Ultrasound Clinical Trial
Official title:
Changes in Ultrasound-guided Skin Markings of the Cricothyroid Membrane in Three Different Neck Positions: a Prospective Observational Pilot Study
Cricothyroid membrane (CTM) localization is a critical step prior to emergent surgical airway access. Ultrasound-guided localization of the CTM on the skin of the neck had been suggested prior to induction of general anesthesia so that a marked entry point can be used to quickly establish emergent front of neck access if required. In this prospective observational study, the investigators aim to determine the potential for migration of the CTM markings in the sagittal plane during neck repositioning.
As defined in recent difficult airway guidelines, successful and rapid cricothyroidotomy
depends on identification of the cricothyroid membrane (CTM), coupled with skillful and
efficient technique. Unfortunately, identification of the CTM is often inaccurate and
complicated by patient factors such as female gender and obesity. Further studies go on to
demonstrate the rates for correct identification of the CTM using palpation methods are low
and range between 11% and 42%, with even lower success of identifying the midline of the CTM.
This traditional palpation method was demonstrated to be fraught with error by different
users including: 2 finger palpation, 4 finger palpation, and neck crease successfully
identified the CTM 62%, 46%, and 50% of the time at time intervals between 11-14 seconds in
non emergency settings.
As a result of previously mentioned patient factors and multiple technical factors, including
poor landmarking, cricothyrotomy has a failure rate as high as 60%, exposing patients to high
risks of mortality and morbidity. Therefore, more accurate methods of CTM identification are
greatly needed at present.
Suggestions of implementing ultrasound in airway management have been brought forth, with
applications such as predicting airway difficulty prior to instrumentation, confirming
endotracheal tube position, or marking the CTM prior to induction of anesthesia. There have
been multiple studies addressing questions such as mean time to identification of CTM in
obese subjects using ultrasound and comparison of transverse versus longitudinal scanning
technique. One group assessed translational movement of the CTM in neutral neck position
versus extended in 23 healthy volunteers, and found a difference in transverse and
longitudinal markings of 0.91mm and 1.04mm respectively, with CTM length ranging from 10.6mm
to 17mm.
Of interest to the investigators is using ultrasound to predict CTM position accurately and
ensuring ability to gain emergency airway access, as the accuracy of ultrasound
identification of the CTM in different neck positions is unknown. What is specifically
unknown is the translational movement of the cricoid between neck positions.
Therefore, the investigators propose an observational prospective trial looking at cricoid
cartilage translation with three different neck positions: neck neutral, neck extension, and
neck sniffing. The investigators will use GE Venue 50 (GE HealthcareTM) ultrasound machine,
and a linear transducer probe with a frequency of 8-13MHz (GE LOGIQ 12L-SC) for measurements.
The measurements will originate at the sternal notch to the superior border of the cricoid
cartilage where the cricoid membrane inserts. These will also be referenced to exterior skin
markings. The outcomes will address if the airway significantly moves during manipulation by
the degree of cricoid cartilage translation between neutral, sniffing and extended neck
positions. Secondarily, The investigators will also aim to address the directionality of a
pre-marked neck and cricoid migration with neck manipulation.
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