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Front of Neck Access Procedures

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Abstract

Any technique performed across the neck and below the level of the vocal cords is Front Of Neck Access (FONA). This includes surgical tracheostomy, percutaneous dilatational tracheostomy (PDT), cricothyrotomy, and transtracheal jet ventilation (TTJV). Each technique has several modifications. Tracheostomy is usually performed as an elective procedure and rarely as an urgent (semi-emergency) or lifesaving procedure. PDT is always an elective procedure whereas cricothyrotomy and TTJV are always used as rescue procedures. For these techniques to succeed a combination of appropriate size and type of equipment, patient selection, drugs, skilled execution of the technique and monitoring is essential.

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References

  1. Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118(2):251–70.

    Article  PubMed  Google Scholar 

  2. Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827–48.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Law JA, Broemling N, Cooper RM, Drolet P, Duggan LV, Griesdale DE, et al. The difficult airway with recommendations for management—part 2—the anticipated difficult airway. Can J Anaesth. 2013;60(11):1119–38.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Rosenstock CV, Nørskov AK, Wetterslev J, Lundstrøm LH, Danish Anaesthesia Database. Emergency surgical airway management in Denmark: a cohort study of 452 461 patients registered in the Danish Anaesthesia Database. Br J Anaesth. 2016;117(Suppl 1):i75–82.

    Article  PubMed  Google Scholar 

  5. Joffe AM, Aziz MF, Posner KL, Duggan LV, Mincer SL, Domino KB. Management of difficult tracheal intubation: a closed claims analysis. Anesthesiology. 2019;131(4):818–29.

    Article  PubMed  Google Scholar 

  6. Cook 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(5):617–31.

    Article  CAS  PubMed  Google Scholar 

  7. CICO Rescue [Internet]. The Vortex approach. [cited 2020 Apr 22]. Available from: http://vortexapproach.org/cico

  8. Myatra SN, Shah A, Kundra P, Patwa A, Ramkumar V, Divatia JV, et al. All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in adults. Indian J Anaesth. 2016;60(12):885–98.

    Article  PubMed  PubMed Central  Google Scholar 

  9. DeVore EK, Redmann A, Howell R, Khosla S. Best practices for emergency surgical airway: A systematic review. Laryngoscope Investig Otolaryngol. 2019;4(6):602–8.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Macêdo MB, Guimarães RB, Ribeiro SM, Sousa KMMD. Emergency cricothyrotomy: temporary measure or definitive airway? A systematic review. Rev Col Bras Cir. 2016;43(6):493–9.

    Article  PubMed  Google Scholar 

  11. Trouillet JL, Collange O, Belafia F, Blot F, Capellier G, Cesareo E, et al. Tracheotomy in the intensive care unit: guidelines from a French expert panel. Ann Intensive Care. 2018;8(1):37. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5854567/

    Article  PubMed  PubMed Central  Google Scholar 

  12. Cook TM, Nolan JP, Magee PT, Cranshaw JH. Needle cricothyroidotomy. Anaesthesia. 2007;62(3):289–90.

    Article  CAS  PubMed  Google Scholar 

  13. Bair AE, Chima R. The inaccuracy of using landmark techniques for cricothyroid membrane identification: a comparison of three techniques. Acad Emerg Med. 2015;22(8):908–14.

    Article  PubMed  Google Scholar 

  14. EP Monthly & ACEP Now Levitan Articles [Internet]. Airway Cam. [cited 2020 May 1]. Available from: https://www.airwaycam.com/articles

  15. Drew T, McCaul CL. Laryngeal handshake technique in locating the cricothyroid membrane: a non-randomised comparative study. Br J Anaesth. 2018;121(5):1173–8.

    Article  CAS  PubMed  Google Scholar 

  16. Kristensen MS, Teoh WH, Rudolph SS. Ultrasonographic identification of the cricothyroid membrane: best evidence, techniques, and clinical impact. Br J Anaesth. 2016;117(Suppl 1):i39–48.

    Article  PubMed  Google Scholar 

  17. Alerhand S. Ultrasound for identifying the cricothyroid membrane prior to the anticipated difficult airway. Am J Emerg Med. 2018;36(11):2078–84.

