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Gottlieb M, O’Brien JR, Ferrigno N, Sundaram T. Point-of-care ultrasound for airway management in the emergency and critical care setting. Clin Exp Emerg Med 2024; 11:22-32. [PMID: 37620036 PMCID: PMC11009714 DOI: 10.15441/ceem.23.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/19/2023] [Accepted: 08/20/2023] [Indexed: 08/26/2023] Open
Abstract
Airway management is a common procedure within emergency and critical care medicine. Traditional techniques for predicting and managing a difficult airway each have important limitations. As the field has evolved, point-of-care ultrasound has been increasingly utilized for this application. Several measures can be used to sonographically predict a difficult airway, including skin to epiglottis, hyomental distance, and tongue thickness. Ultrasound can also be used to confirm endotracheal tube intubation and assess endotracheal tube depth. Ultrasound is superior to the landmark-based approach for locating the cricothyroid membrane, particularly in patients with difficult anatomy. Finally, we provide an algorithm for using ultrasound to manage the crashing patient on mechanical ventilation. After reading this article, readers will have an enhanced understanding of the role of ultrasound in airway management.
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Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
| | - James R. O’Brien
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Nicholas Ferrigno
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Tina Sundaram
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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2
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Gómez-Ríos MÁ, Sastre JA, Onrubia-Fuertes X, López T, Abad-Gurumeta A, Casans-Frances R, Gómez-Ríos D, Garzón JC, Martínez-Pons V, Casalderrey-Rivas M, Fernández-Vaquero MÁ, Martínez-Hurtado E, Martín-Larrauri R, Reviriego-Agudo L, Gutierrez-Couto U, García-Fernández J, Serrano-Moraza A, Rodríguez Martín LJ, Camacho Leis C, Espinosa Ramírez S, Fandiño Orgeira JM, Vázquez Lima MJ, Mayo-Yáñez M, Parente-Arias P, Sistiaga-Suárez JA, Bernal-Sprekelsen M, Charco-Mora P. Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR) Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II. Rev Esp Anestesiol Reanim (Engl Ed) 2024:S2341-1929(24)00022-2. [PMID: 38340790 DOI: 10.1016/j.redare.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/28/2023] [Indexed: 02/12/2024]
Abstract
The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factor, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.
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Affiliation(s)
- M Á Gómez-Ríos
- Anesthesiology and Perioperative Medicine, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain.
| | - J A Sastre
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | | | - Teresa López
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - A Abad-Gurumeta
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - R Casans-Frances
- Department of Anesthesiology, Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain
| | | | - J C Garzón
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - V Martínez-Pons
- Department of Anesthesiology, Hospital Universitari i Politecnic La Fe, Valencia, Spain
| | - M Casalderrey-Rivas
- Department of Anesthesiology. Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - M Á Fernández-Vaquero
- Department of Anesthesiology, Hospital Clínica Universitaria de Navarra, Madrid, Spain
| | - E Martínez-Hurtado
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - L Reviriego-Agudo
- Department of Anesthesiology, Hospital Clínico Universitario, Valencia, Spain
| | - U Gutierrez-Couto
- Biblioteca, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, Spain
| | - J García-Fernández
- Department of Anesthesiology, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Spain; President of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy (SEDAR), Spain
| | | | | | | | | | - J M Fandiño Orgeira
