Improving Cricothyroid Membrane Identification Using Ultrasound in Patients With Anticipated Difficult Airways

Abstract

Purpose: This quality improvement (QI) project aims to improve anesthesia providers’ ability to identify the cricothyroid membrane (CTM) using ultrasound-guided technology during the preoperative phase for patients with increased airway risk. Background: According to the American Society of Anesthesiologists (ASA) closed claims database, difficult airway events are the fourth most common adverse event, leading to severe consequences for patients, families, providers, and institutions (Mark et al., 2018). Between 2000 and 2012, difficult intubation occurred in 35% of cases when one preoperative predictor was present and in 41% of cases when 2 to 6 predictors were present (Joffe et al., 2019). In cases of a difficult airway and failed intubation and oxygenation attempts, accurately identifying the cricothyroid membrane is crucial for performing an emergent cricothyrotomy, the final step in the difficult airway algorithm (Kaye, 2021). However, the literature suggests that anesthetists can only identify the cricothyroid membrane using surface landmarks correctly 30% of the time (Boncyk et al., 2016). Misidentification of the cricothyroid membrane is a significant cause of cricothyrotomy failures and serious complications (You-Ten et al., 2018). Methods: A post-pre-survey was administered after an educational presentation. The educational component included a PowerPoint presentation designed to educate providers on identifying the CTM using ultrasound technology, followed by a hands-on practice session to measure the time required to perform this skill in real-time scenarios. Post-pre-survey results were collected anonymously using a QR code linked to Qualtrics Online Survey software. The aggregated results were evaluated to determine if the educational presentation improved knowledge and intention to change practice in identifying the CTM. Results: Approximately 56% of anesthesia providers (comprised of 60.17% CRNAs and 39.39% RRNAs) at DHR Hospital, completed the survey. The post-pre-survey was analyzed using the Wilcoxon signed rank test, which demonstrated a p-value <0.0001, which indicates a statistical significance in anesthesia providers’ knowledge and intent to change practice. Conclusions: This quality improvement project significantly improved the anesthesia participants’ knowledge and instigated intentions to change practice regarding using ultrasound-guided CTM identification.