    Article  PubMed  Google Scholar 

  18. Siddiqui N, Yu E, Boulis S, You-Ten KE. Ultrasound is superior to palpation in identifying the cricothyroid membrane in subjects with poorly defined neck landmarks: a randomized clinical trial. Anesthesiology. 2018;129(6):1132–9.

    Article  PubMed  Google Scholar 

  19. Kristensen MS, Teoh WH, Rudolph SS, Hesselfeldt R, Børglum J, Tvede MF. A randomised cross-over comparison of the transverse and longitudinal techniques for ultrasound-guided identification of the cricothyroid membrane in morbidly obese subjects. Anaesthesia. 2016;71(6):675–83.

    Article  CAS  PubMed  Google Scholar 

  20. Smith MD, Katrinchak J. Use of a gum elastic bougie during surgical crichothyrotomy. Am J Emerg Med. 2008;26(6):738.e1.

    Article  PubMed  Google Scholar 

  21. Akulian JA, Yarmus L, Feller-Kopman D. The role of cricothyrotomy, tracheostomy, and percutaneous tracheostomy in airway management. Anesthesiol Clin. 2015;33(2):357–67.

    Article  PubMed  Google Scholar 

  22. Brofeldt BT, Panacek EA, Richards JR. An easy cricothyrotomy approach: the rapid four-step technique. Acad Emerg Med. 1996;3(11):1060–3.

    Article  CAS  PubMed  Google Scholar 

  23. Holmes JF, Panacek EA, Sakles JC, Brofeldt BT. Comparison of 2 cricothyrotomy techniques: standard method versus rapid 4-step technique. Ann Emerg Med. 1998;32(4):442–6.

    Article  CAS  PubMed  Google Scholar 

  24. Davis DP, Bramwell KJ, Hamilton RS, Chan TC, Vilke GM. Safety and efficacy of the Rapid Four-Step Technique for cricothyrotomy using a Bair Claw. J Emerg Med. 2000;19(2):125–9.

    Article  CAS  PubMed  Google Scholar 

  25. Schauer SG, Fernandez JRD, Roper JL, Brown D, Jeffers KL, Srichandra J, et al. A randomized cross-over study comparing surgical cricothyrotomy techniques by combat medics using a synthetic cadaver model. Am J Emerg Med. 2018;36(4):651–6.

    Article  PubMed  Google Scholar 

  26. Melker JS, Gabrielli A. Melker cricothyrotomy kit: an alternative to the surgical technique. Ann Otol Rhinol Laryngol. 2005;114(7):525–8.

    Article  PubMed  Google Scholar 

  27. Fikkers BG, Vugt SV, Hoeven JGVD, Hoogen FJAVD, Marres H, a. M. Emergency cricothyrotomy: a randomised crossover trial comparing the wire-guided and catheter-over-needle techniques. Anaesthesia. 2004;59(10):1008–11.

    Article  CAS  PubMed  Google Scholar 

  28. King W, Teare J, Vandrevala T, Cartwright S, Mohammed KB, Patel B. Evaluation of a novel Surgicric® cricothyroidotomy device for emergency tracheal access in a porcine model. Anaesthesia. 2016;71(2):177–84.

    Article  CAS  PubMed  Google Scholar 

  29. Poole O, Vargo M, Zhang J, Hung O. A comparison of three techniques for cricothyrotomy on a manikin. Can J Respir Ther. 2017;53(2):29–32.

    PubMed  PubMed Central  Google Scholar 

  30. Mace SE, Khan N. Needle cricothyrotomy. Emerg Med Clin North Am. 2008;26(4):1085–101. xi

    Article  PubMed  Google Scholar 

  31. Coté CJ, Hartnick CJ. Pediatric transtracheal and cricothyrotomy airway devices for emergency use: which are appropriate for infants and children? Pediatr Anesth. 2009;19(s1):66–76.

    Article  Google Scholar 

  32. Wong DT, Mehta A, Tam AD, Yau B, Wong J. A survey of Canadian anesthesiologists’ preferences in difficult intubation and “cannot intubate, cannot ventilate” situations. Can J Anaesth. 2014;61(8):717–26.