- Servicio de Urgencias, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - M J Vázquez Lima
- Emergency Department, Hospital do Salnes, Vilagarcía de Arousa, Pontevedra, Spain; President of the Spanish Emergency Medicine Society (SEMES), Spain
| | - M Mayo-Yáñez
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - P Parente-Arias
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - J A Sistiaga-Suárez
- Department of Otorhinolaryngology, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain
| | - M Bernal-Sprekelsen
- Department of Otorhinolaryngology, Hospital Clinic Barcelona, Barcelona Spain; President of the Spanish Society for Otorhinolaryngology Head & Neck Surgery (SEORL-CCC)
| | - P Charco-Mora
- Department of Anesthesiology, Hospital Universitari i Politecnic La Fe, Valencia, Spain
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Wang CH, Li JD, Wu CY, Wu YC, Tay J, Wu MC, Hsu CH, Liu YK, Chen CS, Huang CH. Application of Machine Learning to Ultrasonography in Identifying Anatomical Landmarks for Cricothyroidotomy Among Female Adults: A Multi-center Prospective Observational Study. J Imaging Inform Med 2024; 37:363-373. [PMID: 38343208 PMCID: PMC11031510 DOI: 10.1007/s10278-023-00929-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 10/05/2023] [Accepted: 10/06/2023] [Indexed: 03/02/2024]
Abstract
We aimed to develop machine learning (ML)-based algorithms to assist physicians in ultrasound-guided localization of cricoid cartilage (CC) and thyroid cartilage (TC) in cricothyroidotomy. Adult female volunteers were prospectively recruited from two hospitals between September and December, 2020. Ultrasonographic images were collected via a modified longitudinal technique. You Only Look Once (YOLOv5s), Faster Regions with Convolutional Neural Network features (Faster R-CNN), and Single Shot Detector (SSD) were selected as the model architectures. A total of 488 women (mean age: 36.0 years) participated in the study, contributing to a total of 292,053 frames of ultrasonographic images. The derived ML-based algorithms demonstrated excellent discriminative performance for the presence of CC (area under the receiver operating characteristic curve [AUC]: YOLOv5s, 0.989, 95% confidence interval [CI]: 0.982-0.994; Faster R-CNN, 0.986, 95% CI: 0.980-0.991; SSD, 0.968, 95% CI: 0.956-0.977) and TC (AUC: YOLOv5s, 0.989, 95% CI: 0.977-0.997; Faster R-CNN, 0.981, 95% CI: 0.965-0.991; SSD, 0.982, 95% CI: 0.973-0.990). Furthermore, in the frames where the model could correctly indicate the presence of CC or TC, it also accurately localized CC (intersection-over-union: YOLOv5s, 0.753, 95% CI: 0.739-0.765; Faster R-CNN, 0.720, 95% CI: 0.709-0.732; SSD, 0.739, 95% CI: 0.726-0.751) or TC (intersection-over-union: YOLOv5s, 0.739, 95% CI: 0.722-0.755; Faster R-CNN, 0.709, 95% CI: 0.687-0.730; SSD, 0.713, 95% CI: 0.695-0.730). The ML-based algorithms could identify anatomical landmarks for cricothyroidotomy in adult females with favorable discriminative and localization performance. Further studies are warranted to transfer this algorithm to hand-held portable ultrasound devices for clinical use.
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Affiliation(s)
- Chih-Hung Wang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Jia-Da Li
- NTU Joint Research Center for AI Technology and All Vista Healthcare, National Taiwan University, Taipei, Taiwan
| | - Cheng-Yi Wu
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Chen Wu
- Department of Computer Science and Information Engineering, National Taiwan University, Taipei, Taiwan
| | - Joyce Tay
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Meng-Che Wu
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Hang Hsu
- Institute of Information Science, Academia Sinica, Taipei, Taiwan
| | - Yi-Kuan Liu
- NTU Joint Research Center for AI Technology and All Vista Healthcare, National Taiwan University, Taipei, Taiwan
| | - Chu-Song Chen
- Department of Computer Science and Information Engineering, National Taiwan University, Taipei, Taiwan.
- Institute of Information Science, Academia Sinica, Taipei, Taiwan.
