Resources for GEMS March 2017 session
​Topic: Difficult airways and surgical airways

Introduction

CICO is a rare event. The incidence is between 1: 255 000 and 1: 56 000.  In a 20 year career, you may have to deal with 1 such a case. Why is it important? It is an infrequently encountered life threatening problem that is often sub optimally managed. 

What is CICO?
Failing to establish adequate alveolar oxygen delivery by any of the 3 supraglottic ventilation techniques (facemask, supraglottic airway and endotracheal tube).
If a 'best effort' at each of these three lifelines is unsuccessful then a can't intubate, can't oxygenate situation (CICO) situation exists and 'CICO Rescue' (emergency front-of-neck access) must be initiated.

How is CICO poorly managed?

  • ​often not anticipated
  • unwillingness to stop supraglottic airway recue
  • disorganisation and lack of a cohesive team
  • lack of access to, or familiarity with equipment
  • technical failure

Difficult airway?

Any clinician managing an airway should assess the airway for potential difficulty.
​Difficulty may refer to (1) patient anatomy, (2) patient physiology or the (3) situation.
In their editorial “The myth of the difficult airway: airway management revisited”  Huitink & Bouwman state:
“In our opinion, the ‘difficult airway’ does not exist. It is a complex situational interplay of patient, practitioner, equipment, expertise and circumstances.”
Any clinician managing an airway should have a plan in place  and be prepared to deal with difficulties as they arise.
​The UK difficult airway society has very clear guidelines to aid our decision making:

CICO Declared

The decision to perform a surgical airway is often delayed, for various reasons. We should all be familiar with the Elaine Bromiley case, where a CICO situation was neither recognised nor declared and she suffered hypoxic brain damage and tragically died after a routine operation.
​Some people may feel they acknowledge failure (their airway techniques failed) by making the decision to perform a surgical airway. The CICO situation should rather be seen as a situation where a surgical airway is inevitable, rather than using the term "failed airway".

The procedure

1. DECIDE
  • ​Making the decision is the hardest
  • Beware of task fixation
  • Work as a team
  • Train as a team
​2. FIND ​3. STABILISE
  • yourself (breathe!)
  • your team (task focus)
  • the skin (laryngeal handshake)
​4. CUT
  • to air
  • horisontal through CTM
    • vertical if no anatomy visible or palpable
5. BOUGIE
  • Tracheal dilators / hook / haemostat in while scalpel still in place; then remove scalpel
  • Finger vs Direct bougie vs Tracheal dilator
  • Adult 60cm long, caude tip, size 6. Tracheal clicks, hold up, not more than 15 cm
6. TUBE
  • Pass over bougie
  • black line above balloon in just below skin
7. CHECK
  • signs of adequate oxygenation / ventilation (etCO2, oxygen sats improving etc.)
  • tie tube
Link to real life surgical airway (not for the faint hearted!)

Bottom Line

  • Emergency Surgical Airway is a RARE (but technically not difficult) procedure to perform 
  • Declare CICO as soon as recognised
  • Be prepared  to perform emergency FONA               “By failing to prepare, you are preparing to fail” -Benjamin Franklin.
  • Know your kit
  • Practise - as an individual (develop and practise task specific skills) and as a team (SIM)

Resources