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Ultrasonic Assessment of the Cricothyroid Membrane

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Ultrasonic Assessment of the Cricothyroid Membrane

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  1. Ultrasonic Assessment of the Cricothyroid Membrane Better than Landmarking? Dr ZHANG Jinbin MMED (Anaes) Consultant Department of Anaesthesiology, Intensive Care and Pain Medicine Tan Tock Seng Hospital, Singapore

  2. Outline • Anatomy • Locating the cricothyroid membrane (CTM) using ultrasound • Limitations of landmark palpation • Is ultrasound useful?

  3. Why is the Cricothyroid Membrane (CTM) important? • Surgical airway access • Transtracheal injection of LA

  4. Anatomy of the CTM

  5. Superior Thyroid artery Superior Laryngeal artery Cricothyroid artery Conventionally… • Landmark Technique • Between the thyroid and cricoid cartilages

  6. Limitations of Palpation • Poorly discernible landmarks • Thick neck • Thick subcutaneous tissue • Obese patients • Females • Distorted anatomy • Previous radiotherapy to neck • Tracheal deviation due to head & neck tumours • Infection

  7. Landmark palpation is inaccurate • 6 volunteers • BMI from 24-53kg/m2 • 18 participants • 30% within defined area • 10% on target • 51% missed above • 35% missed below Elliot et al. Anaesthesia 2010; 65

  8. Landmark palpation is inaccurate • 56 females, child-bearing age • 15 obese (mean BMI 40.5 + 9.9 kg/m2) • 24 participants • 17 anesthesiologists • 7 OB/GYN trainees • Neutral: • 25% in non-obese • 0% in obese group • Hyperextended: • 29% vs 6% Aslani et al. Anesth Analg 2012:114

  9. Range of values extensive • Ease of ultrasonic assessment did not differ with BMI

  10. Landmark palpation is inaccurate • NAP 4 study • 15/29 (52%) of the cricothyroidotomies performed by anaesthetists failed • 100% success in those done by surgeons

  11. How can Ultrasound help us?

  12. Ultrasound – Tissue air interface M.S Kristensen, W.H.L Teoh. Airway Management 1st Edition, Springer 2014

  13. Advantages Safe Quick Reproducible Non-invasive Portable Available by bedside Gives dynamic images

  14. Localize Cricothyroid membrane

  15. Ultrasound Helps • Ease of image acquisition not affected by BMI • Quick image acquisition • 24.32s + 20.18s (95% CI 18.59 – 30.05) • Poorly discernible landmarks • Easier to locate CTM, retention of training Nicholls et al. Am J Emerg Med 2008;26 Barbe et al. Ann Fr Anesth Reanim 2014; 33

  16. Limitations of Ultrasound • Expertise • Subcutaneous air – image interference • Preparation and boot-up time? • Role for Emergency CICO? • Minimum training required?