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Lohse R, Wagner N, Kristensen MS. Palpation Versus Ultrasonography for Identifying the Cricothyroid Membrane in Case of a Laterally Deviated Larynx: A Randomized Trial. Anesth Analg 2024:00000539-990000000-00727. [PMID: 38295131 DOI: 10.1213/ane.0000000000006867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
BACKGROUND Large neck circumference and displacement of the trachea due to pathology increase the risk of failed identification of the cricothyroid membrane and cricothyroidotomy. We investigated whether ultrasound aids in the successful identification of the cricothyroid membrane in a model of an obese neck with midline deviation of the trachea. METHODS We developed silicone neck models that were suitable for both palpation and ultrasonography and where the trachea deviated laterally from the midline to either side. After reading a book chapter and participating in a 25-minute lecture and a 15- to 23-minute hands-on demonstration and rehearsal of ultrasonography for identification of the cricothyroid membrane, anesthesiologists and anesthesiology residents randomly performed identification with either ultrasound or palpation on 1 of 2 neck models. RESULTS We included 57 participants, of whom 29 and 28 were randomized to palpation and ultrasound, respectively. Correct identification of the cricothyroid membrane was achieved by 21 (75.0%) vs 1 (3.5%) of participants in the ultrasound versus palpation groups (risk ratio [RR], 21.8 [95% confidence interval {CI}, 3.1-151.0]). The tracheal midline position in the sagittal plane was identified correctly by 24 (85.7%) vs 16 (55.2%) of participants in the ultrasound versus palpation groups (RR, 1.6 [95% CI, 1.1-2.2]). CONCLUSIONS Identification of the cricothyroid membrane in a model of an obese neck with midline deviation of the trachea was more often successful with ultrasound compared to palpation. Our study supports the potential use of ultrasound before induction of anesthesia and airway management in this group of patients, and it may even be applied in emergency situations when ultrasound is readily available. Further studies in human subjects should be conducted.
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Affiliation(s)
- Robin Lohse
- From the Department of Anaesthesiology, Centre of Head and Orthopaedics, Copenhagen University Hospital, Copenhagen, Denmark
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Suzuki K, Yambe N, Hojo K, Komatsu Y, Serikawa M, Usami A. Anatomical morphometry for Cricothyrotomy puncture and incision. BMC Surg 2023; 23:198. [PMID: 37438728 DOI: 10.1186/s12893-023-02100-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/07/2023] [Indexed: 07/14/2023] Open
Abstract
PURPOSE Emergency surgical airway securing techniques include cricothyrotomy, puncture, and incision. While the instruments used for these methods vary in size, no index of laryngeal morphology exists to guide instrument selection. Therefore, we measured the morphology of the cricothyroid ligament in Japanese individuals and assessed its correlations with height. METHODS This retrospective study used 61 anatomical practice specimens. The cricothyroid ligament of the laryngeal area was dissected, and a frontal image was recorded. Next, images of the midsagittal sections of the larynx and trachea were recorded. The width and height of the cricothyroid ligament were measured from the frontal images, and the depth of the larynx and the angle to the lower edge of the cricothyroid plate were measured from the mid-sagittal cross-sectional images. The height was estimated from the tibial lengths of the specimens and statistically analyzed for correlations. RESULTS: The width and depth were significantly greater in males. Overall, there was a slight correlation between the results of each laryngeal measurement and estimated height for all items. CONCLUSION The morphology of cricothyrotomy revealed that the width and depth of the laryngeal area varied according to sex. Moreover, the results also showed a correlation with the estimated height. Thus, it is important to predict the morphology of the laryngeal area and cricothyroid ligament by considering factors such as patient sex, weight, and height.
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Affiliation(s)
- Kaiji Suzuki
- Department of Oral Functional Anatomy, Graduate School of Dentistry, Ohu University, Koriyama, Japan
| | - Naohito Yambe
- Community Medicine Support Dentistry, Ohu University Hospital, Koriyama, Japan
| | - Kentaro Hojo
- Department of Oral Anesthesia, School of Dentistry, Ohu University, Koriyama, Japan
| | - Yasunori Komatsu
- Department of Oral Anesthesia, School of Dentistry, Ohu University, Koriyama, Japan
| | - Masamitsu Serikawa
- Department of Morphological Biology, School of Dentistry, Ohu University, Koriyama, Japan
| | - Akinobu Usami
- Department of Morphological Biology, School of Dentistry, Ohu University, Koriyama, Japan.
