So we have discussed my preference for surgical over needle-based techniques for front-of-neck-access (FONA) many times on the podcast. You can see the needle vs. knife discussions in some of the earlier posts as well. Cut to air just works better in my opinion. If you'd like to see how I advocate you perform this procedure, come to the EMCrit Cric Page. This debate has heated up as the airway society of the UK has recently recommended scalpel-bougie cricothyrotomy as the first technique for FONA. Editorials explain why this decision was made. Currently, the Australians are still recommending needle-based techniques. So, to add gasoline to the debate, today I interview Laura Duggan, MD.
Laura completed residencies in both paediatrics and anesthesiology, as well as a cardiothoracic anesthesiology fellowship. She practiced for a time as a paediatric emergency physician in Canada. She now practices cardiac and general anesthesia at a level 1 trauma centre. In short, she is the perfect person to discuss these issues with. I got to chat with Laura at SmaccDUB about a paper she had just written on the high failure rate of transtracheal jet ventilation in can't intubate, can't oxygenate situations.
Laura's TTJV Failure Paper
Recent EM Paper regarding Needle Cricothyrotomy
The Airway App
Download it on the Airway Collaboration Site
The Ventrain Device
I tested this device on the bench (no COI) and the reason I think it is the best of the crop is its active exhalation and the ability to monitor ETCO2. They sell it in kits with a proper cannula as well.
- PMID 24980421
- PMID 21177698
- PMID 20100697
Other Jerry-Rigged Techniques (None are Recommended)
3-Way Stopcocks are Probably Inadequate
Catheter or cath with 3-way stopcock is prob. inadequate for exhalation unless 13 seconds between breaths (Anaesthesia 2009;64:1353 and Pediatric Anesth 2009;19:452)
Use a Ventilator
Br J Anaesth 2013;110(3):456
Additional
- PMID 22436319
-
Mann, C.M., Baker, P.A., Sainsbury, D.M., Taylor, R., 2021. A comparison of cannula insufflation device performance for emergency front of neck airway. Paediatr Anaesth 31, 482–490. https://doi.org/10.1111/pan.14128
Ventrain was the only device in this study that did not produce potentially injurious pressures, but ENK was pretty good and device below has not been tested
Also See
The original needle vs. knife for Andy Heard's Method
If you had to use one, here is the one Ric Solis and I Conceptualized
You can read more about it in EM News
Additional New Information
More on EMCrit
- Guest Post: More from Minh Le Cong on Needle Cricothyrotomy(Opens in a new browser tab)
- Podcast 053 – Needle vs. Knife: Part I(Opens in a new browser tab)
- EMCrit Wee – An Amazing (Wearable) Cric Trainer from Laura Duggan and the AirwayCollaboration Folks(Opens in a new browser tab)
Additional Resources
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Hi Scott and Laura thanks for this update to the long debate of needle vs knife! It was a great discussion of the issues that remain unresolved I think the Airway App is a fantastic idea and the ethos of sharing information via the website and podcasts like this is a better way forward to a resolution. Your discussion made me reflect on one thing that has been bothering me for a while. In my opinion the main educational barrier to this issue of surgical airway and needle techniques in general is the lack of good quality real live recordings… Read more »
Minh, Great thoughts. Scott and Laura, great interview as always. The challenge I encountered recently when trying to evaluate the equipment available for this continence threatening pediatric emergency is that even if you choose a 14G iv catheter, the ‘old school’ IV’s that can have a syringe easily attached to them are very hard to find. Without an attached fluid containing syringe that will allow confirmation of tracheal placement (bubbles on aspiration) trans tracheal needle placement in a pediatric model is pure guess work. The only solution we found in one of our facilities was to ‘borrow’ some IV’s from… Read more »
thanks Rob! I saw your tweet. Perhaps you should share your experience on one of these blog sites?
Its a good point you make in regard to modern IV catheters that have a safety retraction mechanism, preventing mounting on a syringe.
This is in fact a good arguement for what Laura proposes with using commercial designed, purpose built transtracheal catheters.
