Originally published at Pediatric EM Morsels on May 20, 2016. Reposted with permission.

Follow Dr. Sean M. Fox on twitter @PedEMMorsels

“Can’t Intubate Can’t Ventilate” is one of the frightening statements that causes massive surges of adrenaline in everyone. Unfortunately, most neural synapses don’t function well with that large surge of adrenaline, and it is, therefore, imperative to contemplate how to manage this scenario before it arises.  We have previously discussed Transtracheal Ventilation and have several videos to view, but let us review this important topic briefly once more. Can’t Intubate Can’t Ventilate: How Do I Oxygenate?

Can’t Intubate Can’t Ventilate: Anatomy Matters!

• With larger children and adults, the can’t intubate can’t ventilate scenario often leads to the Cricothyrotomy.
• In younger children and infants, the differences in anatomy make a traditional cricothyrotomy challenging.
• In infants and young children:
  • Generous proportions of subcutaneous adipose tissue (chunky little babies are cute…) obscures landmarks.
  • The Hyoid bone is more prominent than the thyroid cartilage.
  • The Thyroid notch is often not palpable.
  • The Cricothyroid membrane is:
    • More horizontally positioned vs its typical vertical position
    • Small!
      • Around 8 years of age it is 1/2 the height and width of an adult’s
      • In neonates, the size is not sufficient enough to insert any commonly used rescue device. [Navsa, 2005]
• The altered anatomy makes location of the cricothyroid membrane more difficult (if at all possible) and the small size may make it impossible to pass a large cric-tube through.

Can’t Intubate Can’t Ventilate: Go Transtracheal

• This is THE MOST IMPORTANT PROCEDURE TO KNOW!
• Transtracheal ventilation has been used successfully in children as well as adults. [Frerk, 2015; Cote, 2009]
• It may not “secure” an airway, but it will provide the patient with oxygen while you sort out the problem (and change your pants).
• It is also easier than placing an IV in a child!
  • Locate the trachea!
    • If you are able to locate the cricothyroid membrane and it is large enough you can use it
    • Potential to use this catheter later to convert to a guidewire-assisted percutaneous cricothyrotomy. [Boccio, 2015]
  • Load a large gauge needle/catheter (14 gauge), ideally one that is reinforced(as simple peripheral IV catheters are prone to kink and become obstructed) onto a fluid-filled syringe.
  • Aspirate as you enter the skin at a 30-45 degree angle aimed caudally.
  • When you aspirate bubbles, you are in the airway! Advance the catheter and retract the needle.
  • Boom… done. High-Fives all around! {oh wait… we need oxygen!}

Can’t Intubate Can’t Ventilate: The Hard Part

• The most difficult aspect of the procedure is not waiting too long to do it and leading to hypoxic insult.
• The next most difficult aspect is figuring out how to connect oxygen to the tiny catheter you just placed in the neck.
• This is where contemplation of how to do this before you need to do it is important, because most of us are not going to successfully “MacGyver it” on the fly.

• Oxygen Connection Options

  1. Commercial products
     • Have flow regulators that are easy to use. [Cote, 2009]
     • Connect easily via Lure-lock to the catheter.
     • Many have pressure regulators as well.
     • Con = Expensive.
  2. Oxygen Tubing and High Flow O2 from Wall 
     • Not as optimal as commercial products, but may be best you have available.
     • Turn flow up all of the way. [Bould, 2008]
     • Need to “MacGyver” a flow regulator and a connector
       • Flow Regulator –
         • Cut large holes (several) in side of oxygen tubing.
         • Need large/multiple holes to allow air flow to egress easily and not add to PEEP. [Sasano, 2014]
         • May also use Y-connector to another oxygen tube.
       • Connector –
         • 3-way stop cock can be used to fit into distal end of oxygen tubing and Lure-lock onto the catheter.
         • Need to ensure 3 way valve is open to flow!
  3. Self-Inflating Ventilation Bag [Sasano, 2014]
     • Not as optimal as commercial products, but may be best you have available.
     • 3.0 ETT bag connector
       • Remove from ETT
       • Insert distal end into catheter
     • 7.5 ETT bag connector
       • Remove from ETT
       • Insert into proximal end of 3 mL syringe (after removing the plunger).
       • Use Lure-lock on syringe to connect to catheter
     • Will need to disengage the bag’s pop-off valve.

• Oxygenate!
  • Occluding the flow regulator will lead to airflow into the trachea (inspiration).
  • Uncovering the flow regulator will allow air flow from oxygen source and patient to escape (expiration).
  • Inspiration : Expiration = 1 second :  4 seconds
  • Use longer expiration phases for completely occluded upper airway (ex, 1:9)
    • Patient will tolerate hypercapnia better than barotrauma/pneumothorax.

Moral of the Morsel

• Do not let the first time you think about transtracheal ventilation be when you realize you need to do it.
• Know what equipment you have available.
  • If you have a commercial product, know how to use it and where it is.
  • If you don’t have a commercial product, make your MacGyver survival bag and keep it handy with the tools you need, so you don’t need to recall how to do it in the time of need.

References