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Lin J, Bellinger R, Shedd A, Wolfshohl J, Walker J, Healy J, Taylor J, Chao K, Yen YH, Tzeng CFT, Chou EH. Point-of-Care Ultrasound in Airway Evaluation and Management: A Comprehensive Review. Diagnostics (Basel) 2023; 13:diagnostics13091541. [PMID: 37174933 PMCID: PMC10177245 DOI: 10.3390/diagnostics13091541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 05/15/2023] Open
Abstract
Airway management is a common and critical procedure in acute settings, such as the Emergency Department (ED) or Intensive Care Unit (ICU) of hospitals. Many of the traditional physical examination methods have limitations in airway assessment. Point-of-care ultrasound (POCUS) has emerged as a promising tool for airway management due to its familiarity, accessibility, safety, and non-invasive nature. It can assist physicians in identifying relevant anatomy of the upper airway with objective measurements of airway parameters, and it can guide airway interventions with dynamic real-time images. To date, ultrasound has been considered highly accurate for assessment of the difficult airway, confirmation of proper endotracheal intubation, prediction of post-extubation laryngeal edema, and preparation for cricothyrotomy by identifying the cricothyroid membrane. This review aims to provide a comprehensive overview of the key evidence on the use of ultrasound in airway management. Databases including PubMed and Embase were systematically searched. A search strategy using a combination of the term "ultrasound" combined with several search terms, i.e., "probe", "anatomy", "difficult airway", "endotracheal intubation", "laryngeal edema", and "cricothyrotomy" was performed. In conclusion, POCUS is a valuable tool with multiple applications ranging from pre- and post-intubation management. Clinicians should consider using POCUS in conjunction with traditional exam techniques to manage the airway more efficiently in the acute setting.
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Affiliation(s)
- Judy Lin
- Department of Emergency Medicine, Baylor Scott & White All Saints Medical Center, Fort Worth, TX 76104, USA
- Burnett School of Medicine, Texas Christian University, Fort Worth, TX 76109, USA
| | - Ryan Bellinger
- Department of Emergency Medicine, Baylor Scott & White All Saints Medical Center, Fort Worth, TX 76104, USA
| | - Andrew Shedd
- Department of Emergency Medicine, Baylor Scott & White All Saints Medical Center, Fort Worth, TX 76104, USA
- Burnett School of Medicine, Texas Christian University, Fort Worth, TX 76109, USA
| | - Jon Wolfshohl
- Department of Emergency Medicine, Baylor Scott & White All Saints Medical Center, Fort Worth, TX 76104, USA
- Burnett School of Medicine, Texas Christian University, Fort Worth, TX 76109, USA
| | - Jennifer Walker
- Department of Emergency Medicine, Baylor Scott & White All Saints Medical Center, Fort Worth, TX 76104, USA
- Burnett School of Medicine, Texas Christian University, Fort Worth, TX 76109, USA
| | - Jack Healy
- Burnett School of Medicine, Texas Christian University, Fort Worth, TX 76109, USA
| | - Jimmy Taylor
- Burnett School of Medicine, Texas Christian University, Fort Worth, TX 76109, USA
| | - Kevin Chao
- Burnett School of Medicine, Texas Christian University, Fort Worth, TX 76109, USA
| | - Yi-Hsuan Yen
- Department of Emergency Medicine, Baylor Scott & White All Saints Medical Center, Fort Worth, TX 76104, USA
- Department of Emergency Medicine, Baylor University Medical Center, Dallas, TX 75246, USA
| | - Ching-Fang Tiffany Tzeng
- Department of Emergency Medicine, Baylor Scott & White All Saints Medical Center, Fort Worth, TX 76104, USA
- Department of Emergency Medicine, Baylor University Medical Center, Dallas, TX 75246, USA
| | - Eric H Chou
- Department of Emergency Medicine, Baylor Scott & White All Saints Medical Center, Fort Worth, TX 76104, USA
- Burnett School of Medicine, Texas Christian University, Fort Worth, TX 76109, USA
- Department of Emergency Medicine, Baylor University Medical Center, Dallas, TX 75246, USA
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Nakazawa H, Uzawa K, Tokumine J, Lefor AK, Motoyasu A, Yorozu T. Airway ultrasound for patients anticipated to have a difficult airway: Perspective for personalized medicine. World J Clin Cases 2023; 11:1951-1962. [PMID: 36998948 PMCID: PMC10044949 DOI: 10.12998/wjcc.v11.i9.1951] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/28/2023] [Accepted: 02/27/2023] [Indexed: 03/16/2023] Open
