Emergency Cricothyroidotomy Research Articles

Comparison of Point-of-Care Ultrasound Guidance and the Traditional Approach in Performing Simulated Emergent Cricothyroidotomy Among Emergency Medicine Physicians, Residents, and Students.

Objective Emergency cricothyroidotomy (EC) is a rare procedure used to establish airway access when both endotracheal intubation and bag-mask ventilation have failed. Point-of-care ultrasound (POCUS) has been proposed as an adjunct to aid in identifying anatomical landmarks. However, its impact on emergency physicians when performing EC remains unclear. This study compared emergency physician and student confidence, preference, and procedure time between POCUS and traditional palpation for EC. Methods Our study utilized a randomized controlled crossover design. Emergency medicine providers attended a didactic lecture demonstrating traditional palpation and POCUS techniques for EC. The participants were randomly allocated to two simulation groups. One group started with the palpation of landmarks, while the other group started with POCUS landmark identification. A randomized crossover design was employed, and in a subsequent simulation, the reverse technique was utilized. Time to anatomic landmark identification was recorded. Participants completed a survey assessing their confidence and preference. Procedure times and confidence level differences were examined via Wilcoxon signed-rank tests. Results Sixteen participants completed the survey and were included in the final analysis. All participants successfully performed EC with the two landmark identification techniques. There was no significant difference in self-reported confidence between POCUS and palpation (p = 0.17). Landmark identification by palpation was significantly faster than POCUS (p = 0.001). A total of 10 (63%) participants preferred palpation over POCUS. Conclusions Both POCUS and traditional palpation were effective in identifying anatomical landmarks for EC. Although palpation was significantly quicker, confidence and preference between the two techniques were similar. The results suggest that both approaches can benefit clinical practice, depending on the context and provider familiarity. Further studies with larger cohorts and real-world scenarios are recommended to explore the effectiveness and safety of POCUS in EC.

Postoperative Bleeding Complications are Common among Patients Undergoing Transcarotid Artery Revascularization

Current practice guidelines recommend dual antiplatelet therapy for at least 30 days postoperatively after transcarotid artery revascularization (TCAR) to promote stent patency. However, many patients are already taking other antithrombotic medications. The optimal pharmacologic regimen in this patient population remains unclear, especially as it pertains to postoperative bleeding complications. All TCAR procedures performed at a large academic medical center from January 1, 2017 to April 30, 2023 were identified via current procedural terminology codes and retrospectively reviewed via electronic medical records. Data were collected on patient demographics, procedural details, postoperative complications, and antithrombotic regimen. Bleeding complications were categorized as surgical and non-surgical, which included any bleeding diatheses that were not related to the neck incision, such as epistaxis, hematuria, melena, or non-cervical hematoma. A total of 116 TCAR procedures were performed. The 30-day incidence of bleeding complications was 12.1% (n=14), which included 8 (6.9%) symptomatic neck hematomas and 6 (5.2%) non-surgical site bleeding complications. Aside from patient age (median 72 y [66-79] vs 79 y [70.5-88], p=0.03), demographics, medical comorbidities, surgical indication, risk-related indication for TCAR, and inpatient/outpatient status were similar between patients who experienced bleeding versus no bleeding complications. Patients who developed bleeding complications experienced higher thirty-day hospital readmission (42.9% vs 9.8%, p<0.001) and reintervention rates (21.4% vs 2.0%, p<0.001) and trended towards longer postoperative length of stay (1.5 d [1-3] vs 1 [1-2] d, p=0.07). Reasons for readmission (n=16) included: epistaxis (1), hematuria (1), headache and melena (1), melena and myocardial infarction (1), fall (1), headache (1), dyspnea (5), delirium (1), diarrhea (1), atrial fibrillation (1), and neck hematoma (1); one patient did not have a readmission reason documented. Reinterventions (n=6) included: neck hematoma evacuation (2), epistaxis cauterization (1), emergent cricothyroidotomy (1), and repeat carotid stenting (1). The management of antithrombotic medications during bleeding events were highly variable amongst providers (11 patients with nothing held, one apixaban held, one aspirin held, one clopidogrel held), however, no patients suffered carotid stent thrombosis. Bleeding complications are common within 30 days of TCAR and frequently result in unplanned hospital readmission and reintervention. There is significant provider-level variability in management of antithrombotic medications during these events. These data highlight need for evidence-based guidelines for the optimal pharmacologic strategy for patients post-TCAR who develop bleeding complications.

