Surgical cricothyrotomy: the tracheal-tube dilemma
2018; Elsevier BV; Volume: 120; Issue: 5 Linguagem: Inglês
10.1016/j.bja.2018.02.005
ISSN1471-6771
Autores Tópico(s)Trauma Management and Diagnosis
ResumoEditor—In a recent issue of the British Journal of Anaesthesia, Higgs and colleagues1Higgs A. McGrath B.A. Goddard C. et al.Guidelines for the management of tracheal intubation in critically ill adults.Br J Anaesth. 2018; 120: 323-352Abstract Full Text Full Text PDF PubMed Scopus (396) Google Scholar published guidelines for the management of tracheal intubation in critically ill adults. I appreciate the authors' successful efforts for implementation of comprehensive guidelines to improve airway management and patient safety in the intensive-care-unit environment. In accordance with current evidence and expert opinion, the authors recommend an open surgical approach (surgical cricothyrotomy) for emergency front-of-neck access in adult patients. They highlight the benefits of this technique: it is fast, reliable, has a high success rate, and provides definitive access to the airway.2Lockey D. Crewdson K. Weaver A. Davies G. Observational study of the success rate of intubation and failed intubation airway rescue techniques in 7256 attempted intubations of trauma patients by pre-hospital physicians.Br J Anaesth. 2014; 113: 220-225Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar, 3Baker P.A. O'Sullivan E.P. Kristensen M.S. Lockey D. The great airway debate: is the scalpel mightier than the cannula?.Br J Anaesth. 2016; 117: 17-19Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar After incision of the cricothyroid membrane, insertion of a tracheal tube via a bougie stylet is advocated. The use of tracheal tubes with an inner diameter (ID) of 5.0 or 6.0 mm is advised, presumably because of the dimensions of the cricothyroid membrane.1Higgs A. McGrath B.A. Goddard C. et al.Guidelines for the management of tracheal intubation in critically ill adults.Br J Anaesth. 2018; 120: 323-352Abstract Full Text Full Text PDF PubMed Scopus (396) Google Scholar Insertion of ‘standard’ tracheal tubes with an ID of 5.0 or 6.0 mm generates a dilemma of potentially limiting the benefits of the surgical technique. The cuff diameter of a tracheal tube of ID 6.0 mm with a high-volume low-pressure cuff is 18–19 mm, or about 13 mm in a tracheal tube of ID 5.0 mm. The upper limits of normal for coronal and sagittal diameters of the trachea in men of 20–79 yr average 25–27 mm, and in women 21–23 mm.4Breatnach E. Abbott G.C. Fraser R.G. Dimensions of the normal human trachea.Am J Roentgenol. 1984; 117: 903-906Crossref Scopus (186) Google Scholar The disparity between the diameters of the inflated cuff and the trachea potentially generates a leak. Insufflation of oxygen via a standard tracheal tube should provide sufficient oxygenation. But, further gains of a surgical approach with tracheal-tube insertion, such as confirmation of success by waveform capnography, protection against aspiration, and application of PEEP, are possibly impeded because of insufficient cuff seal. Thus, are standard tracheal tubes superior for this challenging scenario? Given its advantages, surgical cricothyrotomy is the recommended technique in the ‘cannot intubate, cannot oxygenate’ scenario. To overcome the problem of leakage caused by the mismatch of small tracheal-tube cuff and tracheal diameters, we equip all cricothyrotomy kits for adults with micro-laryngeal tubes (MLTs) ID 5.0 and 6.0 mm (Rüsch® micro-laryngeal endotracheal tube; Teleflex Medical GmbH, Belp, Switzerland). Designed for laryngeal or tracheal surgery and patients with tracheal stenosis, these tubes offer smaller inner (5.0 or 6.0 mm) and outer (7.3 and 8.7 mm) diameters to provide better visualisation and access to the surgical site. But, the cuff diameter averages 31 mm, about the cuff diameter of a standard ID 8.0 mm tube. It is possible to place an ID 5.0 or 6.0 mm tube through the incision in the cricoid membrane, whilst simultaneously achieving a sufficient seal in adults, enabling positive pressure ventilation, sufficient expiration, capnography, etc. We have used this successfully in mannequin tests and in emergencies. I recommend routine use of MLTs instead of standard tracheal tubes for surgical cricothyrotomy procedures in adults, and encourage the authors to take these considerations into account for future updates of their excellent guidelines. None declared. Guidelines for the management of tracheal intubation in critically ill adultsBritish Journal of AnaesthesiaVol. 120Issue 2PreviewThese guidelines describe a comprehensive strategy to optimize oxygenation, airway management, and tracheal intubation in critically ill patients, in all hospital locations. They are a direct response to the 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society, which highlighted deficient management of these extremely vulnerable patients leading to major complications and avoidable deaths. They are founded on robust evidence where available, supplemented by expert consensus opinion where it is not. Full-Text PDF Open ArchiveResponse to ‘Surgical cricothyroidotomy—the tracheal tube dilemma’British Journal of AnaesthesiaVol. 120Issue 5PreviewWe thank Schaeuble1 for his comments on the Plan D, Front-of-Neck-Airway strategy for failed intubation in critically ill adults described in our recent guidelines.2 In essence, Schaeuble contends that when the cuff of 5.0–6.0 mm internal diameter tracheal tubes are inflated in a standard fashion, the diameter of the airway device is insufficient to produce a seal in the adult trachea. He goes on to suggest that larger tubes are too big to pass through the cricothyroid membrane, creating something of a dilemma. Full-Text PDF Open Archive
Referência(s)