The authors thank the Azienda Ospedaliera Universitaria Maggiore della Carit&#224;, Novara, for its help.

The animal anatomic segments, normally intended for human consumption, were purchased at a local butcher&#39;s shop ( Figure 1). Therefore, they could be easily transported and stored with no specific restrictions or sanitary regulations.
1. Cleaning the swine upper airways
<ol>
	<li>With the help of a dissecting scalpel, Adson forceps and Metzembaum scissors, clean the trachea and larynx from excess surrounding tissues (lateral muscles, excess of tongue), by cutting and dissecting.</li>
	<li>Remove tissue until the larynx cartilages are almost exposed and the tracheal rings are easy to palpate.</li>
	<li>Remove the hyoid bone and surrounding soft tissues: find the eminence of the greater horn and follow the horn with the blade, then pass to the contralateral one and repeat the same operation until the whole part is removed.</li>
	<li>Cut the trachea at its distal side approximatively at 15 cm from the larynx using a dissecting knife. 
	NOTE: The removed part, composed by mediastinal organs, will be used for the next step in the procedure.</li>
</ol>
2. Preparing the thyroid
<ol>
	<li>Take the previously discarded mediastinal organs and search for the thymus. 
	NOTE: The thymus is usually located on the frontal portion of the mediastinum right over the right atrium. Adult pigs may have a very small thymus.</li>
	<li>With dissecting forceps, detach the thymus from the surrounding tissue.</li>
	<li>Carve the just obtained pig thymus into a butterfly shape to recreate a simulated thyroid.
	<ol>
		<li>With a dissecting knife, cut a flat slice of thymus 1.5 cm thick.</li>
		<li>With Metzembaum scissors, cut the slice in a butterfly shape with two 3 cm x 2 cm lobes connected by a hystmus. 
		NOTE: The overall dimensions of the thyroid should be 3 cm long, 6 cm large and 1.5cm thick.</li>
	</ol>
	</li>
</ol>
3. Suturing the thyroid to the tracheal wall.
NOTE: For the next step, use the previously prepared upper airways and the simulated thyroid.
<ol>
	<li>Place the simulated thyroid between the first and third tracheal ring.</li>
	<li>Take a needle holder and surgical forceps. Grab a 2/0 silk suture.</li>
	<li>Suture the thyroid with two lateral horizontal mattress stitches passing in each lobe and in the lateral portion of the trachea. 
	NOTE: The horizontal mattress stitch wraps more tissue than the normal stitch. This is important when suturing soft tissues, as pig thymus, that tends to tear up.</li>
	<li>Pass the needle only in the superficial part of the trachea to prevent the possibility of seeing the thread in the tracheal lumen if performing fibroscopy. 
	NOTE: Identification and preservation of the thyroid gland avoiding postoperative bleeding represent crucial surgical steps during tracheotomy procedure.</li>
</ol>
4. Preparing the esophagus
<ol>
	<li>Use the esophagus, which is located on the backside of the trachea, to simulate the neck fascia and muscles.</li>
	<li>Remove the esophagus from its larynx connection by cutting it with a scalpel or with surgical scissors.</li>
	<li>Cut and open the esophagus on its length with surgical scissors.</li>
	<li>Hold the muscle and mucosa with toothed forceps to help the cutting procedure. The result of this operation will be a rectangle of muscle covered by esophagus mucosa.</li>
</ol>
5. Suturing the esophagus to the trachea
<ol>
	<li>Place the just obtained layer of muscles on top of the trachea and larynx with the mucous membrane face up. The aim is to cover the larynx: from the thyroid cartilage summit to the last tracheal rings.</li>
	<li>Suture the opened esophagus with at least 6 simple stitches: 
	One on the proximal side of the model, on the summit of the Thyroid cartilage. 
	One on the distal side of the preparation, on the frontal portion of the last tracheal ring. 
	At least one on each side of the trachea. 
	One on each side of the lower lateral portion of the thyroid cartilage where cricothyroid muscles are.</li>
	<li>Mark a line on the esophagus mucosa with white India ink to simulate the linea alba. 
	NOTE: Identification and proper dissection through the linea alba is an important step during tracheotomy procedure (Figure 2).
	<ol>
		<li>To do so, use white India ink and an insulin syringe.</li>
		<li>Withdraw some ink and then track a line on the simulated fascia by scratching it with the needle while spilling little drops of ink.</li>
		<li>Remove the excess of ink gently with a small swab.</li>
	</ol>
	</li>
</ol>
6. Preparing the foam base for the model
<ol>
	<li>Cut a square of foam of 3 cm x 10 cm x 15 cm.</li>
	<li>Shape a furrow 2.5 cm large and 10 cm long in the center of the foam.
	<ol>
		<li>To do this, fold half of the square of foam so that it creates a longitudinal hump on one side.</li>
		<li>Cut 1 cm of the hump off all its length with scissors.</li>
		<li>Unfold the foam square and trim the just formed furrow smoothly.</li>
	</ol>
	</li>
</ol>
7. Stapling the model to the wooden tablet
<ol>
	<li>Take a wooden tablet of the same dimensions of the foam.</li>
	<li>Place the foam square on the wooden tablet and insert the model in the foam furrow.</li>
	<li>With a wood stapler, place a clip on the end of the trachea, on the remaining lateral muscles of the thyroid cartilage and on the epiglottis.</li>
</ol>
8. Preparing the skin
<ol>
	<li>Take the pig skin collected from the butcher shop and cut it in a square shape big enough to cover the whole model. Usually, a square of 25 cm x 20 cm is sufficient.</li>
	<li>Cut the skin with a dissecting knife and cover the model with it.</li>
</ol>
9. Stapling the skin to the wooden tablet
<ol>
	<li>Take the stapler and fix the skin to the tablet with about 10-15 clips. Place them on the vertical sides of the tablet</li>
	<li>Trim the excess skin on each side of the tablet with the help of a knife.</li>
	<li>Use cocker forceps to firmly hold the skin to allow a safer cutting.</li>
</ol>

