Cricothyrotomy Device Research Articles

Randomized Comparative Assessment of Three Surgical Cricothyrotomy Devices on Airway Mannequins

Background: Airway obstruction is the second leading cause of preventable battlefield death, at least in part because surgical cricothyrotomy (SC) failure rates remain unacceptably high. Ideally, SC should be a rapid, simple, easily-learned, and reliably-performed procedure. Currently, 3 SC devices meet Tactical Combat Casualty Care (TCCC) standards: The Tactical CricKit® (TCK), Control-CricTM(CC), and Bougie-assisted Technique (BAT). However, no previous studies have compared these devices in application time, application success, user ratings, and user preference. Methods: United States Navy Corpsmen (N = 25) were provided 15 minutes of standardized instruction, followed by hands-on practice with each device on airway mannequins. Participants then performed SC with each of the 3 devices in a randomly assigned sequence. In this within-subjects design, application time, application success, participant ratings, and participant preference data were analyzed using repeated-measures ANOVA, regression, and non-parametric statistics at p < 0.05. Results: Application time for CC (M = 184 sec, 95% CI 144-225 sec) was significantly slower than for BAT (M = 135 sec, 95% CI 113-158 sec, p < 0.03) and TCK (M = 117 sec, 95% CI 93-142 sec, p < 0.005). Success was significantly greater for BAT (76%) than for TCK (40%, p < 0.02) and trended greater than CC (48%, p = 0.07). CC was rated significantly lower than TCK and BAT in ease of application, effectiveness, and reliability (each p < 0.01). User preference was significantly (p < 0.01) higher for TCK (58%) and BAT (42%) than for CC (0%). Improved CC blade design was the most common user suggestion. Conclusion: While this study was limited by the use of mannequins in a laboratory environment, present results indicate that none of these devices was ideal for performing SC. Based on slow application times, low success rates, and user feedback, the Control-CricTM cannot be recommended until improvements are made to the blade design.

The Efficacy of Spontaneous and Controlled Ventilation With Various Cricothyrotomy Devices: A Quantitative In Vitro Assessment in a Model Lung

Guidelines for the management of a difficult airway recommend performing a cricothyrotomy in a "can't intubate/can't ventilate" situation. We investigated the tidal volumes delivered by controlled and spontaneous ventilation by seven commercially available cricothyrotomy sets (cuffed: Quicktrach II, Portex Cricothyroidotomy Kit, and Melker cuffed cannula and uncuffed: Airfree, 4.0-mm ID Quicktrach, 6.0-mm inner diameter Melker, and 13-gauge Ravussin cannula) and two improvised devices (14-gauge intravenous cannula and spike and drip chamber device). A LS800 model lung, set at different values for compliance and resistance and modified with different upper airway diameter, was ventilated via the respective cricothyrotomy device mechanically and using a self-inflating bag. With the 13-gauge Ravussin cannula and the 14-gauge intravenous cannula, a Manujet injector was used for jet ventilation. Spontaneous ventilation was simulated with a Michigan 560i lung. During controlled or manual ventilation, all cuffed cricothyrotomy devices yielded adequate tidal volumes. Uncuffed devices provided tidal volumes≥300 mL only with an upper airway diameter of ≤3 mm. With a Manujet injector, adequate tidal volumes required an upper airway diameter between 3 mm and 5 mm. A spike and drip chamber device does not provide suitable emergency airway access. Spontaneous ventilation at adequate inspiratory pressure levels required a device inner diameter of at least 4 mm. As expected, cuffed cricothyrotomy devices yield the best results during controlled, manual, and spontaneous ventilation. With uncuffed cricothyrotomy devices, ventilation becomes ineffective when the upper airway obstruction allows for an upper airway diameter>3 mm.

Preliminary Development and Engineering Evaluation of a Novel Cricothyrotomy Device.