Abstract
Airway ultrasound allows for precise airway evaluation, particularly for assessing the difficult airway and the potential for front of neck access. Many studies have shown that identification of the cricothyroid membrane by airway ultrasound is more accurate than digital palpation. However, no reports to date have provided clinical evidence that ultrasound identification of the cricothyroid membrane increases the success rate of cricothyroidotomy. This is a narrative review which describes patients with difficult airways for whom airway ultrasound may have been useful for clinical decision making. The role of airway ultrasound for the evaluation of difficult airways is summarized and an approach to the use of ultrasound for airway management is proposed. The goal of this review is to present practical applications of airway ultrasound for patients predicted to have a difficult airway and who undergo cricothyroidotomy.
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Affiliation(s)
- Harumasa Nakazawa
- Department of Anesthesiology, Kyorin University School of Medicine, Mitaka 181-8611, Tokyo, Japan
| | - Kohji Uzawa
- Department of Anesthesiology, Kyorin University School of Medicine, Mitaka 181-8611, Tokyo, Japan
| | - Joho Tokumine
- Department of Anesthesiology, Kyorin University School of Medicine, Mitaka 181-8611, Tokyo, Japan
| | - Alan Kawarai Lefor
- Department of Surgery, Jichi Medical University, Shimotsuke 329-0498, Tochigi, Japan
| | - Akira Motoyasu
- Department of Anesthesiology, Kyorin University School of Medicine, Mitaka 181-8611, Tokyo, Japan
| | - Tomoko Yorozu
- Department of Anesthesiology, Kyorin University School of Medicine, Mitaka 181-8611, Tokyo, Japan
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Schneider-Stickler B, Ho GY, Moriggl B. Ultrasound-guided injection into the lateral crico-arytenoid muscle: a pilot study. Eur Arch Otorhinolaryngol 2023; 280:2877-2883. [PMID: 36773100 PMCID: PMC10175418 DOI: 10.1007/s00405-023-07843-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 01/15/2023] [Indexed: 02/12/2023]
Abstract
OBJECTIVES The anterior, percutaneous Botulinum neurotoxin (BoNT) injection in the lateral cricoarytenoid muscle (LCA) guided by laryngeal electromyography (LEMG) is considered the golden standard treatment for several neurolaryngological disorders. The study presented in this article aims to assess the effectiveness of an alternative approach by which the injection is performed laterally under ultrasound monitoring. STUDY DESIGN Anatomical dissection study in human cadavers. SETTINGS Academic health care center. METHODS Ultrasound-guided bilateral dye (0.1 mL of dye solution containing cold-curing polymers, latex, acrylates, acrylic esters, alcohol, and green color) injection in the LCA was performed by means of 24G needles and 1 mL syringes using the lateral approach. The dye location and distribution were assessed by anatomic dissection, performed immediately after the injection. RESULTS In 9/10 specimens, the dye was exclusively detectable in the LCA. In 1/10 case (left side), the dye could not be delivered in the LCA because of unintended penetration of the thyroid cartilage by the needle during injection. Anatomic dissection confirmed that the dye spread neither into the thyroarytenoid (TA) nor the cricothyroid muscle (CT). CONCLUSIONS The anatomic dissection following lateral dye injection in the LCA under ultrasound guide confirmed the precision of this approach in delivery a substance exclusively in a pre-determined target. This feature makes this method an interesting addition or alternative to the standard LEMG-guided BoNT injection at least when the LCA is its target. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Berit Schneider-Stickler
- Division of Phoniatrics, Department of Otorhinolaryngology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Guan-Yuh Ho
- Division of Phoniatrics, Department of Otorhinolaryngology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Bernhard Moriggl
- Institute of Clinical and Functional Anatomy, Medical University of Innsbruck, Innsbruck, Austria
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9
