Research Progress in Adjacent Anatomical Structure and Location of Cricothyroid Membrane / 中国医学科学院学报

Cricothyroid membrane puncture and incision,the key techniques to save the lives of the patients in the Can't Intubate,Can't Oxygenate (CICO) emergency,need to be mastered by all the airway management staff.However,the decision to carry out cricothyroid membrane puncture or incision is often delayed due to the unfamiliarity with the adjacent anatomical structure of the cricothyroid membrane and the inability to accurately locate the cricothyroid membrane.As a result,serious complications and rescue failure occur.Therefore,airway management staff should be familiar with the adjacent structure and positioning methods of the cricothyroid membrane,so as to improve the success rate of emergency airway rescue,reduce complications,and protect the airway and life safety of the patients.

Modified transcricothyroid electrode recording method for monitoring recurrent laryngeal nerve function during thyroidectomy / 中华内分泌外科杂志

Objective:To study the safety, validity and practicability of the modified trans-cricothyroid needle electrode method for neurmonitoring during thyroidectomy.Methods:115 patients from the Department of Thyroid Surgery in Peking University Shenzhen Hospital scheduled for thyroid surgery were recruited into the group. Two paired needle electrodes were obliquely inserted into the cricothyroid membrane from the angle between the rectus cricothyroid muscle and the inferior margin of thyroid cartilage. The function of recurrent laryngeal nerve (RLN) was localized, exposed and evaluated by standard four-step method (V1-R1-R2-V2) . The vocal cord movement was evaluated by electronic laryngoscope before and after operation, and t-test was used to compare the difference of EMG signal amplitude before and after operation.Results:A total of 130 RLN from 115 patients were recorded effective electromyographic (EMG) signals, including 12 cases of giant goiter with tracheal compression stenosis; 13 cases had repeated adjustments of the position of tracheal intubation electrode during operation, but EMG signals were not satisfactory; 15 cases were with of accidental findings during operation and requiring neurmonitoring, but tracheal intubation electrodes were not used in advance. 75 cases were volunteers. The signals of 3 RLN were lost during operation. On the second day after operation, electronic laryngoscope showed that 2 cases had normal vocal cord movement and 1 case had vocal cord paralysis and no recovery for 6 months follow-up. The EMG signals of other 127 nerves were V1/R1=1857±1718μV/2347±2323μV, V2/R2=1924±1705μV/2450±2345μV. There was no significant difference in EMG signals between pre-operation and post-operation ( t=0.31/0.35, P=0.755/0.725) . The electronic laryngoscope showed normal vocal cord movement before and after operation. During the operation, 2 patients had a little bleeding at the needle electrode insertion point, which stopped after 5 minutes of compression. No electro-acupuncture breakage, infection or local hematoma occurred. Conclusions:The modified trans-cricothyroid needle electrode method had been proved to be safe and feasible for evaluating the function of recurrent laryngeal nerve in thyroid surgery. Besides of unaffected by tracheal conditions, it has good stability, simple implantation and low cost. In thyroid surgery, it can be used as a useful supplement to endotracheal intubation electrode.

Ultrasonido como complemento en el manejo de la vía aérea / Ultrasound as a complement in the management of the airway

OBJECTIVE: To analyze the usefulness of ultrasound (US) as a complement to airway management. An overview of how to obtain a real-time airway ultrasound at the bedside is reviewed and the support for its use is checked against the evidence. MATERIALS AND METHODS: The search was carried out in Pubmed and Medline, yielding 722 articles of interest with different levels of evidence. The literature search was limited to studies conducted in humans, published in English and Spanish between August 2011 and August 2021.35 articles were included in this review. DISCUSSION: The usefulness of ultrasound in the evaluation and management of the airway is analyzed: predictors of difficult airway; cervical airway access; confirmation of tracheal intubation; calculation of endotracheal tube (ETT) size and depth. CONCLUSIONS: Airway ultrasound could be a useful tool for anesthesiologists, emergency physicians and intensivists, which could help improve patient care and safety. However, more research is needed to validate its use.