<ol>
	<li>Langvad, S., Hyldmo, P. K., Nakstad, A. R., Vist, G. E., Sandberg, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Emergency+cricothyrotomy--a+systematic+review.">Emergency cricothyrotomy--a systematic review.</a> Scandinavian Journal of Trauma, Resuscitation And Emergency Medicine. 21, 43 (2013).</li><li>Ben-Nun, A., Altman, E., Best, L. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Emergency+percutaneous+tracheostomy+in+trauma+patients:+an+early+experience.">Emergency percutaneous tracheostomy in trauma patients: an early experience.</a> Annals of Thoracic Surgery. 77 (3), 1045-1047 (2004).</li><li>Cook, T. M., Woodall, N., Harper, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Major+complications+of+airway+management+in+the+UK:+results+of+the+Fourth+National+Audit.+Project+of+The+Royal+College+of+Anaesthetists+and+the+Difficult+Airway+Society.">Major complications of airway management in the UK: results of the Fourth National Audit. Project of The Royal College of Anaesthetists and the Difficult Airway Society.</a> British Journal of Anaesthesia. 106, 632-642 (2011).</li><li>Das, B., Nasreen, F., Haleem, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+&amp;#34;cannot+ventilate,+cannot+intubate&amp;#34;+situation+in+a+patient+posted+for+emergency+surgery+for+acute+intestinal+obstruction.">A &amp;#34;cannot ventilate, cannot intubate&amp;#34; situation in a patient posted for emergency surgery for acute intestinal obstruction.</a> Anesthesia Essays and Research. 7 (1), 140-141 (2013).</li><li>Bann, S., Khan, M. S., Datta, V. K., Darzi, A. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Technical+performance:+relation+between+surgical+dexterity+and+technical+knowledge.">Technical performance: relation between surgical dexterity and technical knowledge.</a> World Journal of Surgery. 28 (2), 142-146 (2004).</li><li>Lesko, D., Showmaker, J., Ukatu, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Declining+Otolaryngology+Resident+Training+Experience+in+Tracheostomies:+Case+Log+Trends+from+2005+to+2015.">Declining Otolaryngology Resident Training Experience in Tracheostomies: Case Log Trends from 2005 to 2015.</a> Otolaryngology - Head and Neck Surgery. 156 (6), 1067-1071 (2017).</li><li>Patel, H. H., Siltumens, A., Bess, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+decline+of+tracheotomy+among+otolaryngologists:+a+14-year+review.">The decline of tracheotomy among otolaryngologists: a 14-year review.</a> Otolaryngology - Head and Neck Surgery. 152, 465-469 (2015).</li><li>Maran, N. J., Glavin, R. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Low-to+high-fidelity+simulation+-+a+continuum+of+medical+education?.">Low-to high-fidelity simulation - a continuum of medical education?.</a> Medical Education. 37 (1), 22-28 (2003).</li><li>Lippert, A., Dieckmann, P. G., Oestergaard, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simulation+in+medicine.">Simulation in medicine.</a> Notfall Rettungsmedizin. 12 (2), 49 (2009).</li><li>Beaubien, J. M., Baker, D. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+use+of+simulation+for+training+teamwork+skills+in+health+care:+how+low+can+you+go?.">The use of simulation for training teamwork skills in health care: how low can you go?.</a> Quality &amp; Safety in Health Care. 13 (1), 51-56 (2004).</li><li>Terragni, P., Mascia, L., Faggiano, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+training+approach+in+endoscopic+percutaneous+tracheostomy+using+a+simulation+model+based+on+biological+tissue.">A new training approach in endoscopic percutaneous tracheostomy using a simulation model based on biological tissue.</a> Minerva Anestesiologica. 82 (2), 196-201 (2016).</li><li>Jayaraman, V., Feeney, J. M., Brautigam, R. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+use+of+simulation+procedural+training+to+improve+self-efficacy,+knowledge,+and+skill+to+perform+cricothyroidotomy.">The use of simulation procedural training to improve self-efficacy, knowledge, and skill to perform cricothyroidotomy.