As for 14G IV for a 3kg baby pig, thats a bit big for essentially neonatal airway technique. 16G or 18G would be as good based on flow studies in the past for 3Kg animate.
There is good reason that ANZCA released their statement. http://www.anzca.edu.au/front-page-news/cico-and-front-of-neck-access There seems to be a drive to rid the world of the needle based techniques in the anaesthetic environment on the basis of expert opinion and extrapolated evidence. Secondly there is an emphasis of needle vs scalpel when the actual discussion should be stepwise needle pathway vs scalpel. Thirdly the environment we are talking about is in theatre anaesthetic based, not prehospital, ED. Fourthly the perception of the emergency heroic attempts vs the elective anaesthetic failure of sugraglottic approaches may well have a reporting bias I’m very much a believer… Read more »
Thanks for a great podcast Laura and Scott, I completely agree the main take-home point is that pressure-based options are now obsolete, despite the continued citing of them by guidelines, training manuals and courses that should know better! In general there are some real problems with the arguments around CICO rescue techniques: 1) It is not “Needle versus scalpel” There are some cases where a cannula is more appropriate and some where a scalpel should be used. These are mostly contextual and involve access to equipment, and the nature of the clinical case. If there’s anything I’ve learned about cognition… Read more »
1. The main point of the podcast is that in CICO situations, the needle-based techniques often failed by Device Failure–as in the needle portion of the procedure. This was markedly different from elective situations (or animal lab simulations). Somehow this point keeps getting glossed over. 2. A bunch of different points in here, so difficult to parse what/who you are debating about. Speed has never been the main priority–success on 1st attempt of FONA technique is the key. 3. See #1 4. I AM SUGGESTING YOU USE AN 11-blade. So there goes nobody. An 11 blade is omnipresent in the… Read more »
Great podcast Scott & Laura. Thanks. A few points in addition to the great comments by Pierre & Stu above. 1. Impact of experience on complications: surely comparing complication rates from “jet ventilation” in the elective versus CICO situation is introducing a significant confounder of level of experience/training. Clinicians performing “jet ventilation” in the elective situation are presumably experienced with this technique. Clinicians performing “jet ventilation” in CICO typically have no training/experience. That the latter group has increased complications does not necessarily reflect the validity of the technique but might also indicate the need for education. 2. Technique vs device:… Read more »
Not sure what went wrong with link to Ventrain video. Here it is again:
https://vimeo.com/simpact/ventrain
So Nick, I think you are saying if you dont actually believe in the technique then you wont do it in reality? Well I did a twitter poll this week on whether folks actually believed if any needle rescue technique can actually work in real life CICO/CICV crisis. And its almost a dead even 50:50 SPLIT https://twitter.com/ketaminh/status/788112314780127232 I take it then that majority of folks dont care what is proven to work in elective setting. They just dont believe it can work in a crisis CICO setting. Or moreover they just dont believe any needle technique can work at all.… Read more »
The Airway App is a great idea but we need to look at all the evidence – not just clinical case reports. As you correctly say there will never be a RCT on this so we need to consider animal studies, laboratory setups demonstrating basic physics, etc – and integrate this all with our understanding of the human factors considerations involved. Objections to cannula technique for CICO Rescue seem to centre around 3 things: 1. Refusal to consider evidence other than that from case reports (which have many confounders and cannot necessarily be extrapolated beyond the contexts in which they… Read more »
Oh, and the best way to actually deliver breaths through the cannula is probably the ventilator which can act as a flow adjusted, pressure limited, extremely safe means of jet/flow ventilation. See paper above.
ONe thing to keep in mind is bill No. 1867 (CA 1867), which states that by January 2017, epidural and enteral connections are prohibited to fit into vascular connections. In addition ISO 80369 standard fore small bore connectors may mean that our ability to interconnect jet or other devices to Intravenous devices will be limited. Hence specialized needles will be required for front of neck access. I doubt the market for pediatric will be considered large enough to market specifically to. Hence I favour the scalpel bougie techhnique (and hope like hell I never have to use it)