Negating a Challenging Aspect of Emergent Cricothyroidotomy

Negating a Challenging Aspect of Emergent Cricothyroidotomy

Favour the best in case of emergency cricothyroidotomy-a randomized cross-over trial on manikin focused training and simulation of common devices.

Performing an emergency cricothyroidotomy (EC) is extremely challenging, the devices used should be easy to handle and the selected technique reliable. However, there is still an ongoing debate concerning the most superior technique. Three different techniques were compared using a standardized, simulated scenario regarding handling, performing, training and decision making: The scalpel-bougie technique (SBT), the surgical anatomical preparation technique (SAPT) and the Seldinger technique (ST). First, anaesthesia residents and trainees, paramedics and medical students (each group n = 50) performed a cricothyroidotomy randomly assigned with each of the three devices on a simulator manikin. The time needed for successful cricothyroidotomy was the primary endpoint. Secondary endpoints included first-attempt success rate, number of attempts and user-satisfaction. The second part of the study investigated the impact of prior hands-on training on both material selection for EC and on time to decision-making in a simulated "cannot intubate cannot ventilate" situation. The simulated scenario revealed that SBT and SAPT were significantly faster than percutaneous EC with ST (p < 0.0001). Success rate was 100% for the first attempt with SBT and SAPT. Significant differences were found with regard to user-satisfaction between individual techniques (p < 0.0001). In terms of user-friendliness, SBT was predominantly assessed as easy (87%). Prior training had a large impact regarding choice of devises (p < 0.05), and time to decision making (p = 0.05; 180 s vs. 233 s). This study supports the use of a surgical technique for EC and also a regular training to create familiarity with the materials and the process itself.The trial was registered before study start on 11.11.2018 at ClinicalTrials.gov (NCT: 2018-13819) with Nicole Didion as the principal investigator.

Retention of emergency cricothyroidotomy skills: A multicenter randomized controlled trial.

Emergency cricothyroidotomy is the final approach to establishing a secure airway. The procedure is acute and highly infrequent, making it difficult to achieve and maintain competence in the clinic. Simulation-based training in emergency cricothyroidotomy is effective but it is unknown how often training should be repeated to maintain skills. This study aimed to assess novices' retention of technical skills in emergency cricothyroidotomy after completing SBT. Novices in emergency cricothyroidotomy completed a structured, simulation-based training program and were randomized to retention tests after 1, 3, or 6 months. Participants completed two emergency cricothyroidotomy tests at end-of-training and follow-up retention testing. Test performances were video recorded and evaluated by two experienced blinded raters using a structured assessment tool. Differences in the performances and the pass/fail rates were analyzed. Eighty-two medical students from two different Danish universities were included from April 2021 to February 2022. Paired t-tests showed skills decay significantly after 1 month (mean loss 6.7 points, p < 0.001). The mean loss of points, representing the difference in global score points, from the end-of-training to retention test was 6.7 points (95% confidence interval [CI] 4.5-8.8) for the 1-month group, 8.2 points (95% CI 5.8-10.0) for the 3-months group, and 9.9 points (95% CI 8.1-11.7) for the 6-months group. Six participants in both the 1-month group (23.1%) and the 3-month group (24%) passed the first retention test, but no one in the 6-months group had a passing performance. Novices' technical skills performance in emergency cricothyroidotomy decay significantly already after 1 month. This initial loss of skill seems to be stable until 3 months, after which there is a further significant loss of skills. Recurring training should be implemented for the benefit of patient safety and outcomes.

The Need to Routinely Convert Emergency Cricothyroidotomy to Tracheostomy: A Systematic Review and Meta-Analysis.

