Thanks Scott and Cliff for the interview podcast. There are some good take home messages but I would suggest that you have to be careful drawing strong conclusions from an audit such as NAP4. Whilst it is a very praiseworthy effort in the field of airway management research, it does not compare standard techniques /procedures. If anything it compares different practitioners using a technique they call the same name. To conclude that needle cricothyroidotomy is inferior to surgical open cricothyroidotomy based on an audit of uncontrolled techniques by various levels of provider is a big assumption to make. What is the goal of a rescue cricothyroidotomy anyway? To get a cuffed tube into the trachea or to rescue oxygenate ? If it is to rescue oxygenate I have seen video data from Dr Heard’s wet lab in PErth, Australia that needle cric is quicker than open cric(30 secs versus 100 secs) – oxygen via 14G needle cannula into the trachea. Its true that the Seldinger wire kits to convert a needle cric into a cuffed tube in the trachea are slower to use but this misses the point of rescue oxygenation. The other point that was not addressed is children… Read more »

Minh, Scott great points. I agree that you cannot conclude unequivocally that needle cric is inferior to surgical. I would argue, more importantly, that we will NEVER get that information. The only way to prove this is to complete a RCT comparing some standardized needle technique to surgical cric. With such a rare event and no realistic way to consent to treatment, NAP4 or versions of that study, will be the best we can get. This is even more pronounced in peds, as surgical airway is likely an even more infrequent event. I’m not sure I agree with the idea of a small diameter angiocath in the trachea( introduced via a needle ) providing some sort of ventilation in order to to give you a chance at repeated attempts by laryngoscopy. The whole point of diverting your gaze to the neck is that you failed from above. You shouldn’t be going to the neck unless you’ve exhausted attempts from above and you can’t ventilate at all. Simply stated going to the neck means the ship is sinking and you are locked in to doing a rescue surgical airway. At that point I think cutting until you feel the membrane or… Read more »

Hi all
I would say that every doc who does any sort of anesthesia – ED or OT should be drilled in a simple, reliable technique for surgical airway. Imagine a pilot who never trained to land off the normal runway!

My bias, based on many brown-trouser situations is: scalpel, bougie then a smallish (6 – 6.5) cuffed tube. Use the equipment you know, keep it simple stupid ( the least neurons required the better)

As for kids – very rare in “normal” kids – the anatomy is the same. Usually less fat. I would not change or have a separate technique for such a rare event. Too much to think about in a moment of crisis. – use the kit you have there. The biggest time delay is in looking for the kit, not using it!
Casey

I look forward to a debate on crichothyrotomy methods. I have seen several cases of medical personnel unfamiliar and/or uncomfortable with procedures hesitating, leading to less than ideal outcomes. I would expect this to be a problem with non-surgical crichothyrotomies, as well. Perhaps that is one of the reasons for the low success rate with the non-surgical crichothyrotomies. For capnography, I think that we need to stress that CONTINUOUS waveform capnography is essential. Too many people act as if there is no beneficial information to be obtained from continuing to monitor waveform capnography. I don’t believe that any of you are suggesting check it and forget it, but people hearing/reading this may not realize the benefits of continuing to monitor waveform capnography. I had always assumed that once I connect the waveform capnography, there is no good reason to remove it, but others seem to want to disconnect it as soon as they can. Initial waveform capnography does not suture the tube in place, just as an initial chest X-ray does not spot weld the tube in place. These assessments lose any predictive value as soon as they have been completed. Once the patient has been moved, they are no… Read more »