Indian Journal of Critical Care Medicine

Register      Login



Volume / Issue

Online First

Related articles

VOLUME 24 , ISSUE 3 ( March, 2020 ) > List of Articles


Integration of Pre-intubation Ultrasound into Airway Management Course: A Novel Training Program

Srikar Adhikari, Elaine Situ-LaCasse, Josie Acuña, Steven Irving, Christina Weaver, Kara Samsel, David E Biffar, Mahsaw Motlagh, John Sakles

Keywords : Airway, Cricothyroid membrane, Echocardiography, Emergency medicine, Hemodynamic, Pre-intubation, Ultrasound

Citation Information : Adhikari S, Situ-LaCasse E, Acuña J, Irving S, Weaver C, Samsel K, Biffar DE, Motlagh M, Sakles J. Integration of Pre-intubation Ultrasound into Airway Management Course: A Novel Training Program. Indian J Crit Care Med 2020; 24 (3):179-183.

DOI: 10.5005/jp-journals-10071-23370

License: CC BY-NC 4.0

Published Online: 25-08-2011

Copyright Statement:  Copyright © 2020; The Author(s).


Objectives: To determine the feasibility of integrating pre-intubation ultrasound into airway course and assess emergency medicine (EM) residents’ confidence and comfort level in using ultrasound for pre-intubation hemodynamic stabilization and identifying cricothyroid membrane after the training session. Materials and methods: This is a retrospective study. Pre-intubation ultrasound training was delivered with the following ultrasound components (didactics and hands-on sessions using human models) to EM residents: (1) sonoanatomy and scanning technique to identify cricothyroid membrane and (2) pre-intubation echocardiography for recognition of acute right ventricular failure and pre-intubation hemodynamic stabilization. Results: A total of 56 EM residents participated in this study. Only 21% [95% confidence interval (CI), 10–31%] reported using ultrasound for pre-intubation hemodynamic stabilization. After the training session, 89% (95% CI, 81–97%) reported that ultrasound-based teaching increased their knowledge of pre-intubation hemodynamic stabilization compared with traditional teaching methods. On a scale of 1 (low) through 10 (high), the average comfort level for integrating ultrasound findings into medical decision making for pre-intubation hemodynamic stabilization was 6.8 (95% CI, 6.3–7.3). Seventy-nine percent (95% CI, 68–89%) reported that focused training in airway ultrasound is adequate to identify cricothyroid membrane. On a scale of 1 (low) through 10 (high), the average confidence level for identifying cricothyroid membrane using ultrasound was 6.6 (95% CI, 6.1–7.1). Conclusion: At our institution, we successfully integrated pre-intubation ultrasound into an airway course. Emergency medicine residents had a moderate level of comfort and confidence level using ultrasound for pre-intubation hemodynamic stabilization and identifying cricothyroid membrane after the training session.

