We appreciate the great interest in our article.1In response to Drs. Dulguerov and Gysin, referring to the question of an uncuffed versus a cuffed canula, although it seems obvious that it is easier to insert a smaller canula, the difference is not as great as expected. However, our aim was to compare two different recognized methods of cricothyroidotomy and not a cuffed versus an uncuffed canula. Although ventilation is not comparable between a 3- and a 5-mm tube, oxygenation may be sufficient during the first few minutes. Neither method is assumed to serve as a long-time device.
Referring to the authors' second question, we do not fully understand the “additional 70%”: The few seconds (10–17) spent were necessary to inflate the cuff, to connect the valve of the breathing bag, and to deliver the first squeeze of the bag. Although one assumes that everything goes faster, we often need more time in the real world—at least in this study.
Regarding the failures (page 9, paragraphs 3 and 4), there is confusion of Drs. Dulguerov and Gysin between accurate placement and injuries: There was a failure rate of 11.8% in group 1 (including the four misplacements) and a failure rate of 16% in group 2. The punctures of the thyroid vessels in group 2 are not listed as failures but as injuries and did not necessarily prevent insertion of the canula.
The “Viennese tracheal dilator” is a piece of our standard equipment. We agree that the authors can use the hook or other device they are familiar with.
We are concerned about the authors' use of the aggressive terms of “frivolous” and “misunderstanding.” Having performed more than 500 cricothyroidotomies in corpses ourselves, we are sure that a mean difference of 1.6 cm in neck circumference is not clinically relevant. If someone has performed more cricothyroidotomies in corpses, we are ready for discussion.
In response to Dr. Price, we could not find a major time difference whether a vertical and horizontal incision was used or only horizontal incisions. The reason for a vertical incision is that in wide necks, it is easier to find the cricothyroid membrane.
With regard to time, Holmes et al. 2state,
A surgical airway was established in 28 of 32 attempts with the use of the rapid four-step technique (88%); the average time elapsed before tube placement was 43 s. Thirty of 32 attempts involving the standard technique (94%) were successful; the average time to tube placement was 134 s (95% confidence interval for a difference of 91 s, 63 to 119; P < 0.001). Complications were identified in 12 attempts involving the standard technique (38%; 1 considered major) and in 12 involving the rapid four-step technique (38%; 3 considered major).
The time varies between 4 and 134 s. Furthermore, this study did not include first ventilation. In addition, major complications occurred very often in this study (38% in both groups). So, the fastest time was accompanied by severe complications.
As stated above, we wanted to compare a standard technique to another commercially available kit. Of course, other methods may be similarly useful. We agree that a device with a larger cuff may require more time; however, if it is possible to shorten the time, allowing adequate oxygenation, even without adequate ventilation, may be valuable for patients in the first few minutes.
We thank Dr. Price for the idea of comparing the cuffed Cook Melker airway with a cuffed tracheostomy tube with the rapid four-step technique. If our time allows, we will investigate these devices in the future.
Again, we thank both readers for their valuable comments and helpful criticism. However, we cannot agree that the clinical applicability of our study is limited.
*Medical University of Vienna, Vienna, Austria. email@example.com