PRODUCTS FOR THE DIFFICULT AIRWAY Courtesy of Cook Critical Care
EMERGENCY CRICOTHYROTOMY
Thyroid Cartilage Access Site Cricoid Cartilage Identify the cricothyroid membrane between the cricoid and thyroid cartilages. Posterior Anterior Lateral View
Carefully palpate the cricothyroid membrane and while stabilizing the cartilage, make a vertical incision in the midline.
When advancing the needle forward, verification of entrance into the airway can be confirmed by aspiration on the syringe resulting in free air return.
Remove the syringe and needle, leaving the TFE catheter in place. Advance the soft, flexible end of the wire guide through the TFE catheter and into the airway several centimeters.
Remove the TFE catheter, leaving the wire guide in place.
AIRWAY CATHETER DILATOR EMERGENCY AIRWAY ACCESS ASSEMBLY Advance the handled dilator, tapered end first, into the connector end of the airway catheter until the handle stops against the connector. NOTE: This step may be performed prior to beginning procedure.
Always visualize the proximal end of the wire guide during the airway insertion procedure to prevent inadvertent loss into the trachea. Care should be taken not to advance the tip of the dilator beyond the tip of the wire guide within the trachea.
Remove the wire guide and dilator simultaneously. Connect the emergency airway catheter, using its standard 15-22 adapter to an appropriate ventilatory device.
Figure 1 Attach needle introducer assembly to the cricothyrotomy catheter. Lubricate the catheter. Figure 2
Identify cricothyroid membrane between the cricoid and thyroid cartilages and stabilize trachea with thumb and index finger.
Make a skin incision with the #15 disposable scalpel large enough to admit the catheter, over the cricothyroid membrane, close to the cricoid cartilage. Cannulate the trachea with the catheter tip facing caudad. A loss of resistance is felt when the trachea is entered.
Aspirate air into a water filled 5 cc syringe to confirm catheter position within the tracheal lumen.
Remove the needle and advance the catheter and dilator caudad. Aspirate again to confirm position. Remove the dilator and aspirate once again to ensure correct placement within the trachea.
Thyroid Cartilage Access Site Cricoid Cartilage Identify the cricothyroid membrane between the cricoid and thyroid cartilages. Using the 19 gage needle, fill the supplied 6 cc syringe with sterile water. Remove the 19 gage needle and attach the syringe to the introducer needle assembly side-arm.
Advance the introducer needle assembly through the cricothyroid membrane at a 30-40 angle to the frontal plane in a caudad direction. Verification of entrance into the airway can be confirmed by aspiration on the syringe resulting in free air return. Advance the wire guide through the introducer needle assembly and into the airway by gently pushing it out of the plastic retaining bag.
Remove the introducer needle assembly with attached syringe, leaving the wire guide in place. Make a vertical skin incision next to the wire guide insertion site, using the #11 short handle scalpel blade.
Advance the airway catheter assembly over the wire guide until the proximal stiff end of the wire guide is completely through and visible at the end of the dilator. To prevent injury to the posterior tracheal wall, the wire guide should precede the dilator tip 5-10 cm during placement.
Remove the wire guide and dilator simultaneously by gently twisting free of the female Luer lock connector and withdrawing.
RETROGRADE INTUBATION
Designed to assist in the placement of an endotracheal tube during difficult or emergency airway access procedures. It is particularly useful in situations where visualization of the vocal cords is not possible secondary to secretions, blood and/or anatomic anomalies.
Advance the 18 gage sheath needle (attached to a 6 cc disposable syringe), in a cephalad direction through the cricothyroid membrane and into the trachea. Free flow of air aspirated into syringe will confirm positioning. Remove the needle and syringe, leaving the sheath in place.
POSITIONING MARK POSITIONING MARK Advance the wire guide through the sheath in a cephalad direction, until the tip of the wire guide can be retrieved through the mouth or nose. Remove the sheath, leaving the wire guide in place. NOTE: Alternatively, after initial wire guide positioning, use of a fiberoptic bronchoscope may be employed for direct visualization of the endotracheal tube placement. Wire guide may be placed through suction port of fiberoptic scope.
POSITIONING MARK Advance the 11.0 French black TFE catheter antegrade over the wire guide via the mouth or nose and into the trachea until resistance is met at the cricothyroid membrane.
POSITIONING MARK With the TFE catheter in position, advance the endotracheal tube over the catheter and wire guide below the level of the vocal cords. NOTE: Always maintain control and position of wire guide during advancement of the endotracheal tube.
Remove the wire guide and catheter. Advance endotracheal tube into correct position and inflate the balloon cuff. Verify position and secure in standard fashion.
ENDOTRACHEAL TUBE EXCHANGE
CATHETER Radiopaque RAPI-FIT ADAPTER 1 Plastic RAPI-FIT ADAPTER 2 Plastic 1 15 mm connector 2 Luer lock connector COOK AIRWAY EXCHANGE CATHETERS Cook Airway Exchange Catheters are used for uncomplicated, endotracheal tube exchange and difficult extubation. Use of removable Rapi-Fit TM Adapter permits use of ventilatory device if necessary during exchange procedure.
Before advancing the Cook Airway Exchange (CAE) Catheter into the endotracheal tube to be replaced, confirm correct endotracheal tube position. Advance the CAE catheter (sideported end first) into the endotracheal tube to be replaced. CAUTION: To avoid barotrauma, ensure that the tip of the CAE catheter is always above the carina, preferably 2-3 cm.
Remove the endotracheal tube leaving the CAE catheter in place.
Maintaining position of the CAE catheter, using patient s mouth or nasal orifice (depending on approach) as a landmark, advance the new endotracheal tube over the CAE catheter and position an appropriate distance.
Remove the CAE catheter and inflate the balloon cuff of the new endotracheal tube. Confirm its position using standard methods (e.g., capnography, breath sounds and chest x-ray).