  1. Osman A, Sum KM. Role of upper airway ultrasound in airway management. J Intensive Care 2016;4:52. DOI: 10.1186/s40560-016-0174-z.
  2. Singh M, Chin KJ, Chan VW, Wong DT, Prasad GA, Yu E. Use of sonography for airway assessment: an observational study. J Ultrasound Med 2010;29(1):79–85. DOI: 10.7863/jum.2010.29.1.79.
  3. Lun HM, Zhu SY, Liu RC, Gong JG, Liu YL. Investigation of the upper airway anatomy with ultrasound. Ultrasound Q 2016;32(1):86–92. DOI: 10.1097/RUQ.0000000000000163.
  4. Kristensen MS, Teoh WH, Graumann O, Laursen CB. Ultrasonography for clinical decision-making and intervention in airway management: from the mouth to the lungs and pleurae. Insights Imaging 2014;5(2):253–279. DOI: 10.1007/s13244-014-0309-5.
  5. You-Ten KE, Siddiqui N, Teoh WH, Kristensen MS. Point-of-care ultrasound (POCUS) of the upper airway. Can J Anaesth 2018;65(4):473–484. DOI: 10.1007/s12630-018-1064-8.
  6. Plata P, Gaszyński T. Ultrasound-guided percutaneous tracheostomy. Anaesthesiol Intensive Ther 2019;51(2):126–132. DOI: 10.5114/ait.2019.86277.
  7. Siddiqui N, Arzola C, Friedman Z, Guerina L, You-Ten KE. Ultrasound improves cricothyrotomy success in cadavers with poorly defined neck anatomy: a randomized control rrial. Anesthesiology 2015;123(5):1033–1041. DOI: 10.1097/ALN.0000000000000848.
  8. Gottlieb M, Holladay D, Peksa GD. Ultrasonography for the confirmation of endotracheal tube intubation: a systematic review and meta-analysis. Ann Emerg Med 2018;72(6):627–636. DOI: 10.1016/j.annemergmed.2018.06.024.
  9. Adhikari S, Zeger W, Schmier C, Crum T, Craven A, Frrokaj I, et al. Pilot study to determine the utility of point-of-care ultrasound in the assessment of difficult laryngoscopy. Acad Emerg Med 2011;18(7):754–758. DOI: 10.1111/j.1553-2712.2011.01099.x.
  10. Palkar A, Narasimhan M, Greenberg H, Singh K, Koenig S, Mayo P, et al. Diaphragm excursion-time index: a new parameter using ultrasonography to predict extubation outcome. Chest 2018;153(5):1213–1220. DOI: 10.1016/j.chest.2018.01.007.
  11. Kristensen MS, Teoh WH, Rudolph SS. Ultrasonographic identification of the cricothyroid membrane: best evidence, techniques, and clinical impact. Br J Anaesth 2016;117(Suppl 1):i39–i48. DOI: 10.1093/bja/aew176.
  12. Altun D, Ali A, Koltka K, Buget M, Çelik M, Doruk C, et al. Role of ultrasonography in determining the cricothyroid membrane localization in the predicted difficult airway. Ulus Travma Acil Cerrahi Derg 2019;25(4):355–360. DOI: 10.14744/tjtes.2019.65250.
  13. Mallin M, Curtis K, Dawson M, Ockerse P, Ahern M. Accuracy of ultrasound-guided marking of the cricothyroid membrane before simulated failed intubation. Am J Emerg Med 2014;32(1):61–63. DOI: 10.1016/j.ajem.2013.07.004.
  14. Higgs A, McGrath B, Goddard C, Rangasami J, Suntharalingam G, Gale R, et al. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth 2018;120(2):323–352. DOI: 10.1016/j.bja.2017.10.021.
  15. Cabrini L, Landoni G, Baiardo Redaelli M, Saleh O, Votta CD, Fominskiy E, et al. Tracheal intubation in critically ill patients: a comprehensive systematic review of randomized trials. Crit Care 2018;22(1):6. DOI: 10.1186/s13054-017-1927-3.
  16. Quintard H, l’Her E, Pottecher J, Adnet F, Constantin JM, De Jong A, et al. Experts’ guidelines of intubation and extubation of the ICU patient of French Society of Anesthesia and Intensive Care Medicine (SFAR) and French-speaking Intensive Care Society (SRLF): in collaboration with the pediatric Association of French-speaking Anaesthetists and Intensivists (ADARPEF), French-speaking Group of Intensive Care and Paediatric emergencies (GFRUP) and Intensive Care Physiotherapy Society (SKR). Ann Intensive Care 2019;9(1):13. DOI: 10.1186/s13613-019-0483-1.
  17. Aslani A, Ng S-C, Hurley M, McCarthy KF, McNicholas M, McCaul CL. Accuracy of identification of the cricothyroid membrane in female subjects using palpation: an observational study. Anesth Analg 2012;114(5):987–992. DOI: 10.1213/ANE.0b013e31824970ba.
  18. Tips and Tricks: Intubation in Right Heart Failure,, accessed on July 12, 2019.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.