</a> The American Journal of Surgery. 80 (4), 377-381 (2014).</li><li>Takayesu, J. K., Peak, D., Stearns, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cadaver-based+training+is+superior+to+simulation+training+for+cricothyrotomy+and+tube+thoracostomy.">Cadaver-based training is superior to simulation training for cricothyrotomy and tube thoracostomy.</a> Internal and Emergency Medicine. 12 (1), 99-102 (2017).</li><li>Aho, J. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Every+surgical+resident+should+know+how+to+perform+a+cricothyrotomy:+an+inexpensive+cricothyrotomy+task+trainer+for+teaching+and+assessing+surgical+trainees.">Every surgical resident should know how to perform a cricothyrotomy: an inexpensive cricothyrotomy task trainer for teaching and assessing surgical trainees.</a> Journal of Surgical Education. 72 (4), 658-661 (2015).</li><li>Holak, E. J., Kaslow, O., Pagel, P. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Who+teaches+surgical+airway+management+and+how+do+they+teach+it?+A+survey+of+United+States+anesthesiology+training+programme.">Who teaches surgical airway management and how do they teach it? A survey of United States anesthesiology training programme.</a> Journal of Clinical Anesthesia. 23 (4), 275-279 (2011).</li><li>Makowski, A. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+Survey+of+Graduating+Emergency+Medicine+Residents'+Experience+with+Cricothyrotomy.">A Survey of Graduating Emergency Medicine Residents' Experience with Cricothyrotomy.</a> The Western Journal of Emergency Medicine. 14 (6), 654-661 (2013).</li><li>Tonui, P. M., Nish, A. D., Smith, H. L., Letendre, P. V., Portela, D. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound+Imaging+for+Endotracheal+Tube+Repositioning+During+Percutaneous+Tracheostomy+in+a+Cadaver+Model:+A+Potential+Teaching+Modality.">Ultrasound Imaging for Endotracheal Tube Repositioning During Percutaneous Tracheostomy in a Cadaver Model: A Potential Teaching Modality.</a> Ochsner Journal. 14 (3), 335-338 (2014).</li><li>Netto, F. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+porcine+model+for+teaching+surgical+cricothyridootomy.">A porcine model for teaching surgical cricothyridootomy.</a> The journal of the Brasilian College of Surgeons. 42 (3), 193-196 (2015).</li><li>Varaday, S. S., Yentis, S. M., Clarke, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+homemade+model+for+training+in+cricothyrotomy.">A homemade model for training in cricothyrotomy.</a> Anaesthesia. 59, 1012-1015 (2004).</li><li>Bryant, R. J., Morgan, M. H., Youngquist, S. T., Fix, M. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Edible+Cricothyrotomy+Model:+A+Low-Cost+Alternative+to+Pig+Tracheas+and+Plastic+Models+for+Teaching+Cricothyrotomy.">Edible Cricothyrotomy Model: A Low-Cost Alternative to Pig Tracheas and Plastic Models for Teaching Cricothyrotomy.</a> Journal of Education and Teaching Emergency Medicine. 2 (1), (2017).</li><li>Fikkers, B. G., van Vugt, S., van der Hoeven, J. G., van den Hoogen, F. J., Marres, H. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Emergency+cricothyrotomy:+a+randomised+crossover+trial+comparing+the+wire-guided+and+catheter-over-needle+techniques.">Emergency cricothyrotomy: a randomised crossover trial comparing the wire-guided and catheter-over-needle techniques.</a> Anaesthesia. 59 (10), 1008-1011 (2004).</li><li>Fiorelli, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+home-made+animal+model+in+comparison+with+a+standard+manikin+for+teaching+percutaneous+dilatational+tracheostomy.">A home-made animal model in comparison with a standard manikin for teaching percutaneous dilatational tracheostomy.</a> Interactive Cardiovascular and Thoracic Surgery. 20, 248-253 (2015).</li><li>. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Cricotracheotomy Trainer Manikin - Global Technologies &amp;#34;Simulators for Education&amp;#34;. , (2019).</li></ol>