Traditional surgical teaching advocates converting emergency cricothyroidotomies to tracheostomies to mitigate the risk of subglottic stenosis. A conversion procedure that may risk losing a tenuous airway should have clear benefits over risks. We aimed to evaluate the necessity of routine cricothyroidotomy to tracheostomy conversion by conducting a systematic review and meta-analysis of contemporary literature. We performed a systematic review of experimental and observational studies (published between January 1, 2008, and March 1, 2021) reporting hospital outcomes of adults aged ≥18 years who underwent emergency cricothyroidotomies or tracheostomies. We followed PRISMA guidelines and assessed quality of data using GRADE methodology. Meta-analysis pooled incidence of procedure-specific complications (bleeding, subglottic stenosis, and others) using Freeman-Tukey double arcsine transformation and sensitivity analysis addressed survival bias. A total of 18 studies including 1246 patients were analyzed. Incidence of bleeding (5 [1 to 11]% vs 3 [1 to 7]%), subglottic stenosis (0 [0 to 3]% vs 0 [0 to 0]%) and other complications (12 [8 to 16]% vs 13 [5 to 23]%) were similar among patients undergoing emergency cricothyroidotomy or tracheostomy. Sensitivity analysis evaluating the incidence of complications among only survivors found similar results. Only one study reported complications attributable to cricothyroidotomy to tracheostomy conversion. Subglottic stenosis, the main harm conversion seeks to avoid, appears to be a rare complication after cricothyroidotomy. We did not find evidence supporting routine need to convert cricothyroidotomies to tracheostomies; for many patients, conversion is unlikely to rectify complications attributable to emergency cricothyroidotomy. However, our findings cannot be generalized to patients who require prolonged or permanent airway cannulation. Providers should consider performing cricothyroidotomy to tracheostomy selectively when the benefits clearly outweigh the risks of disrupting a secured airway.

Emergency cricothyroidotomy in difficult airway simulation \u2013 a national observational study of Air Ambulance crew performance

BackgroundAdvanced prehospital airway management includes complex procedures carried out in challenging environments, necessitating a high level of technical and non-technical skills. We aimed to describe Norwegian Air Ambulance-crews’ performance in a difficult airway scenario simulation, ending with a “cannot intubate, cannot oxygenate”-situation.MethodsThe study describes Air Ambulance crews’ management of a simulated difficult airway scenario. We used video-observation to assess time expenditure according to pre-defined time intervals and technical and non-technical performance was evaluated according to a structured evaluation-form.ResultsThirty-six crews successfully completed the emergency cricothyroidotomy with mean procedural time 118 (SD: ±70) seconds. There was variation among the crews in terms of completed procedural steps, including preparation of equipment, patient- monitoring and management. The participants demonstrated uniform and appropriate situational awareness, and effective communication and resource utilization within the crews was evident.ConclusionsWe found that Norwegian Air Ambulance crews managed a prehospital “cannot intubate, cannot oxygenate”-situation with an emergency cricothyroidotomy under stressful conditions with effective communication and resource utilization, and within a reasonable timeframe. Some discrepancies between standard operating procedures and performance are observed. Further studies to assess the impact of check lists on procedural aspects of airway management in the prehospital environment are warranted.

203 Ultrasound Identification of the Cricothyroid Membrane for Emergency Front of Neck Access

The difficult airway society states that emergency front of neck access skills should be recapped every 6 months amongst those practitioners expected to perform the skill. Furthermore, the national audit states that, of the 25 emergency cricothyroidotomy cases, 9 failed. These were largely due to incorrect identification of the midline and tube misplacement. There is a convincing argument for training practitioners in ultrasound identification of the cricothyroid membrane, mitigating the risks of incorrect midline identification and blood vessel damage Our aim was two-fold: introduce and embed the skill of ultrasound identification of the cricothyroid membrane for use in emergency front of neck access and encourage regular recap of these skills through a training package of blended learning, consisting of videos, ‘tea trolley’ style theatre training and a more formal simulation-based course that focuses on the ultrasound and front of neck access skill and human factors as we know this is a key factor in the success or failure of this scenario.A pilot course was rolled out amongst anaesthetic trainees to assess relative comfort with performing emergency front of neck access. The course consisted of a short lecture on the background and anatomy, teaching of the ultrasound skill using live subjects, practising of ultrasound-guided front of neck access on animal necks and finally a simulation with debrief surrounding implementation of the skill itself and human factors. This course is now being rolled out regionally and aims to teach all trainees in the region. We encourage trainees to generate their own informal logbook of ultrasound cases, whereby they consent patients to undergo a short ultrasound scan in the anaesthetic room prior to intubation, have their neck marked and then are rescanned after intubation to confirm correct identification. This should be done with ‘normal’ airways, not just those expected to be difficult, as this practice embeds the skill. Our ‘tea trolley’ style teaching is yet to be commenced but will involve ad hoc teaching within the theatre suite including the multi-disciplinary team who would be involved in such an event – the anaesthetist, operating department practitioner and theatre team. Finally, we are generating a video bank, which can be accessed in users’ own time to recap and review the process and troubleshooting of ultrasound identification of the cricothyroid membrane and ensuing cricothyroidotomy.An improvement was reported in trainees’ comfort levels to perform ultrasound-guided cricothyroidotomy and all trainees felt that this was a worthwhile skill to embed into their practice. These improvements were tested via a pre- and post-course questionnaire. The same we hope will be true for the tea trolley training and we aim to address the human factors involved during these sessions too.The aspiration is that ultimately ultrasound identification of the cricothyroid membrane for emergency front of neck access will at the very least become a skill that all trainees are formally taught and encouraged to practice and at the most will become the new standard for plan D airway access in the difficult airway society guidelines.