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Zasso FB, Lait D, Siddiqui N, Perelman VS, Ye XY, You-Ten KE. Role of ultrasonography in an impalpable tissue larynx model during a simulated front-of-neck access scenario: a randomized simulation study. CAN J EMERG MED 2022; 24:862-866. [PMID: 36346398 DOI: 10.1007/s43678-022-00399-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 10/12/2022] [Indexed: 11/11/2022]
Abstract
PURPOSE A large vertical incision is recommended when performing front-of-neck access in patients with impalpable neck landmarks during a cannot intubate-cannot oxygenate (CICO) scenario. We investigated the impact of ultrasonography on vertical incision size of a front-of-neck access on an ultrasound-compatible impalpable porcine larynx model. METHODS Emergency medicine and anesthesia trainees were randomized to the Ultrasound (US, n = 21) and Non-Ultrasound (NUS, n = 21) groups. Within 1 week after a teaching session on airway ultrasound and Scalpel-Bougie-Tube (SBT) technique, participants were instructed to perform cricothyroidotomy on the model during a simulated cannot intubate-cannot oxygenate scenario. The primary outcome was a vertical size incision. Secondary outcomes were procedural completion time, horizontal size incision, tissue injury severity, and correct tube placement. RESULTS The ultrasound group performed a significantly smaller vertical incision [median (IQR), 35.0 (15, 40) vs 65.0 (52, 100) mm (95% CI) - 30.0 (- 55.1, - 4.9), p = 0.02] and took longer total time to complete the procedure [median (IQR), 200.5 (126, 267) vs 93.5 (71.0, 167.5) secs (95% CI) 91.0 (3.73, 178.3), p = 0.04]. Tissue injury severity and correct tube placement were similar between groups. CONCLUSIONS Ultrasound-guided identification of the cricothyroid membrane significantly reduced the recommended vertical incision size with similar success rates. However, there was an increased time when performing a Scalpel-Bougie-Tube cricothyroidotomy on an impalpable porcine larynx model by physicians in training. Ultrasonography should not be used in an emergency scenario of airway rescue. Its potential use to pre-mark the cricothyroid membrane should be considered in difficult airway management of impalpable neck.
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Affiliation(s)
- Fabricio Batistella Zasso
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital-Sinai Health System, University of Toronto, 7-405, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Dekel Lait
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital-Sinai Health System, University of Toronto, 7-405, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Naveed Siddiqui
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital-Sinai Health System, University of Toronto, 7-405, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Vsevolod S Perelman
- Department of Family Medicine-Emergency Medicine, Mount Sinai Hospital-Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - Xiang Y Ye
- MiCcare Research Centre, Mount Sinai Hospital-Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - Kong Eric You-Ten
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital-Sinai Health System, University of Toronto, 7-405, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
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Cho SA, Kang P, Song IS, Ji SH, Jang YE, Lee JH, Kim JT, Kim HS, Kim EH. Performance time of anesthesiology trainees for cricothyroid membrane identification and characteristics of cricothyroid membrane in pediatric patients using ultrasonography. Paediatr Anaesth 2022; 32:834-842. [PMID: 35362653 DOI: 10.1111/pan.14451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 03/20/2022] [Accepted: 03/28/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Identifying the cricothyroid membrane is an essential technical skill for front-of-neck access procedures. AIMS This study evaluated the usefulness of cricothyroid membrane identification in pediatric patients using ultrasonography by anesthesiology trainees without experience in airway ultrasound and collected anatomical data on the cricothyroid membrane and its surrounding airway structures in children. METHODS This prospective observational study included children aged <18 years scheduled to undergo general anesthesia and anesthesiology trainees who identified the cricothyroid membrane in five sequential anesthetized patients using ultrasonography. A pediatric