Cricothyrotomy is one of the procedures used to ventilate patients with upper airway blockage. This paper examines the most regularly used and preferred cricothyrotomy devices on the market, suggests critical design specifications for improving cricothyrotomy devices, introduces a new cricothyrotomy device, and performs an engineering evaluation of the device’s critical components. Through a review of literature, manufacturer products, and patents, four principal cricothyrotomy devices currently in clinical use were identified. From the review, the Cook™ Melker device is the preferred method of clinicians but the device has acknowledged problems. A new emergency needle cricothyrotomy device (ENCD) was developed to address all design specifications identified in literature. Engineering, theoretical, and experimental assessments were performed. In situ evaluations of a prototype of the new device using porcine specimens to assess insertion, extraction, and cyclic force capabilities were performed. The device was very successful in its evaluation. Further discussion focuses on these aspects and a comparison of the new device with established devices. The proposed emergency needle cricothyrotomy device performed very well. Further work will be pursued in the future with in-vitro and in-vivo with canine models demonstrates the capabilities of the ENCD.

A Randomized Trial Comparing Two Cuffed Emergency Cricothyrotomy Devices Using a Wire-Guided and a Catheter-Over-Needle Technique

According to different algorithms of airway management, emergency cricothyrotomy is the final step in managing the otherwise inaccessible airway. As an alternative to an open surgical procedure, minimally invasive approaches exist. Various sets for different methods are commercially available. QuickTrach™ (VBM Medizintechnik GmbH, Sulz am Neckar, Germany) contains a plastic cannula over a metal needle for direct placement in the trachea, whereas a guide-wire is used for the actual placement of the cannula in the Melker Set™ (Cook Group Incorporated, Bloomington, IN). We hypothesize that the direct puncture involving less discrete steps is faster to perform. However, it will lead to more complications due to the higher force needed to place the relatively thick needle. After approval of the local ethics committee, the study was performed on cadavers of 16 adult sheep. A wire-guided cricothyrotomy was compared with a catheter-over-needle technique. Successful placement and performance time were compared. Complication rate and maximal achieved airway pressure were evaluated. Data is given as mean and interquartile range, and Mann-Whitney U-test (p < 0.05) for significant differences. With the wire-guided technique, successful placement was possible in all attempts. The catheter-over-needle method was successful in 63% and had a higher complication rate (75% vs. 13%). The cannula-over-needle method allowed a faster cricothyrotomy (32 [2-34] vs. 53 [52-56] s). Both methods allowed the delivery of similar maximal airway pressures (50 [44-51] vs. 48 [43-53] mbar). The wire-guided method proved to be the more reliable technique, leading to fewer complications. However, the direct puncture was faster to perform. Placed accurately, both devices allowed sufficient ventilation.

Preliminary Development and Engineering Evaluation of a Novel Cricothyrotomy Device

Cricothyrotomy is one of the procedures used to ventilate upper airway blockage patients. The objectives of this paper are to examine the most regularly used cricothyrotomy devices, to suggest critical design specifications for improving the devices, and to introduce a new cricothyrotomy device as well as perform an engineering evaluation of the devices’ critical components. A review of the literature, manufacturer products and patents was performed to determine current cricothyrotomy devices in use. Four principal cricothyrotomy devices are currently in clinical use. From our review the Cookâ„¢ Melker device is the preferred method of clinicians but has acknowledged problems. Our group has developed a novel cricothyrotomy device, which addresses all design specifications and was shown to be very promising through engineering and in situ evaluations.

A new indicator-guided percutaneous emergency cricothyrotomy device: in vivo study in man

There is presently no ideal method of securing an airway during acute upper airway obstruction. A new cricothyrotomy device has been developed, which has theoretical advantages. The goal of this clinical study in a head and neck cancer centre was to assess the safety of the device in man. Patients undergoing laryngectomy/laryngopharyngectomy for carcinoma were recruited. The outcome measures were as follows: time for completion, cardio-respiratory measurements and complications. Four experiments were performed. Two were performed by doctors trained in the technique and it proceeded smoothly, and ventilation was achieved in 110 and 84 s. Examination of excised larynges revealed minimal, but a short linear abrasion on the posterior wall. Two were performed by doctors who had received a limited explanation of the technique and it did not achieve a secure airway. With adequate prior training, this new cricothyrotomy procedure achieves a secure airway quickly with little trauma. This study supports the use of the new cricothyrotomy device by trained staff, but prospective audit of its application in real trauma settings is required.