The authors have nothing to disclose.

The manufactured low-cost and high-fidelity bench-model simulated the human neck and enabled practice of cricothyrotomy, percutaneous and surgical tracheostomy. The designed survey filled by senior ENT physicians and anesthesiologists evaluated the extent to which the model replicates the physical characteristics of the neck and its suitability for training the given subglottic airway access procedures.
Several home-made models or simulators have been reported and we tried to overcome their li...

Difficult airway management is a critical skill for every physician dealing with critical, ill, and emergency patients. A review published in 2013 estimates that the incidence numbers of &#39;cannot ventilate, cannot intubate&#39; situations with the use of surgical airway techniques vary from 0 to 18.5%1.
Tracheostomy is one of the oldest surgical procedures and is extensively used as the method of choice for subglottic airway access for patients requiring prolonged artificial ventilation. Originally performed in the operating theater, it has become a routine practice bedside at many hospitals, especially in the intensive care unit (ICU)2. Several types of techniques have been described, including surgical (ST) and percutaneous tracheostomy (PCT). Tracheostomy has been widely reported to have high complication rates.A national audit reports that 50% of airway-related deaths or brain damage in critical care are caused by tracheostomy complications3.&#160;Often, the high complication rates reflect lack of familiarity with the technique and inadequate training.
Another way to subglottically access the airways is to perform a cricothyrotomy (CT), which has been broadly recommended as a strategy to deal with &#39;cannot ventilate, cannot intubate&#39;&#160;&#160;situations in both prehospital and intra-hospital care4. Being a fast and potentially lifesaving fallback maneuver in the patients with a failed airway, clinicians responsible for airway management must be familiar with the technique. Practice and training therefore play a pivotal role since its success is dependent on the operator&#39;s dexterity5. However, due to improvements in airway management in the past decades, a decline in the need for tracheotomy and emergency surgical airways was observed. This has resulted in a lack of clinical experience and decreased exposure to this life-saving technique, which may negatively affect the quality of procedures and ultimately the safety of patients6,7.
Nowadays, simulation is a common and effective teaching method to train medical and surgical skills, especially for novices who are learning new abilities8,9. Simulation allows to recreate a clinical procedure or situation, providing trainees with first-hand exposure to clinical scenario and complex techniques while eliminating the risk for patients10.
A broad variety of simulators, from virtual reality to animal models, have been used in training surgical airway management11,12,13,14. Practice on models and mannequins is reported to be the most common form of instruction for Anesthesiology and Emergency Medicine residents15,16. Cadavers have also been used to teach neck anatomy and the procedural skills17. However, the cost of all these options are sometimes prohibitive and can pose ethical and moral constrains and challenges. Low cost simulators have also been described and suggested for educational purposes but have not been used to train all the subglottic airway access procedures.
In this manuscript, we describe how to manufacture an easily-made, low-cost and high-fidelity bench-model that simulates the human neck to perform cricothyrotomy, percutaneous and surgical tracheostomy and its evaluation. The main aim was to design an easy-to-make model with readily and regularly available materials so that anyone can simply emulate and reproduce it. The overall time to assemble the model was about 15 minutes and the cost estimate was approximately of 10&#8364; including resources and manufacturing (20&#8364;/h).

