Skip to 0 minutes and 10 seconds Before attempting a cricothyroidotomy, announce that this is a can’t intubate, can’t oxygenate situation, and call for help. Continue attempts to oxygenate from above and ensure that the patient is paralysed to exclude laryngospasm. Position the patient to extend their neck. Stand on the patient’s left. Using your left hand, perform a laryngeal handshake to identify the larynx, and place your index finger on the cricothyroid membrane. Stabilise the larynx using your left hand and stretch the skin taut between your fingers and thumb. Holding the scalpel in your right hand, make a transverse stab incision through the skin and cricothyroid membrane with the cutting edge of the blade facing towards you. You’ll feel a pop as the scalpel enters the trachea.
Skip to 1 minute and 8 seconds Keep the scalpel perpendicular to the skin and turn it through 90 degrees so the sharp edge points to the feet. Swap your hands so you are holding the scalpel with your left hand. Maintain gentle traction, pulling the scalpel towards you, to maintain a triangular incision. But keep the scalpel handle upright at 90 degrees to the skin. Taking the bougie in your right hand, so it is parallel to the floor and at right angles to the plane of the trachea, push the angled tip down the scalpel blade, keeping contact with the blade until the bougie is in the trachea. Rotate the bougie to align with the trachea and advance gently up to 10 to 15 centimetres. Remove the scalpel.
Skip to 2 minutes and 1 second Advance a size 6 tracheal tube into the trachea, continuously rotating the tube as you advance it. Try to avoid excessive advancements of the tube. Remove the bougie.
Skip to 2 minutes and 17 seconds Attach the circuit and give oxygen. Inflate the cuff. Confirm ventilation with capnography. Finally, recheck the depth of the tube and secure.
Skip to 2 minutes and 39 seconds Before attempting a cricothyroidotomy, announce that this is a can’t intubate, can’t oxygenate situation, and call for help. Continue attempts to oxygenate from above and ensure that the patient is paralysed to exclude laryngospasm. Position the patient to extend their neck. If the cricothyroid membrane is not palpable, or if the stab-twist-bougie-tube has failed, you need to use the scalpel finger technique. With the patient’s neck extended and standing on the patient’s left, perform a laryngeal handshake. Then, use your left hand to fix the neck, stretching the skin between your fingers and thumb. Take the scalpel in your right hand and make an eight to 10 centimetre vertical incision from the sternal notch up towards the chin.
Skip to 3 minutes and 30 seconds If the incision is too short, less than eight centimetres, then it may not be possible to expose the airway. Use the fingers of both hands to pull the soft tissues and strap muscles apart to expose the larynx. Identify the cricothyroid membrane if possible. And using your index finger as a place holder, use your middle finger and thumb to Stabilise cricothyroid cartilage and trachea. This technique will be blind as blood will obscure the surgical field. Now, use the stab-twist-bougie-tube technique to complete the cricothyroidotomy. Holding the scalpel in your right hand, make a transverse stab incision through the cricothyroid membrane with the cutting edge of the blade facing towards you.
Skip to 4 minutes and 16 seconds Keep the scalpel perpendicular to the skin and turn it through 90 degrees so the sharp edge points towards the feet. Swap your hands, so you are holding the scalpel with your left hand. Maintain gentle traction pulling the scalpel towards you, but keep the scalpel handle upright at 90 degrees to the skin. Taking the bougie in your right hand so it is parallel to the floor and at right angles to the plane of the trachea, push the angled tip down the scalpel blade, keeping contact with the blade until the bougie is in the trachea. Rotate the bougie to align with the trachea and advance gently.
Skip to 4 minutes and 56 seconds Remove the scalpel. Advance a size 6 tracheal tube into the trachea, continuously rotating the tube as you advance it. Tried to avoid excessive advancements of the tube. Remove the bougie.
Skip to 5 minutes and 20 seconds Attach the circuit and give oxygen. Inflate the cuff. Confirm ventilation with capnography. And finally, recheck the depth of the tube and secure.
Skip to 5 minutes and 40 seconds The scalpel should not be inserted too deep to avoid trauma to the back wall of the trachea. Rotating the scalpel blade after the transverse stab incision creates a triangular incision with its widest edged bordered by the scalpel. Traction on the scalpel keeps this triangular incision open. Too much traction will narrow the incision and may prevent bougie insertion. After the stab incision, the scalpel must be held perpendicular to the skin. If the scalpel is not perpendicular to the skin, it may not be possible to insert the bougie as the blade causes an obstruction.
