Emergency front of neck access in children: a new learning approach in a rabbit model

Abstract

Background: Cannot intubate-cannot ventilate situations in healthy children are uncommon but are often associated with poor outcome. Several airway management algorithms suggest emergency tracheal access. Little agreement exists on how to perform emergency front of the neck access (eFONA) in children <8 yr. We studied the learning curves of clinicians performing simulated paediatric eFONA.

Methods: After watching an instructional video, 50 physicians, from five medical specialties, performed 10 emergency tracheotomies on rabbit cadavers. We analysed their learning curves relative to performance time and concurring injuries.

Results: With an overall success rate of 94%, performance time decreased from 107 s (standard deviation [sd], 45) to 55 s (sd 17) over 10 attempts. The learning curve was steep between the first and the fourth attempts with an 11% decrease in performance time (95% confidence interval [CI], 9-13%; P<0.001) per attempt and then flattened to a 4% (95% CI, 3-5%; P<0.001) decrease per attempt between the fourth and the tenth attempt. Age, years of clinical experience, and sex showed a significant effect on the learning curve, whereas medical specialty and adult eFONA experience did not. The 58% (95% CI, 44-72%) probability for severe injury during the first attempt decreased to 14% (95% CI, 8-20%) at the second attempt. Men were more likely to cause minor injuries than women (P<0.001).

Conclusions: Irrespective of medical specialty, paediatric clinicians acquired the eFONA technique within four attempts and were on average able to establish an airway in <1 min when performing emergency tracheotomy on a paediatric airway simulator.

Clinical trial registration: NCT03576352.

Keywords: airway management; difficult airway; emergency front of neck access; paediatric airway; training.

Copyright © 2019 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.