EMERGENCY CRICOTHYROIDOTOMY PROCEDURE: LECTURE ON SURGICAL ANATOMY AND BRIEFING OF THE PROCEDURE FOLLOWED BY SKILL ASSESSMENT IN FIRST SEMESTER MEDICAL STUDENTS

Introduction: Emergency Cricothyroidotomy (ECT) is a life-saving procedure where the cricothyroid membrane is incised to access the larynx to establish breathing in ‘can’t intubate, can’t ventilate’ situations. This procedure can be taught along with midline neck anatomy to the first semester medical students and their understanding and application of knowledge could be assessed on cadavers. Materials and methods: Total three sessions was organized to expose and assess the first semester medical students about the Emergency Cricothyroidotomy (ECT) procedure. In each session, a two hour long integrated lecture was delivered regarding the surgical anatomy and the procedure. After that, randomly selected students were assigned a cadaver to locate and puncture the cricothyroid membrane with a sharp pointed wide probe. The time was recorded and pre and post session questionnaire was distributed and response was analysed. Result: The total study participants were 154. Analysis revealed knowledge and confidence of performing the procedure was statistically significantly increased (p &lt;0.005) among the participants after the session. 90% participants successfully pierced the cricothyroid membrane as a team and the average time was 2 minutes 35 seconds. The most students gave a ‘good’ or ‘very good’ rating of this session. Conclusion: The medical students should be exposed to emergency life-saving procedures in relation to their anatomy course in earlier days of medical school. This could make them aware and oriented about the procedures which could be beneficial during their clinical training.

High-fidelity hybrid simulation for emergency cricothyroidotomy using a three-dimensional printed larynx and a simulated patient.

From the Department of Anaesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Bern, Switzerland (SH, RG, NC, SN), the School of Medicine, Sigmund Freud University Vienna, Vienna, Austria (RG) and the Department of Anaesthesia and Pain Management, Sinai Health System, University of Toronto, Toronto, Canada (SN) Correspondence to Sabine Nabecker, Department of Anaesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland E-mail: sabine.nabeck[email protected] Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com).

A Retrospective Cohort Study of Acute Epiglottitis in Adults.

IntroductionAdult epiglottitis is a disease process distinct from pediatric epiglottitis in microbiology, presentation, and clinical course. While traditionally considered more indolent and benign than in children, adult epiglottitis remains a cause of acute airway compromise with a mortality rate from 1–20%. Our objective was to characterize the disease course and evaluate the rate and type of airway management in this population at a tertiary, academic referral center.MethodsWe conducted a retrospective chart review of all adult patients (age ≥ 18) who were definitively diagnosed with infectious “epiglottitis,” “supraglottitis,” or “epiglottic abscess” by direct or indirect laryngoscopy during a nine-year period. Double data abstraction and a standardized data collection form were used to assess patient demographic characteristics, presenting features, and clinical course. The primary outcome was airway intervention by intubation, cricothyroidotomy, or tracheostomy, and the secondary outcome was mortality related to the disease.ResultsSeventy patients met inclusion criteria. The mean age was 50.2 years (standard deviation ± 16.7), 60% of the patients were male, and 14.3% were diabetic. Fifty percent had symptoms that were present for ≥ 48 hours; 38.6% had voice changes, 13.1% had stridor, 12.9% had fever, 45.7% had odynophagia, and 47.1% had dysphagia noted in the ED. Twelve patients (17.1%) received an acute airway intervention including three who underwent emergent cricothyroidotomy, and one who had a tracheostomy. Two patients died and one suffered anoxic brain injury related to complications following difficult airway management.ConclusionIn this case series the majority of patients (82.9%) did not require airway intervention, but a third of those requiring intervention (5.7% of total) had a surgical airway performed with two deaths and one anoxic brain injury. Clinicians must remain vigilant to identify signs of impending airway compromise in acute adult epiglottitis and be familiar with difficult and failed airway algorithms to prevent morbidity and mortality in these patients.

