The pediatric can’t intubate can’t oxygenate scenario (Use a knife)

A can’t intubate can’t oxygenate scenario will always be scary, but after years of mental rehearsal and some real world experience, the idea of surgical front of neck access in an adult doesn’t bother me much. (I think that is an important mental space for emergency physicians to find if you want to be able to perform a cricothyroidotomy in a timely manner when needed.) However, the can’t intube can’t oxygenate scenario in pediatrics still scares the hell out of me. In large part this is because I have no idea what I am supposed to do. Different guidelines suggest different approaches. They often suggest procedures – such as jet ventilation – that I think are a really bad idea based on the adult literature. Indecision about life saving procedures is a great way to screw up a resuscitation. If you don’t know what you are going to do when considering this from home, there is no way you are going to be able to perform with a heart rate of 200 and a dying child in front of you. So I decided to do what I do best, and spent hundreds of hours on PubMed, reading every bit of literature I could find, so I could decide once and for all how best to approach the can’t intubate can’t oxygenate scenario requiring emergent front of neck access in children.

If want to TLDR version, for the pediatric can’t intubate can’t oxygenate scenario, you should use a scalpel not a needle.

Guidelines

I started by searching for current guidelines, to get a sense of expert opinion, but also to scour the citations to ease my way into the literature search. This is a summary of what I found:

American Society of Anesthesiologists 2022 Practice Guidelines for Management of the Difficult Airway (Apfelbaum 2022): In the pediatric difficult airway algorithm, the suggestions for a can’t intubate can’t ventilate scenario are  “invasive airway techniques include surgical cricothyroidotomy, needle cricothyroidotomy if age-appropriate with a pressure-regulated device, large-bore cannula cricothyroidotomy, or surgical tracheostomy. Elective invasive airway techniques include the above and retrograde wire–guided intubation and percutaneous tracheostomy. Also consider rigid bronchoscopy and ECMO.” These guidelines provide very little guidance, in that every option is listed. I will note that earlier in the algorithm, the ASA guidelines put “consider calling for ECMO” ahead of emergency front of neck access, which seems ridiculous. (Apfelbaum 2022) Perhaps their algorithm is just poorly laid out, because that advice is both for “impossible” and “marginal” ventilation in the setting of a failed intubation, but there is just no way that in a can’t intubate can’t oxygenate scenario that you have time to get the patient on ECMO. I don’t understand the fear mongering around performing a surgical airway. Like most guidelines, these state that they are based on a literature review, but provide absolutely no citations for their recommendations, so it is impossible to know why they make the recommendations they do, or whether their recommendations are any good. 

The Association of Paediatric Anaesthetists of Great Britain and Ireland (APA) And Difficult Airway Society (DAS) (Black 2015): They divide their recommendations for the can’t intubate can’t ventilate scenario based on whether an ENT surgeon is available. (I don’t think that makes any sense. Airway providers all need to be proficient at rescue attempts, and we shouldn’t be using an inferior technique, nor delaying care waiting for a surgeon.) In the presence of ENT, a surgical tracheostomy is recommended. In the absence of ENT, they suggest percutaneous cannula cricothyroidotomy for the 1-8 year age group, and then only if unsuccessful to move on to surgical cricothyroidotomy or tracheostomy. They specifically favor small bore needles and jet ventilation. Again, they provide no good evidence, with the only real citation being to the APLS guidelines. They do mention the NAP4 audit, which contained 4 children, and had a 100% success rate of surgical techniques (3/3) and a 0% success rate for the percutaneous approach (0/1), which doesn’t seem to fit well with their consensus guidelines.

Difficult Airway Society (DAS) (Weiss 2010): Although they discuss percutaneous techniques and bronchoscopy, they do say, “surgical cricothyroidotomy is the invasive procedure of choice for emergency access of the airway in patients, regardless of age, when conventional airway control is not possible.” “Cannula cricothyroidotomy in infants and children has an unacceptable high incidence of complications and should therefore not be used in patients below 5–6 years as an emergency adjunct” “Although for anesthesiologists, puncture techniques rather than surgical techniques are recommended, surgical cricothyroidotomy is the invasive procedure of choice for emergency access of the airway in smaller children.”