<table border="0" cellpadding="0" cellspacing="0" style="width:1171px;" width="1168">
	<tbody>
		<tr height="20">
			<td height="20" style="height:20px;width:223px;">Foam&#160;</td>
			<td style="width:475px;">BRICOSELF ITALIA, vercelli&#160;</td>
			<td style="width:123px;">na</td>
			<td style="width:351px;">Used to stabilyze the model on the wooden tablet</td>
		</tr>
		<tr height="18">
			<td height="18" style="height:19px;width:223px;">Insuline Syringe</td>
			<td style="width:475px;">na</td>
			<td style="width:123px;">na</td>
			<td>Used to draw linea alba with india ink</td>
		</tr>
		<tr height="18">
			<td height="18" style="height:19px;width:223px;">Pig Esophagus</td>
			<td style="width:475px;">Butcher shop (Il mercato carni, di Dutto Srl. - 28100, Novara (Italy)</td>
			<td style="width:123px;">na</td>
			<td>Wet material used to build the simulated muscular layers and fascia</td>
		</tr>
		<tr height="18">
			<td height="18" style="height:18px;width:223px;">Pig skin</td>
			<td style="width:475px;">Butcher shop (Il mercato carni, di Dutto Srl. - 28100, Novara (Italy)</td>
			<td style="width:123px;">na</td>
			<td>Wet material used to obtain the simulated skin&#160;</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:223px;">Pig thymus</td>
			<td style="width:475px;">Butcher shop (Il mercato carni, di Dutto Srl. - 28100, Novara (Italy)</td>
			<td style="width:123px;">na</td>
			<td>Wet material used to build the simulated thyroid</td>
		</tr>
		<tr height="62">
			<td height="62" style="height:62px;width:223px;">SILK suture - Vetsuture SILK 2/0 (Metric 3) Ago 3/8 30mm Reverse Cutting (12 pz)</td>
			<td style="width:475px;">Sanitalia Care Srl</td>
			<td style="width:123px;">SILK2CN</td>
			<td>Sutures to tight all the parts of the model</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:223px;">Surgical instruments scissors, forceps, knife, needle holder&#160;</td>
			<td style="width:475px;">na</td>
			<td style="width:123px;">na</td>
			<td>na</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:223px;">Swine upper airways</td>
			<td style="width:475px;">Butcher shop (Il mercato carni, di Dutto Srl. - 28100, Novara (Italy)</td>
			<td style="width:123px;">na</td>
			<td>Wet material used to build the model</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:223px;">white india ink -&#160; pelikan 10ml</td>
			<td>Cartoleria Manzoni di Lo Monaco Rosaria s.a.s. 97019 Vittoria, Italy</td>
			<td align="right">36340</td>
			<td>Ink used to mark the linea alba on the esophagus</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:223px;">Wood stapler</td>
			<td style="width:475px;">BRICOSELF ITALIA, vercelli&#160;</td>
			<td style="width:123px;">na</td>
			<td>Used to staple on the model</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:223px;">Wooden tablet</td>
			<td style="width:475px;">BRICOSELF ITALIA, vercelli&#160;</td>
			<td style="width:123px;">na</td>
			<td>Used to stabilyze the model with the stapler</td>
		</tr>
	</tbody>
</table>

manufacture of a multi-purpose low-cost animal bench-model for teaching tracheostomy

Tracheostomy is one of the most frequent procedures, performed through various techniques in the intensive care unit and emergency situations. Despite this, there is a lack of training on this procedure that affects its outcome, which is also dependent on operator's dexterity. Here, we take the specific training and simulation into consideration. This article aims to describe every step of the manufacture of a new multi-purpose low-cost animal bench-model, with the support of video and images, and to obtain an opinion about the quality of this model by administering a questionnaire to professionals with experience in the procedures. 
Ten experts in the technique were enrolled. The model scored an average of 3.45/5 for its anatomical realism; 4.75/5 for its usefulness as a training tool for simulation courses and assessments. The time necessary to build the model was 15 minutes, and the cost amounted to 10&#8364;. The animal bench-model was considered a very useful simulator for tracheostomy training and assessments. Therefore, it could be used as a tool for medical courses and residencies.

