1. Can’t Intubate Can’t Oxygenate (CICO)
Management of the Critically Obstructed Airway
Session 4: Infraglottic Airway Rescue

2. CICO Plan Part 1 Supraglottic Airway Rescue Part 2 Transition to CICO
Infraglottic Airway Rescue

3. Session aims CICO infraglottic rescue: Algorithm (A Heard) Techniques
Kit
Team-based algorithm

4. Acknowledgements References Dr Andy Heard - Original content
Expert Working Group, RHCE Critically Obstructed Airway Course
References
Heard, R. J. Green and P. Eakins. The Formulation and Introduction of a ‘Can’t Intubate, Can’t Ventilate’ Algorithm into Clinical Practice. Anaesthesia, 2009, 64, pages 601–608.
Dr A.M.B Heard. The Wet Lab-Emergency Airway Management Techniques for the ‘Can’t Intubate, Can’t Oxygenate’ Scenario. March, 2011.

5. CICO algorithm (Heard)
Cannula Cricothyroidotomy or Cannula Tracheotomy
Palpable Neck Airway Anatomy?
Scalpel Finger Cannula
Scalpel Bougie
Melker 5.0 Cuffed Seldinger Technique
Railroad size 6.0 ET Tube
Melker 5.0 Cuffed Seldinger Technique
Consider: Awaken/Other upper airway techniques
FAILURE
Oxygenate and stabilise
SUCCESS NO
YES
CICO
A. M. B. Heard, R. J. Green and P. Eakins. The Formulation and Introduction of a ‘Can’t Intubate, Can’t Ventilate’ Algorithm into Clinical Practice. Anaesthesia, 2009, 64, pg. 601–608.

6. CICO techniques Cannula Cricothyroidotomy Jet oxygenation
Scalpel-bougie
Scalpel-finger-cannula
Melker size 5 cuffed Seldinger conversion to a definitive airway

7. Video – Cannula Cricothyroidotomy

8. Cannula cricothyroidotomy
Equipment

9. Jet oxygenation
You are trying to achieve 2 things with jet oxygenation in the CICO scenario:
Provide oxygen
Prevent/improve airway and alveolar collapse

10. Jet oxygenation Providing oxygen The ManujetTM
Set at 1.0 bar (i.e., Infant setting, in the Yellow Zone) delivers inspiratory flow of approx 250 mls/second
Rapid - O2 oxygen cricothyroidotomy insufflation device (nee Leroy)
Connected to piped O2 at 15L/min, delivers inspiratory flow of approx 250 mls/second

11. Jet oxygenation in a 70kg male
Prevent/improve airway and alveolar collapse
Initial breath
4 seconds duration=approx 1000mL
If there is no response or improvement in SpO2 after 30 seconds, a second jet of 2.0 seconds should be administered.
Whilst applying the first jet, signs of flow must be sought by checking the chest for movement, and listening for flow.

12. Jet oxygenation in a 70kg male
Prevent/improve airway and alveolar collapse
Subsequent breaths
Do not jet again until the SpO2 have dropped by 5% from the maximum achieved with the initial jet.
Subsequent jets should be of 2 seconds duration (Approx 500 mls)

13. Jet oxygenation
IF jetting with the manujet, and there are no signs of expiratory flow
THEN disconnect the manujet to allow some expiration through the cannula (taking care to not inadvertently remove the cannula). This is to ensure hyperinflation causing reduced venous return does not occur.
The Leroy and ENK allow expiration through the cannula and do not require disconnection.

14. Jet oxygenation IF there is no saturation reading for whatever reason
THEN it is safe to insufflate 500 mls every 30 seconds if using a 14g cannnula and Rapid - O2 (Leroy) / ENK (Or disconnected Manujet) even in complete upper airway obstruction.

15. Jet oxygenation
After connecting the cannula to the jet oxygenation device, never let go of the cannula.
Only jet oxygenate whilst watching the chest rise and fall
The rate-limiting step for the frequency of safe jet oxygenation is the patency of the expiratory pathway.

16. CICO algorithm (Heard)
Cannula Cricothyroidotomy or Cannula Tracheotomy
Palpable Neck Airway Anatomy?
Scalpel Finger Cannula
Scalpel Bougie
Melker 5.0 Cuffed Seldinger Technique
Railroad size 6.0 ET Tube
Melker 5.0 Cuffed Seldinger Technique
Consider: Awaken/Other upper airway techniques
FAILURE
Oxygenate and stabilise
SUCCESS NO
YES
CICO
A. M. B. Heard, R. J. Green and P. Eakins. The Formulation and Introduction of a ‘Can’t Intubate, Can’t Ventilate’ Algorithm into Clinical Practice. Anaesthesia, 2009, 64, pg. 601–608.

17. Video - Scalpel-Bougie

18. Scalpel-Bougie
Equipment

19. CICO algorithm (Heard)
Cannula Cricothyroidotomy or Cannula Tracheotomy
Palpable Neck Airway Anatomy?
Scalpel Finger Cannula
Scalpel Bougie
Melker 5.0 Cuffed Seldinger Technique
Railroad size 6.0 ET Tube
Melker 5.0 Cuffed Seldinger Technique
Consider: Awaken/Other upper airway techniques
FAILURE
Oxygenate and stabilise
SUCCESS NO
YES
CICO
A. M. B. Heard, R. J. Green and P. Eakins. The Formulation and Introduction of a ‘Can’t Intubate, Can’t Ventilate’ Algorithm into Clinical Practice. Anaesthesia, 2009, 64, pg. 601–608.

20. Video – Scalpel Finger Cannula

21. MelkerTM conversion
Equipment

22. CICO infraglottic rescue
Key points for success
CICO is recognised
CICO is declared
A plan is activated
Equipment is immediately available
People know their roles

23. ‘Transition’ protocol - CICO
SUPRA-GLOTTIC RESCUE
Continue Supraglottic rescue
Consider waking patient
Review again in 1 min
TRANSITION
Is this a CICO situation? NO
Best attempt at:
Face-mask ventilation?
LMA ventilation?
Endotracheal intubation? AND
Oxygen saturations falling or persistently low?
YES
MOBILISE
RESOURCES
FOR CICO
INFRAGLOTTIC RESCUE
With permission A. Heard and Working group for the Rural Health Continuing Education (RHCE) (Stream 1) ‘Critically Obstructed Airway Workshop’. Contact 2013

24. CAN’T INTUBATE & CAN’T OXYGENATE (CICO) EMERGENCY PROTOCOL
SUPRAGLOTTIC RESCUE – MOBILISE RESOURCES FOR CICO
Is this
a CICO
situation?
Best attempt at supraglottic rescue?
Oxygen saturations persistently low?
Face mask ventilation
LMA ventilation
Endotracheal intubation
Continue supraglottic rescue
Consider waking patient
Review again in 1 min NO
Mobilise resources for CICO
YES
DECLARE CICO
INFRAGLOTTIC RESCUE
Algorithm
ALGORITHM
Resources
1. Cannula-cricothyroidotomy kit
Jet oxygenation tubing
Melker™ kit
Self-inflating bag
2. Scalpel – bougie kit
3. Scalpel – finger – cannula kit
4. Arrest trolley
Team roles
Teamleader
Proceduralist – infraglottic rescue
Proceduralist – supraglotic rescue
Assistant – supraglotic rescue
Assistant – infraglottic rescue
Assistant – equipment set up
Scribe
With permission A. Heard and Working group for the Rural Health Continuing Education (RHCE) (Stream 1) ‘Critically Obstructed Airway Workshop’. Contact: