Melker Cricothyrotomy Kit: An Altemativ e to the Surgical ...€¦ · the Melker kit, leaving unanswered the question of whether the cuffed version of the airway catheter sig-nificantly

Annals ofOiology. Rhinology & Luryngoltigy 114(7):525-528.© 2{H)5 Annals Publishing Company. All rights reserved.

Melker Cricothyrotomy Kit:An Altemative to the Surgical Technique

Jeremy S. Melker, MD; Andrea Gabrielli, MD

Emergent cricothyrotomy is n potentially lifesaving procedure centra! to acute airway algorithms. In most cases in whichcricothyrotomy is indicated, the acuteness of the airway precludes subspecialty consultation before performance of theprocedure. The academic environment is an exception, in which the responsibility of securing a "difticuU" cricothyroidairway may fall uponjunior otolaryngology residents. Described here is the use of the Melker Emergency CricothyrotomyKit. a prepackaged kit that uses a wire-guided percutaneous dilational technique (the Seldinger technique) and a proce-dure-specific polyvinylchloride airway catheter. The wire-guided technique may add a margin of safety for a relativelyinexperienced resident performing cricothyrotomy. Furthermore, a newly released version of the kit includes instrumentationfor insertion of the Melker airway catheter by the classic surgical technique in addition to that required for the Seldingertechnique, which may enable even a seasoned surgeon to secure the airway faster and more safely.

Key Words: alternative, cricothyrotomy, technique.

Emergent cricothyrotomy is a potentially lifesav-ing procedure central to acute airway algorithms. Inmost cases in which cricothyrotomy is indicated, theacuteness of the airway precludes subspecialty con-sultation before performance of the procedure. In-stead, the otolaryngologist may be consulted onlyafter the airway has been secured, for conversion totracheostomy. The academic environment is an ex-ception, in which the responsibility of securing a "dif-ficult" cricothyroid airway may fall upon junior resi-dents. What results is a unique situation in which rela-tively inexperienced surgeons are called upon to per-form a critical procedure that they have had little op-portunity to practice.

As an otolaryngology resident, the first author hasfound that a prepackaged cricothyrotomy kit that in-volves a wire-guided percutaneous dilational tech-nique (Melker Emergency Cricothyrotomy Kit. CookCritical Care, Bloomington, Indiana) has been use-ful on four occasions in rapidly and successfully es-tablishing a cricothyroid airway. The kit has also beenused by two other current otolaryngology residentsin the same department on three separate occasionswith success. Central to the kit is a procedure-spe-cific polyvinylchloride airway catheter, now avail-able in a cuffed version (Fig 1). Although initiallydeveloped to decrease complications associated with

paramedics' attempts at cricothyrotomy, the kit usesthe familiar Seldinger technique, which has made itincreasingly popular among emergency departmentand critical care physicians, anesthesiologists, andmilitary personnel worldwide. However, in the fieldsof otolaryngology and general surgery, in which theprinciples of surgical cricothyrotomy are ingrained,few are aware of the wire-guided technique.

The steps involved in wire-guided insertion of the

Fig 1. Melker Emergency Cricothyrotomy Kit's poly-vinylchloride airway catheter, shown in its cuffed ver-sion. (Reproduced with permission from Cook CriticalCare, Bloominjiton, Indiana.)

From the Departments of Ololaryngology (Melker), Anesthesiology (Gabrielli), and Surgery (Gabrielli), University of Florida Col-lege of Medicine. Gainesville. Florida. The first author's familiarity with the technique presented conies from the fact that his father,Richard J. Melker, MD. PhD. Is the inventor of ihe kit. The University of Florida assigned rights to the technology to Cook CriticalCare, Bloomington, Indiana. Although his father receives royalties from the sale of the device, the author has no direct financialrelationship with Cook Critical Care.Correspondence: Jeremy S. Melker. MD. Gainesville Otolaryngology Group. 6821 NW 11th PI. Gamesville. FL 32605.

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526 Melker & Gabrielli, Melker Cricothyrotomy Kit

—Th>niid Cartilage

—Access SiteCrkoid Carillagc

Fig 2. Schematic representation of steps involved in wire-guided insertion of cuffed Melker airway catheter. A) Anatomiclandmarks. B) Limited skin incision. C) Advancement of 18-gauge needle through incision and cricothyroid membrane untilfree air return is encountered on suction. D) Placement of guidewire through 18-gauge needle. E) Removal of 18-gaugeneedle, leaving guidewire in place. F) Advancement of dilator-airway catheter assembly over guidewire. G) Inflation ofcatheter cuff after removal of guidewire and dilator. (Reproduced witb permission from Cook Critical Care.)

cuffed Melker airway catheter (Fig 2) are pre.sented,logelher with a representative case report. Our pur-pose is to present the technique as a relatively safeand effective altemative to standard surgical cricothy-rotomy.

CASE REPORTA 67-year-old man had a history of recurrent

TlN2a squamous cell carcinoma of the right retro-molar trigone after radiotherapy. After uneventful sal-vage surgery including composite resection, rightmodified radical neck dissection, and right pectora-lis major flap reconstruction, the patient was di.s-charged home on postoperative day 7. At the time ofdischarge, the patient continued to receive nutritionvia a nasogastric tube. The patient returned to theemergency department on postoperative day 10 inrespiratory distress. At the time of presentation, intra-oral examination demonstrated tenacious, peanut but-ter-like secretions filling the oral cavity and adher-ent to the na.sogastric tube and pectoralis flap sutureline. Before attempts at debridetnent of the oral cav-ity could be initiated, acute decompensation occurredwith complete upper airway obstruction.

Attempts to establish mask ventilation were un-successful, and a precipitous decline in oxygen satu-ration to approximately 15% was noted. At the onset

of the episode, a Melker kit was obtained and a wire-guided cricothyrotomy was performed in less than 1minute. This procedure was uneventful despite sig-nificant postsurgical edema and the presence of thepectoralis major flap. The patient briefly became un-responsive, but demonstrated no bradycardia. hypo-tension, or arrhythmia. His oxygen saturation quicklyreturned to 100% while he was breathing room airafter the procedure, and he immediately became re-sponsive with a nonfocal neurologic examination.

The patient was taken emergently to the operatingroom for debridement of the upper airway and con-version to tracheostomy, at which time placement ofthe airway catheter through the cricothyroid mem-brane without cartilaginous injury was confirmed andthe pectoralis flap was noted to be intact. The pa-tient did well after the procedure and was dischargedhome after conversion to a fenestrated tracheostomytube.

DISCUSSIONEmergent cricothyrotomy. when performed in the

appropriate clinical setting, can be a lifesaving pro-cedure. Even though a scalpel and an endotrachealtube may be all that is required to establish a crico-thyroid airway, the number of alternative techniquesthat have been proposed is testament to tbe fact that

Metker & Gabrielli. Melker Cricothxrotamv Kit 527

Fig 3. Newly released Melker Uni-versal Cricothyrolomy CatheterSei contains cuffed airway cath-eter and inslrumentation for bothwire-guided and surgical tech-niques. (Reproduced with permis-sion from Cook Critical Care.)

the surgical technique may not always be easy.In the only published study to specifically com-

pare the Melker kit to surgical cricolhyrotomy, Chanet al' examined the performance of 15 emergencydepartmeni physicians in a randomized crossover trialusing a fresh cadaver model. No stati.stically signifi-cant differences were noted between the two tech-niques for accuracy of airway placement, mean timeto completion of procedure, or complication rate. Themean skin incision length was statistically shorterwith the Melker kit: 0.53 cm (95% confidence inter-val. 0.46 to 0.60 cm), as compared to 2.53 cm (95%confidence interval, 2.04 to 3.01 cm) for the surgicaltechnique (p< .001). Whether this is a clinically sig-nificant difference with regard to bleeding could notbe determined from this cadaver study. Notably, atthe conclusion of the study, 14 of 15 participants(93.3%) stated that they preferred the Melker kit tothe standard surgical technique.