We assessed the feasibility and acceptability of the easily-made, low-cost and high-fidelity bench-model that simulates the human neck as a tool for cricothyrotomy, percutaneous and surgical tracheostomy training. After a review of current literature about simulation in surgical education, a survey instrument was designed. The questionnaire consisted of the following content sessions: 
a. general data and demographics of the participants; 
b. fidelity of the bench-model; 
c...

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Manufacture of a Multi-Purpose Low-Cost Animal Bench-Model for Teaching Tracheostomy

This article illustrates every step of the manufacture of a new multi-purpose low-cost animal bench-model for subglottic airway access management. All the procedures are shown in the video. The model's realism and its suitability for training the given clinical maneuvers were assessed by independent senior otolaryngologists and anesthesiologists.

Tracheostomy is one of the most frequent procedures, performed through various techniques in the intensive care unit and emergency situations. Despite ...

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5.5K Views.  Università del Piemonte Orientale. This article illustrates every step of the manufacture of a new multi-purpose low-cost animal bench-model for subglottic airway access management. All the procedures are shown in the video. The model's realism and its suitability for training the given clinical maneuvers were assessed by independent senior otolaryngologists and anesthesiologists.

Video: Manufacture of a Multi-Purpose Low-Cost Animal Bench-Model for Teaching Tracheostomy

Using Learning Outcome Measures to assess Doctoral Nursing Education

Education programs at all levels must be able to demonstrate successful program outcomes. Grades alone do not represent a comprehensive measurement methodology for assessing student learning outcomes at either the course or program level. The development and application of assessment rubrics provides an unequivocal measurement methodology to ensure a quality learning experience by providing a foundation for improvement based on qualitative and quantitatively measurable, aggregate course and program outcomes.  Learning outcomes are the embodiment of the total learning experience and should incorporate assessment of both qualitative and quantitative program outcomes. The assessment of qualitative measures represents a challenge for educators in any level of a learning program. Nursing provides a unique challenge and opportunity as it is the application of science through the art of caring. Quantification of desired student learning outcomes may be enhanced through the development of assessment rubrics designed to measure quantitative and qualitative aspects of the nursing education and learning process. They provide a mechanism for uniform assessment by nursing faculty of concepts and constructs that are otherwise difficult to describe and measure. A protocol is presented and applied to a doctoral nursing education program with recommendations for application and transformation of the assessment rubric to other education programs. Through application of these specially designed rubrics, all aspects of an education program can be adequately assessed to provide information for program assessment that facilitates the closure of the gap between desired and actual student learning outcomes for any desired educational competency.

The structure and process for measuring student learning outcomes through customizable assessment rubrics is discussed and applied to a doctoral nursing education program.

Education programs at all levels must be able to demonstrate successful program outcomes. Grades alone do not represent a comprehensive measurement ...

Biomarkers in an Animal Model for Revealing Neural, Hematologic, and Behavioral Correlates of PTSD

Identification of biomarkers representing the evolution of the pathophysiology of Post Traumatic Stress Disorder (PTSD) is vitally important, not only for objective diagnosis but also for the evaluation of therapeutic efficacy and resilience to trauma. Ongoing research is directed at identifying molecular biomarkers for PTSD, including traumatic stress induced proteins, transcriptomes, genomic variances and genetic modulators, using biologic samples from subjects' blood, saliva, urine, and postmortem brain tissues. However, the correlation of these biomarker molecules in peripheral or postmortem samples to altered brain functions associated with psychiatric symptoms in PTSD remains unresolved. Here, we present an animal model of PTSD in which both peripheral blood and central brain biomarkers, as well as behavioral phenotype, can be collected and measured, thus providing the needed correlation of the central biomarkers of PTSD, which are mechanistic and pathognomonic but cannot be collected from people, with the peripheral biomarkers and behavioral phenotypes, which can.
Our animal model of PTSD employs restraint and tail shocks repeated for three continuous days - the inescapable tail-shock model (ITS) in rats. This ITS model mimics the pathophysiology of PTSD 17, 7, 4, 10. We and others have verified that the ITS model induces behavioral and neurobiological alterations similar to those found in PTSD subjects 17, 7, 10, 9. Specifically, these stressed rats exhibit (1) a delayed and exaggerated startle response appearing several days after stressor cessation, which given the compressed time scale of the rat's life compared to a humans, corresponds to the one to three months delay of symptoms in PTSD patients (DSM-IV-TR PTSD Criterian D/E 13), (2) enhanced plasma corticosterone (CORT) for several days, indicating compromise of the hypothalamopituitary axis (HPA), and (3) retarded body weight gain after stressor cessation, indicating dysfunction of metabolic regulation.
The experimental paradigms employed for this model are: (1) a learned helplessness paradigm in the rat assayed by measurement of acoustic startle response (ASR) and a charting of body mass; (2) microdissection of the rat brain into regions and nuclei; (3) enzyme-linked immunosorbent assay (ELISA) for blood levels of CORT; (4) a gene expression microarray plus related bioinformatics tools 18. This microarray, dubbed rMNChip, focuses on mitochondrial and mitochondria-related nuclear genes in the rat so as to specifically address the neuronal bioenergetics hypothesized to be involved in PTSD.