A surgical needs assessment for airway rapid responses: A retrospective observational study.

Airway rapid response (ARR) teams can be compiled of anesthesiologists, intensivists, otolaryngologists, general and thoracic surgeons, respiratory therapists, and nurses. The optimal composition of an ARR team is unknown but considered to be resource intensive. We sought to determine the type of technical procedures performed during an ARR activation to inform team composition. A large urban quaternary academic medical center retrospective review (2016-2019) of adult ARR patients was performed. Analysis included ARR demographics, patient characteristics, characteristics of preexisting tracheostomies, incidence of concomitant conditions, and procedures completed during an ARR event. A total of 345 ARR patients with a median age of 60 years (interquartile range, 47-69 years) and a median time to ARR conclusion of 28 minutes (interquartile range, 14-47 minutes) were included. About 41.7% of the ARR had a preexisting tracheostomy. Overall, there were 130 procedures completed that can be performed by a general surgeon in addition to the 122 difficult intubations. These procedures included recannulation of a tracheostomy, operative intervention, new emergent tracheostomy or cricothyroidotomy, thoracostomy tube placement, initiation of extracorporeal membrane oxygenation, and pericardiocentesis. Highly technical procedures are common during an ARR, including procedures related to tracheostomies. Surgeons possess a comprehensive skill set that is unique and comprehensive with respect to airway emergencies. This distinctive skill set creates an important role within the ARR team to perform these urgent technical procedures. Epidemiologic/prognostic, level III.

Use of simulation-based training of surgical technical skills among ENTs: an international YO-IFOS survey.

The aim of this study was to investigate and compare the use of simulation-based technical skills training (SBTST) in the otolaryngology curriculum in different countries, and to explore the needs and opinions about the use of simulation among young otolaryngologists. An e-survey conducted among Young Otolaryngologists of the International Federation of Oto-rhino-laryngological Societies (Yo-IFOS) members. 139 Yo-IFOS members from 51 countries completed the survey. During residency training, 82.7% of respondents have used SBTST on cadavers, 51.8% on physical simulators, and 43.8% on virtual reality simulators. High costs (65.5%), lack of availability (49.2%) and lack of time (25.5%) were the main barriers limiting the practice of SBTST. These barriers also limited teaching using simulation. Sinonasal surgery (72.7%), temporal bone surgery (67.6%), and head/neck surgery (44.6%) were significantly more frequently taught using SBTST than suspension microlaryngoscopy (25.9%) and pediatric surgery (22.3%) (p < 0.001). The procedures rated as the most important to learn through SBTST were tracheotomy (50.4%), emergency cricothyroidotomy (48.9%), and rigid bronchoscopy (47.5%). On an analogic visual scale (0-100) for the question "how important will simulation be for future ENTs in surgical training?", the mean score was 79.5/100 (± 23.3), highlighting the positive attitude toward the use of SBTST in otorhinolaryngology training. SBTST is an attractive learning and teaching method in otorhinolaryngology, but associated costs, lack of access, and lack of time are the main barriers limiting its use. Emergency procedures are key technical skills to be learned using simulation but in some cases, lack relevant simulators for training.

Cricothyroidotomy competence and injuries using nonmedical equipment: A crossover noninferiority randomised controlled trial in a porcine cadaver model.