OBJETIVO: Analizar la utilidad del ultrasonido (US) como complemento al manejo de la vía aérea. Se revisa una descripción general de cómo obtener una ecografía de la vía aérea en tiempo real a la cabecera del paciente y se coteja el respaldo de su utilización con la evidencia. MATERIALES Y MÉTODOS: La búsqueda se realizó en Pubmed y Medline, arrojando 722 artículos de interés con distinto nivel de evidencia. La búsqueda bibliográfica se limitó a estudios realizados en humanos, publicados en inglés y español entre agosto de 2011 y agosto de 2021. Se incluyeron 35 artículos en esta revisión. DISCUSIÓN: Se analiza la utilidad del ultrasonido en la evaluación y manejo de la vía aérea: predictores de vía aérea difícil (VAD); acceso cervical de la vía aérea; confirmación de intubación traqueal; cálculo de tamaño de tubo endotraqueal (TET) y profundidad de éste. CONCLUSIONES: El ultrasonido en la vía aérea podría ser una herramienta útil para anestesiólogos, emergenciólogos e intensivistas, que podrían ayudar a mejorar la atención y la seguridad del paciente. Sin embargo, se necesitan más investigaciones para validar su uso.

Ecografía de vía aérea: en busca de la membrana cricotiroidea / Airway ultrasound: in search of the cricothyoid membrane

Resumen: La ecografía forma parte activa de las herramientas clínicas que tenemos en nuestro arsenal para la valoración de pacientes, y en el manejo de la vía aérea puede permitirnos localizar y marcar la membrana cricotiroidea previo al manejo de un paciente con posible vía aérea difícil (VAD). En manos adiestradas permite identificar la anatomía para poder realizar una cricotiroidotomía con rapidez y precisión en tan sólo 24.3 segundos. En este artículo se muestra una sistemática visual y de rápida localización ecográfica de la membrana cricotiroidea con tiempo estimado inferior a un minuto. Para la exploración se debe usar una sonda lineal de alta frecuencia (5-14 MHz), ya que es probablemente la más adecuada para evaluar estructuras superficiales (dentro de 0-5 cm por debajo de la superficie de la piel). La colocación del operador y del ecógrafo van a depender de la posición del paciente, así en pacientes sentados el operador se coloca detrás de éste y el ecógrafo enfrente de ambos, y en pacientes en decúbito supino el operador se coloca a la cabecera del paciente y el ecógrafo a nivel del codo derecho del mismo.

Abstract: Ultrasonography is an active part of the clinical tools that we have in our arsenal for the evaluation of patients, and in the management of the airway, it can allow us to locate and mark the cricothyroid membrane prior to the management of a patient with a possible Difficult Airway. In trained hands allows the anatomy to be identified so that a cricothyroidotomy can be performed quickly and accurately in just 24.3 seconds. In this article, we show a rapid and visual systematic ultrasound localization of the cricothyroid membrane with an estimated time less than one minute. A linear high-frequency probe (5-14 MHz) should be used for exploration, as it is probably the most suitable for evaluating surface structures (within 0-5 cm below the skin surface). The positioning of the operator and the ultrasound scanner will depend on the patient's position, so in seated patients the operator is placed behind him and the ultrasound scanner in front of both, and in patients in a supine position, the operator is placed at the bedside of the patient and the ultrasound at the level of the right elbow.

Application of tracheotomy combined with thyrocricocentesis and puncture of front tracheal wall in emergency treatment of laryngeal edema in burn patients / 中华烧伤杂志