Skip to 6 minutes and 20 seconds The bougie must be inserted in the horizontal plane touching the scalpel blade and pushing down the blade into the trachea. This avoids creating a false passage.
Skip to 6 minutes and 38 seconds During railroading of the tube over the bougie, the left hand should be used to Stabilise the trachea whilst the dominant hand continuously rotates the tube to prevent the tube being held up at the skin.
eFONA - a Training Video
In this video produced by the Difficult Airway Society (DAS), you will see a demonstration of how to perform an emergency Front of Neck Airway (eFONA) using a “scalpel-bougie-tube” technique. This is based on the 2015 DAS Guidelines for Unanticipated Difficult Intubation recommending the use of scalpel cricothyroidotomy as the fastest and most reliable method of securing the airway in the emergency setting.
A cuffed tube in the trachea protects the airway from aspiration, provides a secure route for exhalation, allows low-pressure ventilation using standard breathing systems, and permits end-tidal CO2 monitoring.
Before proceeding with the technique, you should ensure the following:
1) Call for help and tell your team that this is a “Cant intubate, Can’t Oxygenate (CICO) situation.
2) Position the patient, with the neck extended and a support under the shoulders such as a pillow, a rolled-up blanket or a bag of fluids, or by pulling the patient up so that the head hangs over the top of the trolley.
3) Position yourself on the patients left hand side if you are right handed or on the patient right hand side if you are left handed.
4) Prepare the equipment: scalpel with number 10 blade, a broad blade (with the same width as the tracheal tube) is essential, bougie with coude (angled) tip, tracheal tube, cuffed, size 6.0 mm.
5) Identify the cricoid-thyroid membrane using of the ‘laryngeal handshake’ as described by Levitan (Ref and picture).
5) Ensure adequate muscle paralysis and anaesthesia.
6) Continue to apply 100% oxygen to the upper airway throughout, using a supraglottic airway device, a tightly fitting face mask, or high-flow nasal insufflation.
If the cricoid-thyroid membrane is palpable use the scalpel-bougie-tube technique demonstrated in the video.
If the technique fails or if the cricothyroid membrane is impalpable (for example in patient with obesity, oedema, surgical emphysema, neck haematomas, start with an 8–10 cm midline vertical skin incision, caudad to cephalad. Use blunt dissection with fingers of both hands to separate tissues and identify and stabilize the larynx with left hand. Proceed with the scalpel-bougie-tube as above.
Both techniques are demonstrated in the video and also in the “Can’t Intubate Can’t Oxygenate Action Cards” which are designed for training and are available from the DAS website, and on a DAS App for Android and iOS.
The optimal technique for emergency front of neck airway (eFONA) is still subject of great debate in the medical community. Other techniques are described and practiced, such as cannula techniques (narrow-bore (<4 mm) cannula or wide-bore cannula over guide-wire, non-Seldinger wide-bore cannula) but are not described here. The multitude of commercially available devices presents a problem because familiarity with equipment that is not universally available makes it harder to standardise training. We recommend that clinicians undergo regular training, to maintain familiarity and skills in whichever locally adopted technique.
Of note is the work of Dr Andy Heard, who pioneered the standardisation of training and equipment for two eFONA approaches, that is now common place in Australia. You can read this article or watch these Youtube videos for further information.
In Week 1 Professor Tim Cook explained that it is important for the institution and the individual to be prepared. More important than focusing on the actual technique for eFONA is for institutions to adopt formal guidelines, ensure that staff are adequately trained and that equipment is readily available and clearly signposted. Individual clinicians must ensure that they are familiar with the institution’s guidelines, know where to find the equipment in an emergency and train to become skilled in the technique adopted by the institution.
The Airway App
Although individual clinicians rarely have to undertake this procedure, hundreds are performed annually on a global level. The Airway App designed and developed by Dr Laura Duggan, Canada, is an open access, international collaboration collecting data rendered by clinicians who have performed eFONA. Results are updated regularly and track success with different techniques. If you have performed eFONA, consider contributing to this global database! You can read more about the Airway App in this article
What technique is taught and what equipment is available in your place of work? What were the reasons behind the choice? Share your experience in the discussion here below
© UCL, video shared with permission from the Difficult Airway Society