Cadaveric emergency cricothyrotomy training for non-surgeons using a bronchoscopy-enhanced curriculum

Abstract

Background: Emergency cricothyrotomy training for non-surgeons is important as rare "cannot intubate or oxygenate events" may occur multiple times in a provider's career when surgical expertise is not immediately available. However, such training is highly variable and often infrequent, therefore, enhancing these experiences is important.

Research question: Is bronchoscopy-enhanced cricothyrotomy training in cadavers feasible, and what are the potential benefits provided by this innovation for trainees?

Methods: This study was performed during implementation of a new program to train non-surgeon providers on cadaveric donors on our campus. Standard training with an instructional video and live coaching was enhanced by bronchoscopic visualization of the trachea allowing participants to review their technique after performing scalpel and Seldinger-technique procedures, and to review their colleagues' technique on live video. Feasibility was measured through assessing helpfulness for trainees, cost, setup time, quality of images, and operator needs. Footage from the bronchoscopy recordings was analyzed to assess puncture-to-tube time, safety errors, and evidence for a training effect within groups. Participants submitted pre- and post-session surveys assessing their levels of experience and gauging their confidence and anxiety with cricothyrotomies.

Results: The training program met feasibility criteria for low costs (<200 USD/donor), setup time (<30 minutes/donor), and operator needs (1/donor). Furthermore, all participants rated the cadaveric session as helpful. Participants demonstrated efficient technique, with a median puncture-to-tube time of 48.5 seconds. Bronchoscopy recordings from 24 analyzed videos revealed eight instances of sharp instruments puncturing the posterior tracheal wall (33% rate), and two instances of improper tube placement (8% rate). Sharp instruments reached potentially dangerous insertion depths beyond the midpoint of the anterior-posterior diameter of the trachea in 58.3% of videos. Bronchoscopic enhancement was rated as quite or extremely helpful for visualizing the trachea (83.3%) and to assess depth of instrumentation (91.7%). There was a significant average increase in confidence (64.4%, P<0.001) and average decrease in performance anxiety (-11.6%, P = 0.0328) after the session. A training effect was seem wherein the last trainee in each group had no posterior tracheal wall injuries.

Interpretation: Supplementing cadaveric emergent cricothyrotomy training programs with tracheal bronchoscopy is feasible, helpful to trainees, and meets prior documented times for efficient technique. Furthermore, it was successful in detecting technical errors that would have been missed in a standard training program. Bronchoscopic enhancement is a valuable addition to cricothyrotomy cadaveric training programs and may help avoid real-life complications.

Fig 1. Overview of laryngeal and upper tracheal anatomy.

Fig 2

A. Representative bronchoscopic images of scalpel technique. (A) Scalpel insertion into tracheal lumen; (B) Blunt plastic end of scalpel seen in tracheal lumen, enlarging scalpel incision before insertion of bougie; (C) Bougie insertion; (D) Insertion of 6.0 endotracheal tube over bougie. B. Representative bronchoscopic images of Seldinger technique. (A) Needle insertion; (B) Needle appropriately directed inferiorly before wire insertion; (C) Wire advancing through trocar needle; (D) Scalpel enlarging trocar needle incision before dilator insertion; (E) Introducer tip placed over wire; (F) Tracheostomy tube and balloon entering tracheal lumen.

Fig 3. Bronchoscopic capture of complications with depiction of the midpoint of the anterior-posterior depth of the trachea.

(A) Scalpel puncture of posterior tracheal wall at 4 o’clock position; (B) Scalpel puncture of posterior tracheal wall at 7 o’clock position; (C) Needle puncture of posterior tracheal wall at 6 o’clock position; (D) Needle puncture of posterior tracheal wall at 7 o’clock position; (E) Absence of bougie catheter in trachea after being placed lateral to trachea.