International guidelines recommend cricothyroidotomy as a life-saving procedure for 'cannot intubate, cannot ventilate' situations. Although commercially available sets facilitate surgical cricothyroidotomy, regular training seems to be the key to success. The goal was to investigate if trained anaesthetists are able to transfer their skill in one surgical cricothyroidotomy technique to another. The primary hypothesis postulated that trained anaesthetists could perform an emergency cricothyroidotomy equally fast and successfully with a pocketknife compared with a surgical cricothyroidotomy set. Crossover noninferiority randomised controlled trial. After written informed consent and ethics committee approval, this single-centre study was performed at the University Hospital of Bern, Bern, Switzerland. Altogether, 61 study participants already familiar with surgical cricothyroidotomy were included. The use of a commercially available cricothyroidotomy set was compared with a short-bladed pocketknife and ballpoint pen barrel. A pig-larynx cadaver model including trachea, with pig skin overlaid, was used. Participants underwent additional training sessions in both procedures. The primary outcome was the time necessary to position the tracheal tube or pen barrel in the trachea. Other outcome parameters were success rate, tracheal and laryngeal injuries and preferred device. Cricothyroidotomy with the pocketknife was performed significantly faster and equally successfully as compared with the cricothyroidotomy sets. Tracheal and laryngeal injuries were similar in both groups. Paratracheal or submucosal placement of the pen barrel occurred in 32%, compared with 29% for the tracheal tube. Sixty-six per cent of participants preferred the cricothyroidotomy set. Regularly trained anaesthetists are able to accomplish cricothyroidotomy irrespective of the equipment used. A pocketknife with a ballpoint pen barrel was just as effective as a commercially available surgical set.

Design, application and evaluation of a cricothyrotomy model for a multidisciplinary simulation. An observational single centre study

BackgroundThe management of a difficult airway requires training in cricothyroidotomy (CT). The objectives of this study were: (i) to describe technical changes made to The REAL CRIC Trainer model in order to increase its realism, (ii) to assess the model by experts in comparison to a commercial dry model, (iii) to evaluate its performance in a realistic simulation scenario for training technical and behavioural skills, and (iv) to assess whether the model can help to identify anatomic structures by ultrasound (US). MethodsAn observational prospective study was conducted in which an assembled modified model was assessed by five experts in CT and comparing it with a commercial dry model. The fidelity of US images obtained in the model was compared to those obtained from volunteers. The usefulness and realism of the model, attached to a high-fidelity simulator's neck in emergent CT clinical scenario, was assessed by the 11 ICU staff taking part. ResultsUsing a score out of 10, CT performance in our model and in a dry model was rated by the experts as 9 vs. 6, respectively in external appearance, 8.4 vs. 5.8 in tactile fidelity, and 8.6 vs. 4.1 in technical realism. Participants in the simulation gave a mean score of 7.7/10 to the fidelity parameters. Usefulness for training of the model integration into a simulation scenario was rated as 9.6. Ultrasound images were evaluated as high fidelity. ConclusionsOur modified REAL CRIC Trainer model was rated high by experts in CT and participants in a simulated clinical scenario, and may be useful for a complete emergent CT training closer to the clinical reality than the models currently available.

Cricothyroidotomy in the emergency setting: indications, techniques and outcomes

Cricothyroidotomy is a lifesaving procedure performed in acute respiratory failure secondary to upper airway obstruction to restore a patent airway. Emergency cricothyroidotomy is considered to be the technique of choice to provide oxygenation to patients in “Can’t Intubate, Can’t Oxygenate” (CICO) scenario. In this study, we describe and discuss indications, different techniques and complications of cricothyroidotomy performed for establishing an airway in the emergency setting from a multidisciplinary point of view.