anesthesiologist confirmed the accuracy of the identified cricothyroid membrane and recorded the performance time. The primary aims were the cricothyroid membrane identification success rate and performance time. The secondary aims were the characterization of the cricothyroid membrane and its surrounding structures. RESULTS Overall, 150 pediatric patients and 30 anesthesiology trainees were analyzed. The cricothyroid membrane identification success rate using ultrasonography was 100% in all the attempts using a transverse approach. The mean (standard deviation) performance time was 27.2 (18.6) s and 31.0 (23.8) s using the transverse and longitudinal approaches, respectively. The performance time decreased by 3.1 (p = .003, 95% confidence interval [CI] = -5.1--1.0) and 5.2 (p = .007, 95% CI = -8.9--1.4) seconds per increase in number of attempts with the transverse and longitudinal approaches, respectively. The cricothyroid membrane length was mostly correlated with the patients' height (r = .75, p < .001), and the blood vessels surrounding the cricothyroid membrane were observed in 95.9% of the patients. CONCLUSIONS Anesthesiology trainees without experience in airway ultrasound successfully identified the cricothyroid membrane in pediatric patients using ultrasonography after a brief training period. Further research is required as the identification of a structure does not predict the success of the actual procedure, particularly if done in an emergency situation.
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Affiliation(s)
- Sung-Ae Cho
- Department of Anesthesiology and Pain Medicine, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - Pyoyoon Kang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - In-Sun Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sang-Hwan Ji
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Young-Eun Jang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ji-Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Eun-Hee Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Lee SY, Hong DK, Kim CJ, Chung MY, Lee S, Chae MS. Association between Successful Palpation of the Cricothyroid Membrane and the 3-3-2 Rule for Predicting Difficult Airway in Female Patients Undergoing Non-Neck Surgery: A Prospective Observational Cohort Study. J Clin Med 2022; 11:jcm11092316. [PMID: 35566446 PMCID: PMC9103161 DOI: 10.3390/jcm11092316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/12/2022] [Accepted: 04/20/2022] [Indexed: 02/05/2023] Open
Abstract
Background: Prediction of difficult airway is important for airway management in patients undergoing surgery. The assessment of airway structures and establishment of protective airway strategies are essential to improve patient safety. However, the association between successful palpation of the cricothyroid membrane and airway predictions has not been fully elucidated in patients undergoing surgery. We investigated this in female patients undergoing non-neck surgery. Methods: A total of 68 female patients were enrolled in this prospective observational cohort study between January 2021 and June 2021 at Eunpyeong St. Mary’s Hospital, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea. Exclusion criteria were male patients and those with neck pathology or neck surgery. The assessment of difficult airway was performed before the induction of anesthesia and was defined by one of the following conditions: inter-incisor distance < 3 fingerbreadths, hyoid-to-mental distance < 3 fingerbreadths, and thyroid-to-hyoid distance < 2 fingerbreadths (the “3-3-2 rule”). The accuracy of palpable identification of the cricothyroid membrane was confirmed by ultrasonography (US). The patients were divided into the non-difficult airway (NDA) group (n = 30) and the difficult airway (DA) group (n = 30). Results: The two groups were comparable in terms of age, but the DA group had higher body mass index (BMI). In airway assessment, 9 patients showed inter-incisor distance < 3 fingerbreadths, 3 patients showed hyoid-to-mental distance < 3 fingerbreadths, and 24 patients showed thyroid-to-hyoid distance < 2 fingerbreadths in the DA group. The rate of successful palpation of the cricothyroid membrane was higher in the patients without than in those with difficult airway variables. Conclusions: Patients with a positive 3-3-2 rule showed a poor palpability of cricothyroid membrane.