    Article  PubMed  Google Scholar 

  33. Pawar DK, Doctor JR, Raveendra US, Ramesh S, Shetty SR, Divatia JV, et al. All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in paediatrics. Indian J Anaesth. 2016;60(12):906.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Ryder IG, Paoloni CC, Harle CC. Emergency transtracheal ventilation: assessment of breathing systems chosen by anaesthetists. Anaesthesia. 1996;51(8):764–8.

    Article  CAS  PubMed  Google Scholar 

  35. Hubble MW, Wilfong DA, Brown LH, Hertelendy A, Benner RW. A meta-analysis of prehospital airway control techniques part II: alternative airway devices and cricothyrotomy success rates. Prehosp Emerg Care. 2010;14(4):515–30.

    Article  PubMed  Google Scholar 

  36. Sukhupragarn W, Rosenblatt WH. Kinking of catheters during translaryngeal jet ventilation: a bench model investigation of eight devices. J Med Assoc Thail. 2011;94(8):972–7.

    Google Scholar 

  37. Heymans F, Feigl G, Graber S, Courvoisier DS, Weber KM, Dulguerov P. Emergency cricothyrotomy performed by surgical airway–naive medical personnel: a randomized crossover study in cadavers comparing three commonly used techniques. Anesthesiology. 2016;125(2):295–303.

    Article  PubMed  Google Scholar 

  38. Langvad S, Hyldmo PK, Nakstad AR, Vist GE, Sandberg M. Emergency cricothyrotomy—a systematic review. Scand J Trauma Resusc Emerg Med. 2013;31(21):43.

    Article  Google Scholar 

  39. Zasso FB, You-Ten KE, Ryu M, Losyeva K, Tanwani J, Siddiqui N. Complications of cricothyroidotomy versus tracheostomy in emergency surgical airway management: a systematic review. BMC Anesthesiol. 2020;20(1):216.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Kothekar A, Myatra SN. Emergency front of neck access in ICU. Bangladesh Crit Care J. 2016;4(2):114–22.

    Article  Google Scholar 

  41. Flint NJ, Russell WC, Thompson JP. Comparison of different methods of ventilation via cannula cricothyroidotomy in a trachea–lung model. Br J Anaesth. 2009;103(6):891–5.

    Article  CAS  PubMed  Google Scholar 

  42. Hamaekers AE, van der Beek T, Theunissen M, Enk D. Rescue ventilation through a small-bore transtracheal cannula in severe hypoxic pigs using expiratory ventilation assistance. Anesth Analg. 2015;120(4):890–4.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Coté CJ, Eavey RD, Todres ID, Jones DE. Cricothyroid membrane puncture: oxygenation and ventilation in a dog model using an intravenous catheter. Crit Care Med. 1988;16(6):615–9.

    Article  PubMed  Google Scholar 

  44. Gaughan SD, Benumof JL, Ozaki GT. Can an anesthesia machine flush valve provide for effective jet ventilation? Anesth Analg. 1993;76(4):800–8.

    Article  CAS  PubMed  Google Scholar 

  45. Yealy DM, Stewart RD, Kaplan RM. Myths and pitfalls in emergency translaryngeal ventilation: correcting misimpressions. Ann Emerg Med. 1988;17(7):690–2.

    Article  CAS  PubMed  Google Scholar 

  46. Bould MD, Bearfield P. Techniques for emergency ventilation through a needle cricothyroidotomy. Anaesthesia. 2008;63(5):535–9.

    Article  CAS  PubMed  Google Scholar 

  47. Scrase I, Woollard M. Needle vs surgical cricothyroidotomy: a short cut to effective ventilation. Anaesthesia. 2006;61(10):962–74.

    Article  CAS  PubMed  Google Scholar 

  48. Duggan LV, Ballantyne Scott B, Law JA, Morris IR, Murphy MF, Griesdale DE. Transtracheal jet ventilation in the “can’t intubate can’t oxygenate” emergency: a systematic review. Br J Anaesth. 2016;117(Suppl 1):i28–38.