Objective@#To explore the effect of tracheotomy combined with thyrocricocentesis and puncture of front tracheal wall in emergency treatment of laryngeal edema in patients with burns.@*Methods@#From November 2000 to August 2018, 22 patients with severe burn or extremely severe burn combined with acute laryngeal edema were rescued in the author′s unit, including 18 males and 4 females, aged 17 to 68 years. All patients were complicated with mild inhalation injury or above and more than deep partial-thickness burn to head, face, and neck. From November 2000 to October 2012, simple emergency tracheotomy was performed for 12 cases. From May 2013 to August 2018, tracheotomy combined with thyrocricocentesis and puncture of front tracheal wall was performed for 10 cases. Rescue effect and complication of the two kinds of tracheotomy were recorded. Data were processed with Fisher′s exact probability test.@*Results@#Among the 12 patients treated with simple emergency tracheotomy, 5 cases survived and 7 cases died of suffocation during tracheotomy. Among the 10 patients treated with tracheotomy combined with thyrocricocentesis and puncture of front tracheal wall, 9 cases survived and 1 case died of cardiac arrest caused by arrhythmia. There was statistically significant difference in successful rescue effect between the two kinds of tracheotomy (P<0.05). Among the 14 patients who were successfully rescued, symptoms of insomnia and post-traumatic stress disorder occurred in 12 cases, which were relieved after symptomatic treatment for 14 to 45 d without permanent hypoxic brain damage.@*Conclusions@#In case of loss of the condition of preventive tracheotomy, first aid of acute laryngeal edema of burn patient is very difficult. Tracheotomy combined with thyrocricocentesis and puncture of front tracheal wall is simple and rapid with high successful rate and amelioration of hypoxia, which is an ideal plan for laryngeal edema.

The application of the ultrasonic atomization surface anesthesia with lidocaine for an awake endotracheal intubation during autonomous position -display / 中国基层医药

Objective To explore the feasibility of the ultrasonic atomization surface anesthesia with lido-caine for awake fiberoptic endotracheal intubation in patientsˊautonomous position -display before general anesthesia and to evaluate its advantages.Methods 68 adult patients who needed prone position for elective surgery under general anesthesia were selected and randomly divided into two groups,the control group and the treatment group,each group in 34 cases.In control group patients were received surface anesthesia of cricothyroid membrane puncture.In treatment group,nebulized 2% lidocaine with ultrasonic nebulizer was used for topical anesthesia.Patients lied in the prone position according to their own comfort with the guide of the medical staff in the waking state after an awake fiberoptic endotracheal intubation.The statistics of mean arterial pressure (MAP)and heart rate (HR)were recorded respectively in the basal state(T0),in the time instantly after intubations(T1 ),in the 3 minute after intubations(T2 ) and in the time instantly after the body turning(T3 ).Choking cough response were recorded during endotracheal intubation.Patients were asked the efficacy of surface anesthesia and the tolerance for awake intubation after operation.Results Patients in both two groups completed the whole process smoothly.MAP and HR had no signifi-cant differences between the two groups in the same time point (all P >0.05).There were no statistical significance between the two groups in choking cough response,the time of surface anesthesia and intubation,neither (all P >0.05).Conclusion The surface anesthesia with lidocaine by continuous ultrasonic atomizing inhalation is a good and simple method deserving generalization with plenty merits and is practicable for patients to display position autonomously. This method have the advantages of small operation,it will and can replace cricothyroid membrane puncture.

A Case of Neurilemmoma of the Larynx Excised via Trans-Cricothyroid Membrane Approach without Tracheostomy / 대한이비인후과학회지

Neurilemmoma of the head and neck is not rare in parapharynx, but rare in the larynx. The treatment of choice in neurilemmoma of the larynx is a complete surgical resection. A small size lesion can be removed via an endoscopic approach. For a large size lesion, an external approach, such as the median or lateral thyrotomy, or pharyngotomy, can be more useful. These surgical methods often require preliminary tracheostomy to secure the airway. Through a case of neurilemmoma of the larynx, we present this disease and the treatment course of a patient, who has been successfully treated by surgical excision via trans-cricothyroid membrane approach without tracheostomy. Furthermore, we discuss its symptoms, physical examinations, microscopic features and other options of treatment for laryngeal schwannoma through literature reviews.

