Anaesthetists and surgeons reach agreement on front of neck emergency techniques in life-threatening ‘CICO’ situations

A new research paper1, jointly published today by the British Journal of Anaesthesia and Clinical Otolaryngology, recommends the scalpel-bougie cricothyroidotomy technique2 as the most efficient and reliable method of obtaining emergency front of neck access to the trachea in a situation where the patient’s airway is blocked and routine methods fail.

Without this rescue technique many of these patients would die. The technique, which involves placing a tube into the windpipe using a scalpel and a small guide, is recommended by a working group of anaesthetists and ear, nose and throat surgeons, led by the Royal College of Anaesthetists, which is working to spread this information to clinicians across the country.

Patients who are unconscious, either through illness or during anaesthesia, require a tube to be placed into the trachea to enable oxygen to reach the lungs. Although anaesthetists are able to manage the vast majority of difficult airways, some may rapidly develop into ‘can’t intubate, can’t oxygenate’ (CICO) events, which are one of the most feared emergencies in clinical medicine. These life-threatening situations, occurring  approximately 100 times per year in the UK, often take place after instances of failed airway management and, if not managed correctly will lead to death or brain damage from lack of oxygen.

Anaesthetists and surgeons must work quickly and collaboratively to place a tube in the front of the neck (a front of neck airway, FONA). Good team communication, correct choice of FONA techniques and timing of interventions are all critical to the survival of the patient suffering from life-threatening breathing problems.

The working group recommend that, based on the most recent guidelines2 by the Difficult Airway Society, supported by research by the Royal College of Anaesthetists3, a scalpel-bougie cricothyroidotomy will be the quickest and most appropriate technique to access the airway and allow oxygenation when CICO occurs. The group acknowledge however, that variable training has been devoted to this technique in anaesthesia or surgery, and stress that clinicians charged with the provision of the airway should choose the most appropriate technique based on their own experience and clinical judgement.

Cricothyroidotomy is the technical term for placing a tube into the trachea (windpipe) just below the Adam’s apple. The ‘scalpel-bougie technique’ uses surgical knife (scalpel) and a small guide (bougie) before passing an airway tube into the trachea. The technique may be performed by an anaesthetist or a surgeon. Currently other techniques such as use of a needle in the trachea or a tracheostomy are more commonly used.

For some clinicians other techniques such as use of a needle in the trachea or a tracheostomy are more commonly used than the scalpel-bougie technique. The editorial recommends regular multidisciplinary training in FONA techniques, including scalpel-bougie cricothyroidotomy, in the form of team rehearsals that cover communication, human factors and team dynamics, as well as the use of relevant equipment.

Dr Richard Marks, Chair of the Working Group and Vice President of the Royal College of Anaesthetists, said: “Although ‘can’t intubate, can’t oxygenate’ events are fortunately very rare, anaesthetists and surgeons have a responsibility to make themselves familiar with emergency airway procedures including  scalpel-bougie cricothyroidotomy. We believe there is a good opportunity here for anaesthetists and surgeons to work even more effectively together to tighten emergency protocols and improve training to ensure that patients with breathing problems are offered the best chance of survival during these life threatening events.”

1:  Surgical intervention during a Can't Intubate Can't Oxygenate (CICO) event: Emergency Front-of-neck Airway (FONA)?
2: Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults:
3: NAP4. Fourth National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society. Major Complications of Airway management in the United Kingdom. Report and Findings. Editors Cook TM, Woodall N, Frerk C. March 2011. ISBN 978-1-9000936-03-3 Royal College of Anaesthetists. London

19 September 2016