Royal Perth Hospital solution for managing the ‘can't intubate, can't ventilate’ crisis

Abstract

Editor'We commend the Royal College of Anaesthetists and Difficult Airway Society (DAS) in producing the Fourth National Audit Project ‘Major complications of airway management’.1Cook TM Woodall N Frerk C Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia.Br J Anaesth. 2011; 106: 617-631doi:10.1093/bja/aer058Abstract Full Text Full Text PDF PubMed Scopus (1165) Google Scholar 2Cook TM Woodall N Harper J Benger J Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency department.Br J Anaesth. 2011; 106: 632-642doi:10.1093/bja/aer059Abstract Full Text Full Text PDF PubMed Scopus (614) Google Scholar Practicing anaesthetists should be alarmed at how ineffective traditional techniques are in managing the ‘can't intubate, can't ventilate’ (CICV) crisis. More than 65% (16 of 25) cricothyroidotomy attempts by anaesthetists failed to secure the airway.1Cook TM Woodall N Frerk C Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia.Br J Anaesth. 2011; 106: 617-631doi:10.1093/bja/aer058Abstract Full Text Full Text PDF PubMed Scopus (1165) Google Scholar The authors estimate that anaesthetists in the UK are likely to experience a CICV scenario once every 6 yr. Poor management was thought to be an aetiological factor in the majority of airway-related deaths in their series prompting the authors to conclude ‘research is needed to identify equipment and techniques most likely to be successful for direct tracheal access’. We would like to draw attention to excellent work that addresses a number of these questions. The Royal Perth Hospital has published a CICV algorithm, the result of a number of years of airway crisis simulation and training using anaesthetized sheep.3Heard AMB Green RJ Eakins P The formulation and introduction of a ‘can't intubate, can't ventilate’ algorithm into clinical practice.Anaesthesia. 2009; 64: 601-608doi:10.1111/j.1365-2044.2009.05888.xCrossref PubMed Scopus (128) Google Scholar The authors identified that in a CICV situation, the DAS Difficult Intubation algorithm leaves one at a difficult junction: should you perform a cannula or a surgical cricothyroidotomy? What if you fail with your first choice? What if you cannot clearly identify the midline structures? Without a clear management plan, this incredibly stressful situation becomes even more challenging. The Royal Perth algorithm outlines a logical progression of techniques from the least invasive through to the most successful, but most invasive. The algorithm emphasizes rapid oxygenation and favours the skill complement of the anaesthetist, who may be more reluctant than a surgeon to reach for a scalpel. The algorithm initially recommends attempting cannula cricothyroidotomy or tracheotomy. If successful, jet oxygenation can stabilize the patient. The algorithm next suggests either waking the patient, considering further upper airway techniques, or placing a COOK Melker Seldinger guided 5.0 tube. If the initial cannulation fails, the next step depends on having palpable neck airway anatomy. If palpable, then a ‘scalpel bougie’ technique is recommended. The COOK Frova Bougie has a lumen to facilitate jet ventilation. This is introduced into the trachea through a surgical incision and guided into the trachea against the scalpel blade. This allows jet ventilation to oxygenate and stabilize, before railroading a 6.0 tube. If the ‘scalpel bougie’ technique fails or the airway anatomy is not palpable at the outset, the Royal Perth algorithm recommends a 6 cm longitudinal scalpel incision and finger dissection until the neck anatomy is palpable. A cannula tracheotomy then allows jet oxygenation. Crisis algorithms successfully facilitate logical task progression in a stressful environment. The current DAS algorithm is excellent until arriving at the CICV scenario. We believe that the Royal Perth CICV guideline complements the current DAS algorithm and importantly provides guidance at the CICV juncture. At our institution, we have initiated anaesthetic CICV training adopting this algorithm and technique. The YouTube videos produced by the authors greatly facilitated this process.4DrAMBHeardAirway DrAMBHeardAirway's Channel. YouTube.http://www.youtube.com/user/DrAMBHeardAirwayGoogle Scholar The algorithm was easily learned and understood. The practical techniques were quickly mastered using manikin and pig specimens. We are now better prepared for a CICV crisis. None declared. Download .zip (.0 MB) Help with zip files