Surface Landmarks do not Correspond to Exact Levels of the Cervical Spine: References According to the Sex, Age and Height

OBJECTIVE: A general orientation along the cervical spine could be estimated by external landmarks, and it was useful, quick and less exposable to radiation, but, sometimes it gave reference confusion of target cervical level. The authors reviewed the corresponding between the neck external landmarks and cervical levels. METHODS: Totally 1,031 cervical lateral radiographs of different patients were reviewed in single university hospital. Its compositions were 534 of males and 497 females; 86 of second decades (10-19 years-old), 169 of third decades, 159 of fourth decades, 209 of fifth decades, 275 of sixth decades, and 133 of more than seventh decades (>60 years-old). Reference external landmarks (mandible, hyoid bone, thyroid cartilage, and cricothyroid membrane) with compounding factors were reviewed. RESULTS: The reference levels of cervical landmarks were C2.13 with mandible angle, C3.54 with hyoid bone, C5.12 with thyroid cartilage, and C6.01 with cricothyroid membrane. The reference levels of cervical landmarks were differently observed by sex, age, and somatometric measurement (height) accordingly mandible angle from C1 to C3, hyoid bone from disc level of C2 and C3 to C5, thyroid cartilage from disc level of C3 and C4 to C7, and cricothyroid membrane from C4 to disc level of C7 and T1. CONCLUSION: Surface landmarks only provide general reference points, but not correspond to exact levels of the cervical spine. Intraoperative fluoroscopy ensures a more precise placement to the targeted cervical level.

Development and experimental study of disposable thyrocricoid puncture cannula / 中国基层医药

Objective To investigate the development and application of a simple one-time cricothyroid membrane fast trocar.Methods The cricothyroid membrane puncture ventilation device can be divided into two parts.Respectively was the casing column stabber parts,parts of the cutter head was an isosceles triangle,the column part slightly flat column arc,the rear end was provided with a cylindrical handle,it was also casing inner core.The second was casing parts.Corresponding for columnar needle knife,the rear end of the sleeve had a cylindrical breathing tube interface,can be connected with the breathing bag or ventilator breathing.Material thyrocricoid puncture sleeve was ABS engineering plastic,the first trial was made of three D printer technology.After technology finished the plastic injection machine or machine production were used to make it.Using this instrument 6 healthy dogs were in the cricothyroid membrane puncture.Respectively after operation with 2 days,4 days,7 days,drug treatment did not be taken during this period after they were observed after 6-12 months.Results 6 dogs were thyrocricocentesis cannulation success only once,with no infection.For 6-12 months after extubation,the dogs bark and systemic activity were normal,no abnormal shortness of breath,breathing difficulties and complications were taken placed.Conclusion The research and production of this instrument has been successful,through animal experiments illustrate the use of this device is safe and effective.It has the advantages of convenient operation and no complications.

Retrograde Tracheal Intubation through Cricothyroid Membrane and Cricotracheal Ligament / 대한마취과학회지

Numerous devices and techniques have been devised to facillitate the difficult endotracheal intubation. Percutaneous retrograde intubation was first described by Waters, who used a Tuohy needle to puncture the cricothyroid membrane and an epidural catheter as a guideline in 1963 and many variations on the technique have been described. Failure to intubate 2 male adult patients were planned retrograde tracheal intubation using the cricothyroid membrane. While the patients were awake, and after adequate local anesthesia was obtained, a 16G Medicut was punctured through cricothyroid membrane. After confirmation of the intratracheal position by aspiration of air into syringe, the opening of the Medicut was directed upward foward the larynx and the epidural catheter was inserted through it and advanced retrograde between the vocal cords and into mouth. The epidural catheter tip was passed through the Murphy's eye from outside to inside and out of the tracheal tube. By keeping the catheter taut and coincidently pulling back, the tube was advanced into trachea. Correct positioning of the tracheal tube inside the trachea was confirmed by end-tidal carbon dioxide monitoring and auscultation. Another 2 male adult patients were intubated by using cricotracheal retrograde approach method. We experienced successful retrograde tracheal intubation without significant complications using an epidural catheter through cricothyroid membrane and cricotracheal ligament in 4 male adult patients who were predicted impossibility of simple orotracheal intubation. (Korean J Anesthesiol 1995; 29: 304~309)