    Article  PubMed  Google Scholar 

  49. Lenfant F, Péan D, Brisard L, Freysz M, Lejus C. Oxygen delivery during transtracheal oxygenation: a comparison of two manual devices. Anesth Analg. 2010;111(4):922–4.

    Article  CAS  PubMed  Google Scholar 

  50. Hamaekers AE, Henderson JJ. Equipment and strategies for emergency tracheal access in the adult patient. Anaesthesia. 2011;66(Suppl 2):65–80.

    Article  PubMed  Google Scholar 

  51. de Wolf MWP, Gottschall R, Preussler NP, Paxian M, Enk D. Emergency ventilation with the Ventrain® through an airway exchange catheter in a porcine model of complete upper airway obstruction. Can J Anaesth. 2017;64(1):37–44.

    Article  PubMed  Google Scholar 

  52. Paxian M, Preussler NP, Reinz T, Schlueter A, Gottschall R. Transtracheal ventilation with a novel ejector-based device (Ventrain) in open, partly obstructed, or totally closed upper airways in pigs. Br J Anaesth. 2015;115(2):308–16.

    Article  CAS  PubMed  Google Scholar 

  53. Carden E, Calcaterra TC, Lechtman A. Pneumatocele of the larynx: a complication of percutaneous transtracheal ventilation. Anesth Analg. 1976;55(4):600–1.

    Article  CAS  PubMed  Google Scholar 

  54. Rajesh O, Meher R. Historical review of tracheostomy. Internet J Otorhinolaryngol [Internet]. 2005;4(2) Available from: http://ispub.com/IJORL/4/2/7498

  55. Gupta S, Dixit S, Choudhry D, Govil D, Mishra RC, Samavedam S, et al. Tracheostomy in adult intensive care unit: An ISCCM Expert Panel Practice Recommendations. Indian J Crit Care Med. 2020;24(Suppl 1):S31–42.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Pracy JP, Brennan L, Cook TM, Hartle AJ, Marks RJ, McGrath BA, et al. Surgical intervention during a Can’t intubate Can’t Oxygenate (CICO) Event: Emergency Front-of-neck Airway (FONA)? Br J Anaesth. 2016;117(4):426–8.

    Article  CAS  PubMed  Google Scholar 

  57. Epstein SK. Anatomy and physiology of tracheostomy. Respir Care. 2005;50(4):476–82.

    PubMed  Google Scholar 

  58. Furlow PW, Mathisen DJ. Surgical anatomy of the trachea. Ann Cardiothor Surgery. 2018;7(2):255–60.

    Article  Google Scholar 

  59. Boon JM, Abrahams PH, Meiring JH, Welch T. Cricothyroidotomy: a clinical anatomy review. Clin Anat. 2004;17(6):478–86.

    Article  CAS  PubMed  Google Scholar 

  60. Durbin CG. Techniques for performing tracheostomy. Respir Care. 2005;50(4):488–96.

    PubMed  Google Scholar 

  61. Brass P, Hellmich M, Ladra A, Ladra J, Wrzosek A. Percutaneous techniques versus surgical techniques for tracheostomy. Cochrane Database Syst Rev. 2016;7:CD008045.

    PubMed  Google Scholar 

  62. Griggs WM, Worthley LI, Gilligan JE, Thomas PD, Myburg JA. A simple percutaneous tracheostomy technique. Surg Gynecol Obstet. 1990;170(6):543–5.

    CAS  PubMed  Google Scholar 

  63. Ciaglia P, Firsching R, Syniec C. Elective percutaneous dilatational tracheostomy. A new simple bedside procedure; preliminary report. Chest. 1985;87(6):715–9.

    Article  CAS  PubMed  Google Scholar 

  64. Kidane B, Pierre AF. From open to bedside percutaneous tracheostomy. Thorac Surg Clin. 2018;28(3):263–76.

    Article  PubMed  Google Scholar 

  65. Ronen O, Rosin I, Taitelman UZ, Altman E. Comparison of ciaglia and griggs percutaneous tracheostomy techniques—a biomechanical animal study. Indian J Crit Care Med. 2019;23(6):247–50.