European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines (Disma 2024): ”After induction of general anaesthesia, when tracheal intubation fails, oxygenation and ventilation via a supraglottic airway device or face mask are severely impaired or impossible, and spontaneous breathing cannot be restored, a surgical tracheotomy should be performed. Of several techniques described, evidence is lacking for superiority of one technique over another. Surgical cricothyroidotomy and percutaneous needle crico-thyroidotomy are not suitable options in neonates and infants; for the former because the small size of the cricothyroid membrane will likely render insertion of a tracheal tube impossible, and for the latter because of the unfavourable anatomy.”

Evidence

Unsurprisingly, the guidelines do not provide perfect guidance, with mixed messages as to the best approach. Some of the guidelines specifically recommend percutaneous approaches over surgical in the absence of ENT, whereas others state the exact opposite. Although the guidelines and initial reviews I read made it pretty clear that evidence was sparse, I am stubborn, and so still spent hundreds of hours searching the depths of PubMed trying to determine the best approach to front of neck access in the pediatric population. This is what I could find. 

Some anatomy and physiology

Basic science is still science, and can help us predict what approach might be best. As compared to adults, pediatric airways are more elastic, which will make any front of neck approach more difficult. (Berger-Estilita 2021) However, moveable and elastic structures will be more problematic for percutaneous approaches. 

The larynx is much higher in children, and therefore a much steeper approach will be required to access the cricothyroid membrane. (Berger-Estilita 2021) To me, that seems like an argument for a surgical approach, as the percutaneous approach is more more dependent on the angle of the needle, which might be impossible to achieve.

In neonates, the outer diameter of the smallest available endotracheal tube is larger than the diameter of the cricothyroid membrane. (Berger-Estilita 2021) The cricoid membrane is only approximately 2.6 mm in neonates, meaning you will not be able to pass an endotracheal tube with an outer diameter greater than 2.5mm, leading to the suggestion that surgical tracheostomy is the best approach. (Haag 2024)

Bottom line: Although there are some arguments in both directions, the bulk of the evidence suggests that needle based approaches will be more difficult in children than in adults, with no factors to mitigate their many harms (see below). 

Pediatric evidence

There is very little clinical evidence looking at front of neck access in children. 

There are a couple pediatric case reports that seem to demonstrate a lack of success of percutaneous approaches in the real world. Santoro and colleagues present the case of a 4 year old with a can’t intubate can’t oxygenate scenario in which the ENT surgeon failed a needle cricothyroidotomy, but subsequently succeeded with an open tracheostomy. (Santoro 2012) Okada and colleagues discuss a 3 year old with a CICO, in which a needle based approach failed, and then a cricothyroidotomy kit (Mini‐Trach II) cannula kinked and failed, and the airway was ultimately rescued with an open tracheostomy. (Okada 2017) In one case report in a subglottic stenosis in a neonate, a needle approach with a 16 gauge angiocath was successful at improving oxygen saturation, but this did not occur until the 20 minute mark and the child died. (Karnik 2017)

In a prospective cohort of 28 pediatric patients undergoing elective transtracheal jet ventilation as the preferred airway method for larynx surgery, in which the needle was inserted into the trachea under bronchoscopy guidance, first pass success occurred in 26. (One was inserted into the esophagus, and one was submucosal in the trachea, which could have been very problematic if the procedure wasn’t being watched by a bronchoscope.) Severe complications occurred in 11% (3 patients). One was a case of cervical emphysema, pneumomediastinum, and pneumoperitoneum. Another was bilateral pneumothoraces, and subcutaneous emphysema extending to the mediastinum and the peritoneum. The third was significant bradycardia and hypotension. So even in the perfect scenario, where the catheter is placed under visual guidance with bronchoscopy, success is imperfect and complications are high. 

Bottom line: Clearly the evidence is very weak. It suggests that we should not expect percutaneous approaches to be successful, and that complications from jet ventilation are to be expected. 

Animal and simulation models

There are a bunch of animal studies looking at the many different devices. I cannot cover them all, and there could be examples that I have missed. My search focused on pediatric sized equipment in pediatric sized airways. The participants in these studies vary widely, but I am going to assume that no one is a master of pediatric surgical airway, so that an anesthesiologist’s performance is likely equivalent to an emergency physician.

