hub and taking it off is practical and effective in the emergency setting. A colleague and I had one successful case of a child with epiglottitis,rescued with this technique after failed intubation. It was enough to maintain oxygenation to have a second more controlled attempt at intubation which was successful. I must try to acquire a Ventrain and conduct testing of it as you have.

    • Minh Le Cong says:

      Lars, I wanted to add that in my view you cant always rely upon one technique in the CICO situation. There will be cases when needle cric will have a high failure rate if not impossible. if you transect your trachea, the needle will fail always. colleagues of mine had to deal with a real case of this in WA.

      • Thank you for your comments, Minh! This post was very interesting, and the Needle vs Knife-podcast really was a eye-opener for me to the fact that the needle technique has such a low successrate, according to some of the studies mentioned. The use of the tubing directly on the needle was new to me too, simple and easy! I’ve never heard about the “low-flow” option either, many good points!

        Hopefully, I will never have to deal with such a situation where TTJV is impossible. As a nurse anesthetist, without “the license to use a scalpel”, needle is my last chance. Of course we mostly have an anesthesiologist or surgeon nearby, but in some situations we work independently(transports, prehospital etc) , and then we have to rely on the needle. I also think most anesthesiologists here would prefer to try the needle before the knife also in ED/trauma(we still do not have emergency doctors as a subspeciality in Norway).

        I’m really looking forward to hear if there is someone having experiences with the Ventrain. It seems to adress the most serious risk with TTJV, barotrauma due to too short expiration in case of obstructed airway. I’m a bit concerned about the risk for pulmonary edema if too negative pressure/too long active expiration time (NPPE), but there will also be a risk for this in many situations due to the indication for invasive ventilation (obstructed airway).

  4. Minh Le Cong says:

    18 G or bigger is the way to go. Adult and kids. The Black et al study of low flow rescue oxygenation used a 15 G catheter. honestly , use something big whatever you got.

  5. Minh Le Cong says:

    the caveat about initial insp time with this technique is reversing the lung collapse during apnoea. In the scenario of a failed intubation and a period of apneoa, there will be collapsed lung to overcome initially. Providing an initial longer period of inspiration wiht the needle cric may be optimal but not proven yet. Certainly a low flow rate seems to be enough to provide rescue oxygenatioon in the animal model.

  6. Lars & Minh,
    Regarding the ventrain: I think this device has many advantages and is probably the best commercial option I have seen thus far. That being said, any of these devices scare me b/c of the cognitive dependence they encourage. If you train with a ventrain and then it is missing, there is a barrier to saving the patient while someone is looking for a replacement. Minh’s concept of oxygen tubing held (not attached) to the cath hub is the CLEANEST technique I have come across. It has changed my teaching entirely. In cric situations, needle or surgical, I think we need to reduce complexity and necessity to the barest minimum.

  7. Minh Le Cong says:

    Let me share with you a frustrating, somewhat humorous anecdote from a retrieval I did 2 days ago. We were flying a ventilated patient. OUr drug and airway packs are kept stored in slide out drawers in the aircraft. Well one of the drawers containing our airway pack decided to get stuck and refused to open. This pack has all the laryngoscopes, bougies, stylets and ETTs! I thought what do I do now if we get a cuff leak and I need to exchange the ETT??
    Yes Scott’s right. We should not rely upon certain pieces of gear to always be there. Luckily I always carry a spare laryngoscope as well as a King vision VL nowadays. I used to carry my own Fastrach ILMAs but my service now stores some in a separate rescue airway pack..which luckily is kept in another drawer we could access…potential disaster averted!

  8. Dr Tom Palfi says:

    Hi Minh,

    I work in a small provincial hospital in Gisborne, New Zealand (on the East Coast of the North Island).

    One of my colleagues was recently called to a respiratory arrest in the surgical ward. A middle-aged man with a throat malignancy had been admitted for an elective tracheostomy the following day. Unfortunately he developed a complete airway obstruction, had a respiratory arrest and lost consciousness soon after admission.

    Due to problems locating the ‘Difficut Airway Trolley’ my colleague did exactly what you recommended in your video i.e. inserted a 14G angiocath through the cricothyroid membrane and connected it to the wall oxygen directly. WORKED BRILLIANTLY! Patient improved his sat’s within a few seconds, woke up….. and then tried to rip out the tubing!

