Mind the gap when performing emergency front-of-neck access

Editor—Plan D of the Difficult Airway Society guidelines¹ on managing the can't intubate can't oxygenate (CICO) scenario states that a 6.0 mm cuffed tracheal tube should be railroaded over the bougie when performing scalpel cricothyroidotomy. During our departmental CICO training sessions, conducted on sheep larynxes, we have noticed that candidates have difficulties railroading the tube over the bougie (Frova Intubating Introducer, Cook Medical Ltd. Limerick, Ireland) when using a 6 mm cuffed tracheal tube. This appears to be caused by the tip of the tube catching on the airway as it is being advanced, because of the large gap between the bougie and the tube (Fig. 1A). We noted that when using a smaller 5 mm tube, railroading appeared to be easier, perhaps because the gap between the bougie and the tube is smaller (Fig. 1B). The resistance to advancing the tube over the bougie was almost negligible when using a size 5 mm Melker cuffed emergency cricothyrotomy catheter (Cook Medical Ltd, Limerick, Ireland), as this tube has a tapered tip that fits snugly over the bougie (Fig. 1C).

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