A commercially available kit that involves a plastic cannula over a metal needle (Quicktrach baby) was tested in an animal model, and was successful in 10 out of 10 attempts in a median time of 44 seconds. However, ventilation was only confirmed by auscultation, and oxygenation and ventilation weren’t tested over time, which is the real weakness of the cannula based techniques. Complication rate (larynx fracture, hematoma) was 30%. (Metterlein 2011) 

Looking at tracheostomy in an animal model, a Seldinger kit (COOK 3.5 Melker) was compared to the scalpel bougie approach. (Prunty 2014) The Seldinger kit had an overall success rate of 100% as compared to 75% with scalpel/bougie. However, this study was odd, in that they performed multiple attempts at different levels on the same animal, which clearly isn’t what you would do in real life. (An already lacerated trachea is going to make a second surgical tracheostomy more difficult, whereas repeated needle based approaches are less problematic). On the first attempt, both techniques were 100% successful. Complication rate was above 30% in both groups. They make no mention of time to procedure completion. 

In an animal model, transtracheal jet ventilation was compared with a traditional surgical tracheostomy (using more tools than we would in the ED). (Johansen 2010) Jet ventilation was achieved by placing a 16 or 18 gauge angiocatheter, attaching a 3 way stop cock, and connecting to wall oxygen. Confirmation was just by watching for chest wall rise. Placement of the transtracheal angiocath was only successful within 2 minutes in 27% of attempts! The surgical approach was successful 80% of the time, although with an extra 2 minutes allotted. They do not specifically discuss complications, but in at least one case jet ventilation was attempted when the angiocatheter was outside the trachea, which can result in disastrous subcutaneous emphysema. 

In another animal model, 2 anesthesiologists repeatedly attempted needle tracheotomy with either an 18 or 14 gauge cannula. (Stacey 2012) (Two experts specifically working in a lab dedicated to difficult airway doing the procedure repeatedly probably results in a much higher success rate than in real life.) The overall success rate was 60%. Among the successful cases, there was a 42% complication rate (puncturing the back wall). They also made 13 attempts with a commercial needle cricothyrotomy kit (Quicktrach Child) and failed in all 13. 

In another animal model, a commercial kit for jet ventilation was compared to a standard angiocath jet ventilation. (Holm-Knudsen 2012) Overall success rate within 2 minutes was about 65% with both jet ventilation techniques. The complication rate was over 50%. As a secondary outcome, they also looked at surgical tracheostomy, which had a 97% success rate, and complication rate was 9%. 

In a rabbit model looking only at surgical tracheostomy using a scalpel, Frova intubating introducer (similar to a bougie), and an endotracheal tube, overall success rate was 95% with a median time to completion of 67 seconds. (Both 2021) In this study, training did not have a measurable effect. In a similar rabbit model, open tracheostomy had a 94% success rate with an average time to completion of less than 60 seconds. (Ulmer 2020) However, major injuries occurred in 16% of attempts. In this study, training did decrease time to completion and decrease complications. 

There is a rabbit based RCT comparing a scalpel bougie tracheostomy to a modified rapid (but more traditional) open tracheostomy approach. (Riva 2024) There were no statistical differences, but participants somewhat preferred the scalpel bougie approach. The scalpel bougie approach had a 97% success rate, with a median time to completion of 48 seconds. Injuries to the tracheal structures were high in both groups, but lower with the scalpel bougie technique. 

Bottom line: This data is messy, and obviously of questionable significance to real life pediatric emergencies. However, I think it is consistent with the adult data and case reports in suggesting that percutaneous techniques have worryingly low success rates and high rates of complication. On the other hand, surgical approaches mostly have a very high success rate. 

Adult evidence

In the Fourth National Audit Project from the UK, a large national airway audit, they report a 100% success rate for tracheostomy (29 total cases) as an airway rescue technique. (Cook 2011) In comparison, the success rate of cricothyrotomy was poor. Needle cricothyrotomy failed in 12 of 19 attempts (63%). Large bore Seldinger techniques failed in 3 of 7 attempts (43%). Surgical cricothyrotomies were 100% successful (but with only 3 total attempts). 

