Sydney Clinical Skillsand Simulation Centre

Can’t Intubate Can’t Oxygenate (CICO)

Management of the Critically Obstructed AirwaySession 4: Infraglottic Airway Rescue

CICO Plan

Part 1Supraglottic Airway Rescue

Part 2Transition to CICO

Part 3Infraglottic Airway Rescue

Session aimsCICO infraglottic

rescue:

1. Algorithm (A Heard)

2. Techniques

3. Kit

4. Team-based algorithm

Acknowledgements

Dr Andy Heard - Original content Expert Working Group, RHCE Critically Obstructed Airway

Course

References1. Heard, R. J. Green and P. Eakins. The Formulation and

Introduction of a ‘Can’t Intubate, Can’t Ventilate’ Algorithm into Clinical Practice. Anaesthesia, 2009, 64, pages 601–608.

2. Dr A.M.B Heard. The Wet Lab-Emergency Airway Management Techniques for the ‘Can’t Intubate, Can’t Oxygenate’ Scenario. March, 2011.

CICO algorithm (Heard)

A. M. B. Heard, R. J. Green and P. Eakins. The Formulation and Introduction of a ‘Can’t Intubate, Can’t Ventilate’ Algorithm into Clinical Practice. Anaesthesia, 2009, 64, pg. 601–608.

Cannula Cricothyroidotomy or Cannula Tracheotomy

Palpable Neck Airway Anatomy?

Scalpel Finger Cannula

Scalpel Bougie

Melker 5.0 Cuffed Seldinger Technique

Railroad size 6.0ET Tube

Melker 5.0 Cuffed Seldinger Technique

Consider:Awaken/Other upper

airway techniques

FAILURE

Oxygenate and stabiliseOxygenate and stabilise

SUCCESSFAILURE

NO YES

Oxygenate and stabilise

FAILURE

CICO

CICO techniques

1. Cannula Cricothyroidotomy

2. Jet oxygenation

3. Scalpel-bougie

4. Scalpel-finger-cannula

5. Melker size 5 cuffed Seldinger conversion to a definitive airway

Video – Cannula Cricothyroidotomy

Cannula cricothyroidotomyEquipment

You are trying to achieve 2 things with jet oxygenation in the CICO scenario:

1. Provide oxygen

2. Prevent/improve airway and alveolar collapse

Jet oxygenation

Jet oxygenation

The ManujetTM

Set at 1.0 bar (i.e., Infant setting, in the Yellow Zone) delivers inspiratory flow of approx 250 mls/second

Rapid - O2 oxygen cricothyroidotomy insufflation device (nee Leroy)Connected to piped O2 at 15L/min, delivers inspiratory flow of approx 250 mls/second

Providing oxygen

Jet oxygenation in a 70kg male

Initial breath4 seconds duration=approx 1000mL

If there is no response or improvement in SpO2 after 30 seconds, a second jet of 2.0 seconds should be administered.

Whilst applying the first jet, signs of flow must be sought by checking the chest for movement, and listening for flow.

Prevent/improve airway and alveolar collapse

Jet oxygenation in a 70kg male

Subsequent breaths

Do not jet again until the SpO2 have dropped by 5% from the maximum achieved with the initial jet.

Subsequent jets should be of 2 seconds duration (Approx 500 mls)

Prevent/improve airway and alveolar collapse

Jet oxygenationIF jetting with the manujet, and there are no signs of expiratory flow

THEN disconnect the manujet to allow some expiration through the cannula (taking care to not inadvertently remove the cannula). This is to ensure hyperinflation causing reduced venous return does not occur.

The Leroy and ENK allow expiration through the cannula and do not require disconnection.

Jet oxygenationIF there is no saturation reading for whatever reason

THEN it is safe to insufflate 500 mls every 30 seconds if using a 14g cannnula and Rapid - O2 (Leroy) / ENK (Or disconnected Manujet) even in complete upper airway obstruction.

Jet oxygenation

After connecting the cannula to the jet oxygenation device, never let go of the cannula.