Improvised Cricothyrotomy Provides Reliable Airway Access in an Unembalmed Human Cadaver Model

Patients with injuries requiring surgical airway management occurring far from medical care might benefit from the availability of a simple, reliable, improvisational method of cricothyrotomy with materials available in a wilderness or prehospital setting. We evaluated an improvised cricothyrotomy device in an experimental, unembalmed human cadaver model. A high-flow intravenous spike and drip chamber was cut through the drip chamber and used as the sole apparatus for performing cricothyrotomy on unembalmed cadavers whose anterior neck surfaces and deep tissues were warmed to or near body temperature. Correct placement in the trachea and damage to the posterior wall of the trachea were assessed by either fiberoptic bronchoscopy or neck dissection. Video recordings were used to time each procedure. Each operator was responsible for both device insertion and bag valve mask attachment and ventilation, modeling as the sole care provider for the patient. One physician and 3 emergency medicine residents, all without previous, specific instruction, performed 10 procedures on 5 female and 5 male unembalmed cadavers weighing a mean of 65 kg (range 45-110 kg). All 10 attempts at placement of the intravenous tubing spike through the cricothyroid membrane were successful. On 2 attempts, the initial placement of the device was incorrect, but the error was immediately identified on attempt to ventilate the patient. Repositioning of the device resulted in appropriate cannulation of the trachea in both attempts. The median time span from manual identification of the cricothyroid membrane to percutaneous access and connection of the bag valve mask with successful ventilation was 27.3 seconds. Violation of the posterior tracheal wall was not seen on any of the 5 procedures in which fiberoptic visualization was available or in the 5 procedures evaluated by neck dissection. Cricothyrotomy is the quickest and most effective method for obtaining airway access when nonsurgical methods of securing the airway are contraindicated or fail. Although frequently described, no improvised airway devices of this type have been tested in a systematic manner. We tested the reliability and utility of cricothyrotomy with a high-flow intravenous spike and drip chamber. Our results suggest that the spike and drip chamber is a plausible means of temporarily establishing airway access in patients with acute airway obstruction in a wilderness or prehospital environment.

An Improvised Cricothyrotomy Device Provides Reliable Airway Access in Un-Embalmed, Partially Re-Warmed, Human Cadavers

Study Objectives: To determine the utility of an improvised cricothyrotomy device in an experimental, un-embalmed human cadaver model. Patients in settings not adequately prepared for the performance of this procedure might benefit from the availability of a simple method of cricothyrotomy using materials readily available in any hospital, clinic, pre-hospital, combat or wilderness setting.

Ventilation of a model lung through various cricothyrotomy devices

Ventilation of a model lung through various cricothyrotomy devices

A survey of emergency airway management in the United Kingdom.

A postal questionnaire aiming to ascertain the availability of cricothyrotomy and transtracheal ventilation equipment, and experience of its use, was sent to all tutors of the Royal College of Anaesthetists in the United Kingdom and Ireland. The response rate was 74.9%. Almost half of the respondents had experience of cricothyrotomy. The 'Portex Minitrach' (58.6%) was the most commonly used preformed device, followed by the 'William-Cook' cannula (8.5%). The 14-G intravenous cannula (21.1%) was the most frequently improvised cricothyrotomy device. Seventy six percent of all theatres had equipment available for such emergency airway management. Sixty five percent of Portex-Minitrach insertions resulted in complications, more than half of which were serious (total failure to cannulate (17.1%), multiple attempts (20.7%), pneumothorax (8.5%) and severe bleeding (7.3%)). Major complication rates of the 'William-Cook' device and 14-G intravenous cannula were 27.3% and 22.2% respectively. Seventy five percent of patients reported had eventual successful airway management with full recovery, while 9.6% had partial recovery and 15.4% died. Formal training of emergency airway management was practised in 14.2% of anaesthetic departments, while 73.6% had informal training. Twelve percent of the departments did not specifically teach their trainees the skill of emergency airway management.

Cricothyrotomy device

Cricothyrotomy device

Evaluation of an emergency cricothyrotomy instrument.

An emergency cricothyrotomy device was placed in 11 anesthetized dogs in order to assess airway damage and problems in placement, ventilation, and design. Posterior airway perforation without esophageal damage occurred in three animals. Submucosal hematomas or cricoid cartilage injury occurred in seven animals. As placement by an untrained operator was surprisingly difficult, prior operator training with this device is recommended. When properly installed, an excellent emergency airway was achieved. Some minor design shortcomings are noted and suggestions for improvement are made.