A systematic review and meta-analysis of UK prehospital data supports the findings of NAP4. (Morton 2023) They have data from 1229 front of neck access attempts. The needle technique had the worst success rate at 50% (although with only 19 attempts). Tracheostomy kits were successful 93% of the time with 219 attempts. The surgical approach was 100% successful on 603 attempts. 

In a systematic review by Laura Duggan and colleagues looking at 428 cases of jet ventilation from 44 studies, they found a failure rate of 42%, a 32% rate of barotrauma, and a 51% overall complication rate. They suggest against the use of jet ventilation. 

Bottom line: The combination of NAP4 and the Duggan paper have strongly shaped my adult practice. I recommend strongly against percutaneous approaches, and advocate for the scalpel finger bougie approach in adults. However, this has left me quite uncomfortable when caring for young children, where guidelines still mostly suggest percutaneous approaches in children under 8, which is what prompted this entire exercise in the first place. 

Other reviews

Based on a review of similar evidence, Berger-Estilita and colleagues “recommend emergency tracheotomy for FONA in children 8 years or younger….In a CICO crisis, we perform an emergency tracheotomy in children ≤8 years and a scalpel cricothyroidotomy technique in children older than 8 years. Our reasons for choosing the surgical approach in both groups are the higher rate of success and lower risk of severe complications in comparison with percutaneous techniques and the impracticality of cricothyroidotomy in newborns and infants.” (Berger-Estilita 2021)

Overall summary

I agree strongly with the conclusions of Berger-Estilita and colleagues. (Berger-Estilita 2021) I think the evidence in pediatrics is very similar to the evidence in adults. Percutaneous approaches have a higher rate of failure and higher complication rate than surgical approaches. The anatomical data also suggests that a surgical approach is ideal. Although the available data is imperfect, I think it is enough to make a strong recommendation for a surgical approach to front of neck access in all age groups (and therefore a recommendation against percutaneous approaches.)

A few other important notes

In adults, we are used to performing cricothyroidotomy. The larynx is a relatively rigid structure, making it very difficult to cut through the back or side walls while performing the procedure. We will not have that safety cage when performing a tracheostomy on younger patients. “It is important to remember to access the trachea using a vertical incision and to avoid incision of more than 2 tracheal rings, since this drastically reduces the risk of severe and irreparable complications. The risk of complete transection of the trachea can be reduced by avoiding a horizontal Cut.” (Berger-Estilita 2021)

I have seen some people suggest that needle based techniques should be preferred because these are rare events and clinicians will not be adequately trained. If anything, I think the available data suggests that needle based techniques are harder, with a higher failure rate, and a high rate of complication, and therefore need at least as much (if not more) training than surgical approaches. If you manage pediatric airways, you must train on emergency front of neck access. Lack of training should not be used as an excuse to use one technique or another. 

Clinical Summary

For children over the age of 8, I think you can safely proceed exactly as you would for adults. The best approach is a surgical cricothyroidotomy using the scalpel bougie technique.

In children under the age of 8, the cricoid membrane may be too small for a cricothyroidotomy. There is a lot of variability, and no one should use 8 as a strict binary cut-off. Cricothyroidotomy may still be a reasonable approach, but in younger children a surgical tracheostomy should be the first choice for emergency front of neck access in a can’t intubate can’t oxygenate scenario.

Peer Review

Thank you so much to Natalie May, Casey Parker, and Andy Tagg for providing thoughtful feedback and critical appraisal of this article. 

Other Can’t Intubate Can’t Oxygenate FOAMed

The First10EM airway series:

• Emergency Airway Management Part 1: Optimizing the basics
• Emergency Airway Management Part 2: Is the patient ready for intubation?
• Emergency Airway Management Part 3: Intubation – the procedure
• Emergency Airway Management Part 4: Cricothyroidotomy (surgical front of neck access)
• Emergency Airway Management Part 5: Post intubation care

Don’t forget the bubbles: A simplified approach to managing the difficult airway in children

Don’t forget the bubbles: Can’t intubate, can’t oxygenate

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