Only jet oxygenate whilst watching the chest rise and fall

The rate-limiting step for the frequency of safe jet oxygenation is the patency of the expiratory pathway.

CICO algorithm (Heard)

A. M. B. Heard, R. J. Green and P. Eakins. The Formulation and Introduction of a ‘Can’t Intubate, Can’t Ventilate’ Algorithm into Clinical Practice. Anaesthesia, 2009, 64, pg. 601–608.

Cannula Cricothyroidotomy or Cannula Tracheotomy

Palpable Neck Airway Anatomy?

Scalpel Finger Cannula

Scalpel Bougie

Melker 5.0 Cuffed Seldinger Technique

Railroad size 6.0ET Tube

Melker 5.0 Cuffed Seldinger Technique

Consider:Awaken/Other upper

airway techniques

FAILURE

Oxygenate and stabiliseOxygenate and stabilise

SUCCESSFAILURE

NO YES

Oxygenate and stabilise

FAILURE

CICO

Video - Scalpel-Bougie

Scalpel-BougieEquipment

CICO algorithm (Heard)

A. M. B. Heard, R. J. Green and P. Eakins. The Formulation and Introduction of a ‘Can’t Intubate, Can’t Ventilate’ Algorithm into Clinical Practice. Anaesthesia, 2009, 64, pg. 601–608.

Cannula Cricothyroidotomy or Cannula Tracheotomy

Palpable Neck Airway Anatomy?

Scalpel Finger Cannula

Scalpel Bougie

Melker 5.0 Cuffed Seldinger Technique

Railroad size 6.0ET Tube

Melker 5.0 Cuffed Seldinger Technique

Consider:Awaken/Other upper

airway techniques

FAILURE

Oxygenate and stabiliseOxygenate and stabilise

SUCCESSFAILURE

NO YES

Oxygenate and stabilise

FAILURE

CICO

Video – Scalpel Finger Cannula

MelkerTM conversionEquipment

CICO infraglottic rescueKey points for success

1. CICO is recognised

2. CICO is declared

3. A plan is activated

4. Equipment is immediately available

5. People know their roles

Best attempt at:• Face-mask ventilation?• LMA ventilation? • Endotracheal intubation? AND

Oxygen saturations falling or persistently low?

Is this a CICO situation?

INFRAGLOTTIC RESCUE

YES

Continue Supraglottic

rescue

Consider waking patient

Review again in 1 min

With permission A. Heard and Working group for the Rural Health Continuing Education (RHCE) (Stream 1) ‘Critically Obstructed Airway Workshop’. Contact smsc@nsccahs.health.nsw.gov.au. 2013

SUPRA-GLOTTIC RESCUE

NO

TR

AN

SIT

ION

‘Transition’ protocol - CICO

MOBILISE RESOURCES

FOR CICO

Best attempt at supraglottic rescue?

Oxygen saturations persistently low?

Is this

a CICO

situation?

DECLARE CICO

CAN’T INTUBATE & CAN’T OXYGENATE (CICO) EMERGENCY PROTOCOL

Resources

1. Cannula-cricothyroidotomy kit• Jet oxygenation tubing• Melker™ kit• Self-inflating bag

2. Scalpel – bougie kit3. Scalpel – finger – cannula kit4. Arrest trolley

NO

Continue supraglottic rescueConsider waking patient

Review again in 1 min

With permission A. Heard and Working group for the Rural Health Continuing Education (RHCE) (Stream 1) ‘Critically Obstructed Airway Workshop’. Contact: smsc@nsccahs.health.nsw.gov.au. 2013 .

SUPRAGLOTTIC RESCUE – MOBILISE RESOURCES FOR CICO

INFRAGLOTTIC RESCUE

Team roles

ALGORITHM

1. Teamleader2. Proceduralist – infraglottic rescue3. Proceduralist – supraglotic rescue4. Assistant – supraglotic rescue5. Assistant – infraglottic rescue6. Assistant – equipment set up7. Scribe

Algorithm

Mobilise resources for CICOYES

Face mask ventilationLMA ventilationEndotracheal intubation