Advanced Airway Management
Your Go-To for Advanced Airway How-To's
Expanded Guide:
Emergency Front of the Neck Airway (eFONA)
In a Cannot Intubate - Cannot Ventilate (CICV) emergency, minutes count. In the absence of ventilation and following the onset of hypoxia, brain damage can occur within 4-8 minutes if not reversed. Almost uniformly, it is both the delay in recognizing a CICV emergency as well as the delay in taking action to obtain a surgical airway, which contribute most significantly to patient injury and death. Therefore, when other measures to ventilate and oxygenate a patient have failed, all efforts to expedite the creation of an airway through the "front of the neck” (FONA) are warranted.
This includes performance of the procedure by the most experienced provider who is immediately available. At times, this may be the surgeon and at others it will be the anesthesiologist. And though many ORs will have a scalpel available in the room for the planned procedure, there are many cases where this won’t be so. In these time critical moments, waiting for the arrival of a surgical airway kit or scalpel can take more time than is available. The immediate availability of basic FONA equipment is intended to minimize such delays and improve patient outcomes.
In addressing this, a simple “FONA” kit, containing skin prep, a 10-0 broad blade scalpel, a bougie and a 6-0 ETT, is now stocked in every anesthesia machine drawer as well as in each of the code bags.
There is broad national and international consensus that immediate access to emergency invasive airway equipment makes anesthesia safer. Though data may favor a scalpel technique, the ASA recommends providers choose the approach based on their own experience and training. Thus, emergency needle cricothyrotomy kits remain stocked in our anesthesia machine drawers. And, as always, the Melker – Emergency Cricothyroidotomy Kits will continue to be stocked in our anesthesia supply rooms. It is recommended that presence of a provider's preferred emergency equipment be routinely confirmed, as part of the basic room setup, prior to initiating any anesthetic.
Scalpel-Bougie-Tube FONA Technique
A tough situation. Simple equipment.
Emergency FONA through the cricothyroid membrane can be performed with very minimal equipment, such as described below. Several slight variations of this technique exist (largely distinguished by how the scalpel is utilized and whether a tracheal hook is used).
Ultimately, the equipment and technique of choice is up to each individual provider. This step-by-step guide is ONE suggested approach, endorsed by several airway societies.
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Once entry into the emergency arm of the airway algorithm has been identified, take the following immediate steps.
1
CALL FOR HELP and ANNOUNCE to the room this is a Cannot Intubate-Cannot Ventilate (CICV) Emergency
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2
Continue 100% OXYGENATATION attempts
via Face mask, Hi-flow, LMA etc.
3
​​​PARALYZE the patient
Rules out laryngospasm & eases attempts at ventilation
Prepare Equipment​
Gather equipment right there in your anesthesia drawer.
All necessary equipment for eFONA should already be stocked in all anesthetizing locations. As always, check for desired emergency equipment availability prior to initiating any anesthetic.
Position Patient
The sniffing position is not helpful here.
Palpation of relevant anterior neck anatomy is difficult or impossible without head and neck extension. If feasible, consider hyperextension,
Position Yourself
Non-dominant hand palpates. Dominant hand wields scalpel.
The non-dominant hand palpates and identifies the cricothyroid membrane while the dominant hand uses the scalpel.
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Palpate
Palpate the cricothyroid membrane (CTM).
The 'dip' immediately above the cricoid cartilage is the cricothyroid membrane
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7
Palpate with your non-dominant hand, starting at the sternal notch
Reliably midline and palpable, even in cases of obesity, neck pathology or tracheal deviation
8
With your thumb and index finger, move upwards along the tracheal rings until the large cricoid cartilage is palpated
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9
The 'dip' immediately above the cricoid cartilage is the cricothyroid membrane (about the size of the pad of your index finger) which is immediately caudad to the thyroid cartilage (Adam’s apple)
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10
Stabilize the larynx in the midline
& maintain hand positioning for next steps
STAB incision
Go time.
Make a horizontal STAB incision through the cricothyroid membrane (CTM)
11
PREP skin
May omit if not immediately available
12
Make a horizontal incision in the CTM
Twist blade
Rotate blade within incision.
Keeping the blade inserted into your incision, rotate blade vertically and maintain traction
13
TWIST blade vertically
14
Maintain traction within incision by pulling blade back towards you
Insert bougie. Railroad tube.
Rotate blade within incision.
Keeping the blade inserted into your incision, rotate blade vertically and maintain traction
15
Insert the bougie while abutting coude tip against the blade
16
Advance to 10 cm
17
'Railroad' the ETT over the bougie. Rotation of tube while railroading will ease insertion as will holding skin traction. Consider lubrication if available.
Tip
If the bougie gets “hung up” at a depth of less the 5cm, you have created a false passage and the bougie IS NOT in the trachea. Proceed back to STAB incision and start over.
Tip
The carina is approximately 9-11 cm below the CTM. To decrease risk of blunt trauma and perforation, do not insert the bougie past this depth.
Confirm ETCO2 & Oxygenate
18
Confirm ETCO2 with capnography
EZ cap is prone to false positives yet can be used first while awaiting capnography
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19
Oxygenate
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No ETCO2?
Quickly rule out mucous plug by passing soft suction catheter and check circuit connections
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No ETCO2?
Rule out false passage by direct visualization of tracheal rings with bronchoscope.
FLAT TRACE = WRONG PLACE
​A flat ETCO2 tracing must ALWAYS prompt actions to rule out a misplaced ETT.
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Tips
Avoid creating SQ emphysema with large volume/high pressure tidal volumes UNTIL you’ve confirmed your ETT is in the trachea
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Even with cardiac arrest, small ETCO2 waveform “bumps” will be observed, even in the absence of chest compressions!
Formalize the airway
Crisis averted. But securing the ETT can be a challenge.
A surgical specialty team should be consulted stat (if not already called) to help evaluate the next best course of action.
This procedure assumes I can find the cricothyroid membrane (CTM).
But what if I can't?
For nonpalbable structures
Due to obesity, overlying pathology, etc.
Skin incision & blunt tissue dissection down to CTM
1
Make a generous vertical skin incision of at least 5 cm through tissue overlying the CTM. Make sure the incision is deep enough to extend all the way down to the laryngeal structures.
2
Finger dissection down to the CTM
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3
“Stab twist bougie tube” as already described above