    Article  PubMed  PubMed Central  Google Scholar 

  66. Byhahn C, Zgoda M, Birkelbach O, Hofstetter C, Gromann T. Ciaglia Blue Dolphin: a new technique for percutaneous tracheostomy using balloon dilation. Crit Care. 2008;12(2):P333.

    Article  PubMed Central  Google Scholar 

  67. Araujo JB, Añón JM, García de Lorenzo A, García-Fernandez AM, Esparcia M, Adán J, et al. Late complications of percutaneous tracheostomy using the balloon dilation technique. Med Intensiva. 2018;42(3):151–8.

    Article  CAS  PubMed  Google Scholar 

  68. Fantoni A, Ripamonti D. A non-derivative, non-surgical tracheostomy: the translaryngeal method. Intensive Care Med. 1997;23(4):386–92.

    Article  CAS  PubMed  Google Scholar 

  69. Divisi D, Altamura G, Di Tommaso S, Di Leonardo G, Rosa E, De Sanctis C, et al. Fantoni translaryngeal tracheostomy versus ciaglia blue rhino percutaneous tracheostomy: a retrospective comparison. Surg Today. 2009;39(5):387–92.

    Article  PubMed  Google Scholar 

  70. Westphal K, Maeser D, Scheifler G, Lischke V, Byhahn C. PercuTwist: a new single-dilator technique for percutaneous tracheostomy. Anesth Analg. 2003;96(1):229–32.

    Article  PubMed  Google Scholar 

  71. Montcriol A, Bordes J, Asencio Y, Prunet B, Lacroix G, Meaudre E. Bedside percutaneous tracheostomy: a prospective randomised comparison of PercuTwist versus Griggs’ forceps dilational tracheostomy. Anaesth Intensive Care. 2011;39(2):209–16.

    Article  CAS  PubMed  Google Scholar 

  72. Johnson-Obaseki S, Veljkovic A, Javidnia H. Complication rates of open surgical versus percutaneous tracheostomy in critically ill patients. Laryngoscope. 2016;126(11):2459–67.

    Article  PubMed  Google Scholar 

  73. Fernandez-Bussy S, Mahajan B, Folch E, Caviedes I, Guerrero J, Majid A. Tracheostomy tube placement: early and late complications. J Bronchology Interv Pulmonol. 2015;22(4):357–64.

    Article  PubMed  Google Scholar 

  74. Flin R, Fioratou E, Frerk C, Trotter C, Cook TM. Human factors in the development of complications of airway management: preliminary evaluation of an interview tool. Anaesthesia. 2013;68(8):817–25.

    Article  CAS  PubMed  Google Scholar 

  75. Chrimes N, Higgs A, Law JA, Baker PA, Cooper RM, Greif R, et al. Project for Universal Management of Airways—part 1: concept and methods. Anaesthesia. 2020;75(12):1671–82.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Department of Anaesthesiology, Manipal Hospital, Bengaluru, Karnataka, India

    Vinayak Pujari

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  1. Vinayak Pujari
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Editors and Affiliations

  1. Department of Anaesthesiology, Jerudong Park Medical Centre, Jerudong Park, Brunei Darussalam

    Raveendra Shankaranarayana Ubaradka

  2. Department of Anesthesiology (BRA-IRCH), All India Institute of Medical Sciences, New Delhi, Delhi, India

    Nishkarsh Gupta

  3. Division of Neuroanesthesiology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, Pondicherry, India

    Prasanna Udupi Bidkar

  4. Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

    Debendra Kumar Tripathy

  5. Department of Anaesthesia Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, Delhi, India

    Anju Gupta

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Pujari, V. (2023). Front of Neck Access Procedures. In: Ubaradka, R.S., Gupta, N., Bidkar, P.U., Tripathy, D.K., Gupta, A. (eds) The Airway Manual. Springer, Singapore. https://doi.org/10.1007/978-981-19-4747-6_25

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  • DOI: https://doi.org/10.1007/978-981-19-4747-6_25

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