Written by Aaron Lacy
Patients with potentially difficult airways were oxygenated and ventilated in the operating room via an endotracheal tube in the pharynx, which could be applied to a ‘can’t intubate, can’t oxygenate (CICO)’ scenario.
TTIP for CICO?
The CICO scenario is a shared nightmare for those who manage airways. In this situation, the airway algorithm usually ends with front of neck access. However, there have been case reports of CICO scenarios being rescued by placing an endotracheal tube into the pharynx to provide rescue oxygenation and ventilation. This author group sought to compare mask ventilation with ventilation via a tracheal tube in the pharynx (TTIP). 136 patients scheduled for surgery with potentially difficult airways were recruited into the study and randomized to either 1 minute of mask ventilation followed by 1 minute of TTIP ventilation or the reverse after induction. The overall success of ventilation via TTIP was higher than mask ventilation (93.5% vs 84.6%, p=0.02), and there were no instances of failed TTIP rescue after failed mask ventilation (n= 13/13 successful TTIP rescue).
The technique for TTIP oxygenation and ventilation is pictured below, and requires selecting the right size tube (B), inserting to the right depth (D) , and sealing off the mouth and nares (C).
How will this change my practice?
This is an intriguing method to attempt rescue from a CICO scenario. A key reason for poor outcomes in CICO scenarios is the delay to commit or recognize the need to cut the neck. I can see myself asking a team member who is familiar with the technique to do this while also prepping for cricothyrotomy. This can be taught to advanced airway clinicians but cannot distract from the need to act if a surgical airway is required.
Source
Effectiveness of Ventilation via an Endotracheal Tube in Pharynx Versus a Facemask in Patients With Potentially Difficult Airway: A Randomized, Crossover, and Blind Trial. Anesth Analg. 2025 Feb 1;140(2):280-289. doi: 10.1213/ANE.0000000000007273. Epub 2024 Dec 20. PMID: 39705182
