Can't intubate, can't oxygenate? What is the preferred surgical strategy? A retrospective analysis

• Published in: Anaesthesiology intensive therapy : official publication of the Polish Society of Anaesthesiology and Intensive Therapy Vol. 56; no. 1; pp. 37 - 46
• Main Authors: Nachshon, Akiva, Firman, Shimon, Batzofin, Baruch Mark, Miklosh, Bala, van Heerden, Peter Vernon
• Format: Journal Article
• Language: English
• Published: Poland Termedia Publishing House 01.01.2024
• Subjects: Adult; Aged; airway access; airway emergency; Airway Management - methods; cannot intubate cannot oxygenate or ventilate (cicov); Cricoid Cartilage - surgery; cricothyrotomy; Female; Humans; Intubation, Intratracheal - methods; Male; Middle Aged; Original and Clinical; percutaneous dilatational tracheostomy (pdt); Respiration, Artificial - methods; Retrospective Studies; surgical airway; Tracheostomy - methods; Young Adult; cannot intubate cannot oxygenate or ventilate (CICOV); airway emergency; percutaneous dilatational tracheostomy (PDT); surgical airway; cricothyrotomy; airway access
• ISSN: 1642-5758; 1731-2531
• DOI: 10.5114/ait.2024.138437

Cricothyrotomy (CTM) is currently recommended as the preferred method due to its ease, speed, and safety in life-threatening airway emergencies where standard tracheal intubation and mask ventilation fail. This retrospective study analyzed 33 cases of "can't intubate, can't oxygenate or ventilate" (CICOV): 12 of percutaneous dilatational tracheostomy (PDT) and 21 of CTM. The CTM group was younger (median age 44) and mainly consisted of trauma patients. The PDT group was more diverse and procedures were performed by anesthesia and critical care consultants. Initial success rates were 100% for PDT (12/12) and 86% for CTM (18/21), with one conversion from CTM to PDT. No perioperative complications occurred in the PDT group, while the CTM group experienced two cases of false tracts requiring re-do and three cases of bleeding. Immediate mortality within 24 hours was reported in 5/19 CTM patients and none in the PDT group. Successful liberation from mechanical ventilation at hospital discharge was achieved in 6/12 PDT patients and 11/21 CTM patients. Among the 21 CTM cases, all 16 survivors underwent subsequent tracheostomy. Tracheal decannulation occurred in 4/12 PDT patients and 10/21 CTM patients. Favorable immediate neurological outcomes (GCS ≥ 11T) were observed in 8/12 PDT patients and 8/21 CTM patients, while 3 PDT patients remained anesthetized until death and 7 CTM patients died within the first 72 hours without recovery attempts. In experienced hands, PDT could be a legitimate clinical option for the surgical airway in cases of CICOV. CTM may be more suitable for practitioners who encounter CICOV infrequently.