We describe a rat model of post traumatic stress disorder (PTSD) that reveals the persistent alterations in neuroendocrine function and the delayed long-term, exaggerated fear response, characteristic of PTSD patients. The animal model and methods described here are useful for correlating biomarkers in brain nuclei, which are mechanistic but cannot be measured in patients, with biomarkers in peripheral white blood cells, which can.

Identification of biomarkers representing the evolution of the pathophysiology of Post Traumatic Stress Disorder (PTSD) is vitally important, not only for ...

An Isolated Working Heart System for Large Animal Models

Since its introduction in the late 19th century, the Langendorff isolated heart perfusion apparatus, and the subsequent development of the working heart model, have been invaluable tools for studying cardiovascular function and disease1-15. Although the Langendorff heart preparation can be used for any mammalian heart, most studies involving this apparatus use small animal models (e.g., mouse, rat, and rabbit) due to the increased complexity of systems for larger mammals1,3,11. One major difficulty is ensuring a constant coronary perfusion pressure over a range of different heart sizes &#8211; a key component of any experiment utilizing this device1,11. By replacing the classic hydrostatic afterload column with a centrifugal pump, the Langendorff working heart apparatus described below allows for easy adjustment and tight regulation of perfusion pressures, meaning the same set-up can be used for various species or heart sizes. Furthermore, this configuration can also seamlessly switch between constant pressure or constant flow during reperfusion, depending on the user&#8217;s preferences. The open nature of this setup, despite making temperature regulation more difficult than other designs, allows for easy collection of effluent and ventricular pressure-volume data.

Most studies involving the Langendorff apparatus use small animal models due to the increased complexity of systems for larger mammals. We describe a Langendorff system for large animal models that allows for use across a range of species, including humans, and relatively easy data acquisition.

Since its introduction in the late 19th century, the Langendorff isolated heart perfusion apparatus, and the subsequent development of the working heart ...

Isolating and Using Sections of Bovine Mesenteric Artery and Vein as a Bioassay to Test for Vasoactivity in the Small Intestine

Mammalian gastrointestinal systems are constantly exposed to compounds (desirable and undesirable) that can have an effect on blood flow to and from that system. Changes in blood flow to the small intestine can result in effects on the absorptive functions of the organ. Particular interest in toxins liberated from feedstuffs through fermentative and digestive processes has developed in ruminants as an area where productive efficiencies could be improved. The video associated with this article describes an in vitro bioassay developed to screen compounds for vasoactivity in isolated cross-sections of bovine mesenteric artery and vein using a multimyograph. Once the blood vessels are mounted and equilibrated in the myograph, the bioassay itself can be used: as a screening tool to evaluate the contractile response or vasoactivity of compounds of interest; determine the presence of receptor types by pharmacologically targeting receptors with specific agonists; determine the role of a receptor with the presence of one or more antagonists; or determine potential interactions of compounds of interest with antagonists. Through all of this, data are collected real-time, tissue collected from a single animal can be exposed to a large number of different experimental treatments (an in vitro advantage), and represents vasculature on either side of the capillary bed to provide an accurate picture of what could be happening in the afferent and efferent blood supply supporting the small intestine.

The small intestine is frequently exposed to toxins that can influence blood flow and negatively impact nutrient absorption. Using a multimyograph and mesenteric artery and vein isolates, compounds or toxins of interest can be screened for vasoactivity.

