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eFONA - a Training Video

This video produced by the DAS Guidelines Implementation Group demonstrates the recommended technique for surgical cricothyroidotomy.

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