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Affiliation(s)
- So Yeon Lee
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.Y.L.); (D.K.H.); (C.J.K.); (M.Y.C.)
| | - Da Kyung Hong
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.Y.L.); (D.K.H.); (C.J.K.); (M.Y.C.)
| | - Chang Jae Kim
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.Y.L.); (D.K.H.); (C.J.K.); (M.Y.C.)
| | - Mee Young Chung
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.Y.L.); (D.K.H.); (C.J.K.); (M.Y.C.)
| | - Sanghoon Lee
- Department of Anesthesiology and Pain Medicine, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Korea
- Correspondence: ; Tel.: +82-2-2258-6150; Fax: +82-2-537-1951
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Chang JE, Kim H, Won D, Lee JM, Kim TK, Min SW, Hwang JY. Comparison of the Conventional Downward and Modified Upward Laryngeal Handshake Techniques to Identify the Cricothyroid Membrane: A Randomized, Comparative Study. Anesth Analg 2021; 133:1288-1295. [PMID: 34517392 DOI: 10.1213/ane.0000000000005744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Accurate identification of the cricothyroid membrane is crucial for successful cricothyroidotomy. The aim of this study was to compare the conventional downward and modified upward laryngeal handshake techniques in terms of accuracy to identify the cricothyroid membrane in nonobese female patients. METHODS In 198 anesthetized female patients, the cricothyroid membrane was identified by either the conventional downward laryngeal handshake technique (n = 99) or the modified upward laryngeal handshake technique (n = 99). According to the conventional downward laryngeal handshake technique, the cricothyroid membrane was identified by palpating the neck downward from the greater cornu of the hyoid bone, thyroid laminae, and cricoid cartilage. According to the modified upward laryngeal handshake technique, the cricothyroid membrane was located by moving up from the sternal notch. The primary outcome was the accuracy of identifying the cricothyroid membrane. Secondary outcomes included the accuracy of midline identification and time taken to locate what participants believed to be the cricothyroid membrane. The primary and secondary outcomes according to the technique were analyzed using generalized estimating equations. RESULTS The cricothyroid membrane could be identified more accurately by the modified upward laryngeal handshake technique than by the conventional downward technique (84% vs 56%, respectively; odds ratio [OR], 4.36; 95% confidence interval [CI], 2.13-8.93; P < .001). Identification of the midline was also more accurate by the modified laryngeal handshake than by the conventional technique (96% vs 83%, respectively; OR, 4.98; 95% CI, 1.65-15.01; P = .004). The time taken to identify the cricothyroid membrane was not different between the conventional and modified techniques (20.2 [16.2-26.6] seconds vs 19.0 [14.5-26.4] seconds, respectively; P = .83). CONCLUSIONS The modified upward laryngeal handshake technique that involved tracing the trachea and laryngeal structures upward from the sternal notch was more accurate in identifying the cricothyroid membrane than the conventional downward technique in anesthetized female patients.
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Affiliation(s)
- Jee-Eun Chang
- From the Department of Anesthesiology & Pain Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Hyerim Kim
- From the Department of Anesthesiology & Pain Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Dongwook Won
- From the Department of Anesthesiology & Pain Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Jung-Man Lee
- From the Department of Anesthesiology & Pain Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Tae Kyong Kim
- From the Department of Anesthesiology & Pain Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea.,Department of Anesthesiology & Pain Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Seong-Won Min
- From the Department of Anesthesiology & Pain Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea.,Department of Anesthesiology & Pain Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Jin-Young Hwang
- From the Department of Anesthesiology & Pain Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea.,Department of Anesthesiology & Pain Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea
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Kristensen MS, Teoh WH. Ultrasound identification of the cricothyroid membrane: the new standard in preparing for front-of-neck airway access. Br J Anaesth 2020; 126:22-27. [PMID: 33131758 DOI: 10.1016/j.bja.2020.10.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 10/01/2020] [Indexed: 12/15/2022] Open
Affiliation(s)
- Michael S Kristensen
- Department of Anaesthesia, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Wendy H Teoh
- Private Anaesthesia Practice, Wendy Teoh Pte. Ltd., Singapore
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