    This case actually highlighted another problem with the resuscitation equipment up in our wards – a lack of suitable drugs on our trolleys for immediate post-resuscitation sedation/paralysis.

    Keep up the great work guys – you actually make CME fun!!!

    Tom

    • Minh Le Cong says:

      Hi Tom
      Is it possible to invite your colleague to do an interview with me via Skype on his case ? You can contact me via my email, mlecong@rfdsqld.com.au

      It would be great to record the details to share to colleagues who might find themselves in exactly in the same situation one dark night shift!

      • Minh Le Cong says:

        Imagine one dark night you are working late in the hospital, when a patient is admitted for tracheostomy the next day due to a laryngeal tumour.
        imagine you are called to this patient who has developed worsening airway obstruction and he suffers a respiratory arrest and goes blue in front of you.
        Imagine you have no useful airway equipment nearby….what do you do? Start CPR? get a knife from the dinner trolley? Try a digital oral intubation?

        This is what you do. You run to the IV trolley and grab a 14G needle cannula. You run back and insert this into the neck, pass the cannula and then grab oxygen tubing connected to a wall flow meter. You dial up 15Lmin flow. You hold the oxygen tubing end directly onto the cannula hub. ON and off. Within 20 seconds the patient starts to wake up and tries to pull the cannula out! You have to quickly sedate him with midazolam…crisis averted and surgical help is on its way.

        when asked later, you reply “it had to be done , so I did it”. inspirational stuff.
        This story is shared so that others may learn

  9. Minh Le Cong says:

    Tom, thanks for the great feedback. You have made this dreary week so much brighter for me! God speed and all my prayers to you all in your next resuscitation. I dont believe in dificult airway trolleys any more based on similar bitter experiences. I think the best difficult airway gear is what you can carry in your pockets and the thing between your ears. If it cant fit in my pockets I am suspiscious that when badness visits, it will not help me…but then again I have pretty big pockets. Airway kung fu, folks. Bruce would have been proud of your mate.

    • Tom fantastic work! Minh-best line of the year, “the most important equipment to manage a difficult airway is carried between your ears.” love it!

  10. It had to be done, so I did it is the line of the year! See Minh’s story in the comments of this post: http://t.co/4uxkrUVt

  11. Must read post (and comments!) on emergency airway management and needle cric – it changed my thinking http://t.co/JSHtqXkd

  12. I just saw this post today- reminded me of many experiments I did (with fake lungs/trachs, etc) while I worked for a prehospital service where needle cric was an important option in our protocols for inability to ventilate noninvasively. I spent a lot of time sitting on the floor making many many variations of improvised devices.

    The three-way stopcock method Minh shows in his video was one of the iterations but I decided I would be uncomfortable with it in the field primarily because it tended to allow huge pressure build-up in the lungs if there was obstruction (or even significant partial obstruction) in the upper tract, especially at the ~1:1 I:E ratios from the video. This seemed particularly scary, since it was those pts that were difficult to ventilate that were most likely to have some degree of obstruction. I figured this was a well founded fear, as at the time barotrauma seemed to be the major failing of this method when using pressure sufficient to provide any ventilation. There are some large-bore 3-ways available which were a little better at allowing passive exhalation, but still not enough to make me happy.

    I was curious whether anyone has done some of these dry-run experiments with a manometer hooked up to the fake lung with somewhat physiologic properties. It would be interesting to see how various iterations (catheter size, degree of upper airway obstruction, oxygen L/min, passive exhalation port size on device, I:E ratio, etc) are seen in the end organ.

    I would guess (and this is based only on theory, not on practical experience) that if it comes to this again I will prefer the simple 14g/direct-tubing method Minh shows in the video, but probably would lean towards a far more conservative I:E ratio (allow long exhalation phase).

    Any one messed around with this? Any specific experience to share?

    • The best paper on this issue is
      - Anaesthesia 2009;64:1353

      Shows inadequate exhalation with stopcock or catheter in general
      and the similar study
      - Pediatric Anesth 2009;19:452

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