In another study, which compared the Melker kitand three other prepackaged emergency airway ac-cess devices in a human patient simulator, the inves-tigators judged both the Melker kit and the Quick-trach device to be 100% successful in achieving anadequate airway within their acceptable time limits.-In 10 trials, the mean time to achieve a patent airwaywith the Melker kit was 38 seconds (range, 30 to 54seconds) and the mean time taken to achieve a par-tial pressure of oxygen in the simulator "lung" of>I3.3 kPa was 130 seconds (range, 111 to 180 sec-onds). With the Quicktrach device, the times were51 seconds (range, 42 to 73 seconds) and 58 seconds(range, 50 to 86 seconds), respectively. Two cases oftrauma to the posterior tracheal wall, as evidencedby puncture marks or tears in the simulator, werenoted with all four kits tested. The authors concluded

that botb the Melker kit and tbe Quicktrach devicewere technically reliable in the human patient simu-lator, and that tbe Quicktrach provided the fastestand most effective means of reestablishing oxygena-tion. Notably, the study used the uncuffed version ofthe Melker kit, leaving unanswered the question ofwhether the cuffed version of the airway catheter sig-nificantly reduces the time to restore oxygenation.

Since its release in the early 1990s, the Melker kithas been successfully used by the United States andIsraeli armies, among others. A "special operations"version is packaged without a guidewire and withthe airway catheter preloaded on the dilator. Becauseof tbe success of the military' version, and cognizantof differences in surgeon preference. Cook CriticalCare has recently released the Melker Universal Cri-cotbyrotomy Catheter Set. The set includes a cuffedairway catheter flanked by instruments needed to per-form both the Seldinger and the surgical techniques(Fig 3). The kit adds a curved blunt dilator, a tra-cheal hook, and a Trousseau tracbeal dilator for thosewbo prefer the surgical technique.

For the relatively inexperienced physician, the Sel-dinger technique may add a margin of safety by al-lowing confirmation of intra-airway placement be-fore advancement of the airway catheter. Further-more, the guidewire ensures that the vector of forceapplied during airway catheter insertion remains cen-tered in the cricothyroid membrane, potentially de-creasing the risk of extra-airway placement. Again,the added step of guidewire placement did not pro-long the time to securing the airway in the cadavermodel.'

The kit's tailored dilator-airway catheter assem-bly may offer advantages over standard tracheostomy

528 Melker & Gahrielli. Melker Cricothyrolomy Kit

or endotracheal tubes. Tbe dilator's tip is smaller thantbe obturators of tracheostomy tubes, and the airwaycatheter is softer than the tubes themselves. This fea-ture may lead to less traumatic insertion; in the freshcadaver model, even tracheostomy tubes that hadbeen properly placed through the cricothyroid mem-brane sometimes caused cartilaginous injury.' At thesame time, the dilator-airway catheter assembly ismore robust than soft endotracheal tubes, which may

buckle on attempts at placement.

With the recent release of the Universal CatheterSet, the Melker Emergency Cricothyrotomy Kit hasbeen further refined for its specific application. Withail instruments immediately at hand, even the sea-soned surgeon who prefers to forgo the Seldinger tech-nique may be able to secure tbe airway faster andmore safely using the kit.

REFERENCES1. Chan TC. Vilke GM. Bramwell KJ. Davis DR Hamilton

RS. Rosen P. Comparison of wire-guided cricothyrotomy ver-sus standard surgical cricothyrotomy technique. J Emerg Med1999:17:957-62.

2. Vadodaria BS. Gandhi SD, Mclndoe AK. Comparison offour different emergency airway aceess equipment sets on ahuman patient simulator. Anaesthesia 2004;59:73-9.

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