CLOSURE OF A BRONCHOPLEURAL FISTULA WITH ONE-WAY ENDOBRONCHIAL VALVES WHILE ON HIGH-FREQUENCY OSCILLATORY VENTILATION

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: A bronchopleural fistula (BPF) is an abnormal sinus tract between the tracheobronchial tree and the pleural space whose presence is associated with increased morbidity, mortality and extended hospital duration. Additionally, a large airway defect can result in refractory hypercapnia rendering periprocedural ventilation exceedingly difficult. Preferred definitive management is surgical resection. However, for the non – surgical candidate a handful of bronchoscopic and pleural interventions, including compassionate placement of one – way valves, have been successfully described for the treatment of a persistent BPF. CASE PRESENTATION: A 25 – year old male with restrictive lung disease secondary to severe muscular dystrophy was admitted to a surgical ICU after a difficult intubation resulting in an emergent cricothyroidotomy and placement of two unilateral surgical chest tubes. The patient’s underlying lung disease combined with intra-parenchymal placement of one of the chest tubes resulted in mixed respiratory failure. Multiple modes of conventional ventilation with neuromuscular blockade were trialed with persistent life threatening hypercapnia prior to being stabilized on a High – Frequency Oscillatory Ventilator (HFOV). His clinical course was complicated by bacteremia, fungemia and a large continuous air-leak. On bronchoscopy, the right upper lobe (RUL) was identified as the anatomic origin of the defect following occlusion with a 5.5 Fr Fogarty Balloon catheter and resolution of the air leak. Definitive management was attempted by placement of four one – way Spriation endobronchial values within the RUL segments while concurrently on HFOV. Significant decrement of the air leak was successfully obtained as well as improvement of his oxygenation and ventilation. DISCUSSION: Chest trauma, including inadvertent intra – parenchymal placement of a chest tube is a rare cause of a bronchopleural fistula. We describe a case of a BPF complicated by a large persistent air leak with initial management via ventilation on a high frequency oscillatory ventilator followed by a novel attempted at definitive treatment with placement of endobronchial values while concurrently on HFOV. CONCLUSIONS: Compassionate placement of endobronchial one – way vales can be safely executed while on HFOV for management of a severe BPF in non – surgical candidates. Reference #1: Gilbert, C. R., Casal, R. F., Lee, H. J., Feller-Kopman, D., Frimpong, B., Dincer, H. E., … Yarmus, L. B. (2016). Use of One-Way Intrabronchial Valves in Air Leak Management After Tube Thoracostomy Drainage. The Annals of Thoracic Surgery, 101(5), 1891–1896. doi: 10.1016/j.athoracsur.2015.10.113 Reference #2: Keshishyan, S., Revelo, A. E., & Epelbaum, O. (2017). Bronchoscopic management of prolonged air leak. Journal of Thoracic Disease, 9(S10). doi: 10.21037/jtd.2017.05.47 Reference #3: Ha, D. V., & Johnson, D. (2004). High frequency oscillatory ventilation in the management of a high output bronchopleural fistula: a case report. Canadian Journal of Anesthesia/Journal Canadien Danesthésie, 51(1), 78–83. doi: 10.1007/bf03018553 DISCLOSURES: No relevant relationships by Rohini Chatterjee, source=Web Response No relevant relationships by Michal Sobieszczyk, source=Web Response No relevant relationships by Bryce Warren, source=Web Response No relevant relationships by Whittney Warren, source=Web Response

The necessity of practical emergency cricothyroidotomy training during undergraduate medical education

BackgroundA cricothyroidotomy is a procedure which creates a laryngeal opening. Medical students are told that this procedure is without major complications and simple to perform; however, professionals who have witnessed a laryngotomy include considerable hemorrhage and issues locating the correct insertion site in procedure preparation. Various laryngeal devices were analyzed, and determination of superiority was based on ease and success of insertion. MethodsOur study was limited to 30 healthcare professional volunteers and 3 devices: a scalpel, steak knife, and percutaneous cricothyroidotomy key-ring device (PCKD). Their task was to perform a laryngotomy within a set time period on a cadaver. ‘Success or failure’ was determined through dissection at a later date. ResultAmong 30 volunteers, 21 successfully accessed the larynx. Success was highest with the steak knife and lowest with the PCKD, revealing device familiarity may be influential. Participants with previous clinical experience also had higher success, indicating practical experience may play a role in addition to anatomical knowledge. ConclusionCricothyroidotomy is a procedure mentioned in medical school, where theoretical knowledge is readily taught. Yet those who are deemed familiar with the anatomy is not reassuring. This presses the importance of medical curriculums implementing practical training, while simultaneously teaching the underlying anatomy and physiology. Trial registrationThis study was approved by the St. George's University IRB, No. 06014.

Blame it on the bougie (or lack thereof): Retrograde intubation in emergency cricothyroidotomy

Blame it on the bougie (or lack thereof): Retrograde intubation in emergency cricothyroidotomy

Quality improvement project: where are the emergency cricothyroidotomy kits?

Quality improvement project: where are the emergency cricothyroidotomy kits?