Does a patient with a cricothyroidotomy (cricothyrotomy) and being bagged with a Bag Valve Mask (BVM) require mechanical ventilation?

From the Guidelines

A patient with a cricothyroidotomy being bagged with a Bag Valve Mask (BVM) will eventually require mechanical ventilation in most clinical scenarios. While BVM ventilation through a cricothyroidotomy can provide temporary oxygenation and ventilation in an emergency, as noted in the difficult airway society guidelines for management of the unanticipated difficult intubation 1, it is not sustainable for extended periods due to the physical demands on providers and the inconsistency in delivering precise volumes. Mechanical ventilation offers more precise control of respiratory parameters including tidal volume, respiratory rate, FiO2, and PEEP, which are essential for optimal gas exchange and improving patient outcomes in terms of morbidity, mortality, and quality of life.

Some key considerations for the management of a patient with a cricothyroidotomy include:

• The need for a high-pressure source to achieve effective ventilation through a cannula, with an initial inflation pressure of less than 4 kPa (55 psi) to minimize the risk of barotrauma 1.
• The importance of verifying correct cannula placement by aspiration of air into a large syringe before the use of high-pressure ventilation 1.
• The potential advantages and disadvantages of cannula and surgical cricothyroidotomy, including the risk of bleeding and the need for dedicated equipment and trained staff 1.

When transitioning to mechanical ventilation, initial settings may include:

• A tidal volume of 6-8 mL/kg ideal body weight
• A respiratory rate of 12-16 breaths per minute
• A PEEP of 5 cmH2O
• FiO2 adjusted to maintain oxygen saturation above 92% It is also important to consider the smaller diameter of a cricothyroidotomy tube compared to an endotracheal tube, which may require adjustments to ventilator settings to accommodate increased airway resistance.

From the Research

Cricothyroidotomy and Mechanical Ventilation

• A patient with a cricothyroidotomy and being bagged with a Bag Valve Mask (BVM) may require mechanical ventilation, depending on the individual's specific needs and condition 2.
• The use of a self-inflating bag with a cuffed tube inserted through a horizontal scalpel incision can provide sustained adequate ventilation, with a relatively low complication rate compared to needle cricothyroidotomy 2.
• However, the decision to use mechanical ventilation should be based on the patient's overall clinical status, including their ability to maintain adequate oxygenation and ventilation with the current airway management strategy.

Indications for Mechanical Ventilation

• Mechanical ventilation may be indicated in patients with cricothyroidotomy who are unable to maintain adequate oxygenation and ventilation with BVM, or who require prolonged airway support 3.
• The use of lung-protective ventilation strategies, including the use of smaller tidal volumes and lower inspiratory pressures, may be beneficial in patients with acute respiratory distress syndrome or other forms of lung injury 3.
• The decision to initiate mechanical ventilation should be made on a case-by-case basis, taking into account the individual patient's specific needs and clinical status.

Complications and Outcomes

• Cricothyroidotomy is a high-risk procedure, with a significant risk of complications and mortality, particularly in patients with severe trauma or other life-threatening conditions 4, 5.
• The overall mortality rate for patients undergoing cricothyroidotomy is high, ranging from 56.9% to 88.9% in some studies 5.
• However, the use of cricothyroidotomy can be life-saving in emergency situations where other airway management strategies are not possible or have failed.