Mammalian gastrointestinal systems are constantly exposed to compounds (desirable and undesirable) that can have an effect on blood flow to and from that ...

Open Tracheostomy Gastric Acid Aspiration Murine Model of Acute Lung Injury Results in Maximal Acute Nonlethal Lung Injury

Acid pneumonitis is a major cause of sterile acute lung injury (ALI) in humans. Acid pneumonitis spans the clinical spectrum from asymptomatic to acute respiratory distress syndrome (ARDS), characterized by neutrophilic alveolitis, and injury to both alveolar epithelium and vascular endothelium. Clinically, ARDS is defined by acute onset of hypoxemia, bilateral patchy pulmonary infiltrates and non-cardiogenic pulmonary edema. Human studies have provided us with valuable information about the physiological and inflammatory changes in the lung caused by ARDS, which has led to various hypotheses about the underling mechanisms. Unfortunately, difficulties determining the etiology of ARDS, as well as a wide range of pathophysiology have resulted in a lack of critical information that could be useful in developing therapeutic strategies.
Translational animal models are valuable when their pathogenesis and pathophysiology accurately reproduce a concept proven in both in vitro and clinical settings. Although large animal models (e.g., sheep) share characteristics of the anatomy of human trachea-bronchial tree, murine models provide a host of other advantages including: low cost; short reproductive cycle lending itself to greater data acquisition; a well understood immunologic system; and a well characterized genome leading to the availability of a variety of gene deletion and transgenic strains. A robust model of low pH induced ARDS requires a murine ALI that targets mainly the alveolar epithelium, secondarily the vascular endothelium, as well as the small airways leading to the alveoli. Furthermore, a reproducible injury with wide differences between different injurious and non-injurious insults is important.
The murine gastric acid aspiration model presented here using hydrochloric acid employs an open tracheostomy and recreates a pathogenic scenario that reproduces the low pH pneumonitis injury in humans. Additionally, this model can be used to examine interaction of a low pH insult with other pulmonary injurious entities (e.g., food particles, pathogenic bacteria).

This protocol induces acute lung injury in a mouse that has close fidelity to the pathogenesis of acid pneumonitis observed in humans. We generate a maximal acute nonlethal low pH lung injury and account for differences in rodent-human anatomic respiratory structure using an open tracheostomy coupled with circumferential pressure release.

Acid pneumonitis is a major cause of sterile acute lung injury (ALI) in humans. Acid pneumonitis spans the clinical spectrum from asymptomatic to acute ...

Assessment of Plasma Coagulation on Liver Tissue in a Large Animal Model In Vivo

Plasma coagulation as a form of electrocautery is used in liver surgery for decades to seal the large liver cut surface after major hepatectomy to prevent hemorrhages at a later stage. The exact effects of plasma coagulation on liver tissue are only poorly examined. In our porcine model, the coagulation effects can be examined close to the clinical application. A combined laser Doppler flowmeter and spectrophotometer documents microcirculation changes during coagulation at 8 mm tissue depth noninvasively, providing quantifiable information about hemostasis beyond the subjective clinical impression. The temperature at coagulation site is assessed with an infrared thermometer prior and post coagulation and with a thermographic camera during coagulation, a measurement of the gas beam temperature is not possible due to the upper threshold of the devices. The depth of coagulation is measured microscopically on hematoxylin/eosin stained sections after calibration with an object micrometer and gives an exact information about the power setting-coagulation depth-relation. The sealing effect is examined on the bile ducts as it is not possible for a plasma coagulator to seal larger blood vessels. Burst pressure experiments are carried out on explanted organs to rule out blood pressure related effects.

Assessment of Plasma Coagulation on Liver Tissue in a Large Animal Model In Vivo

Here we present a protocol to experimentally assess plasma coagulation in liver tissue in vivo. In a porcine model, microcirculation is examined by laser Doppler, coagulation depth is measured histologically, temperature at coagulation site by infrared thermometer and thermographic camera, and duct sealing effect is documented by burst pressure experiments.

Plasma coagulation as a form of electrocautery is used in liver surgery for decades to seal the large liver cut surface after major hepatectomy to prevent ...

A Small Animal Model of Ex Vivo Normothermic Liver Perfusion

There is a significant shortage of liver allografts available for transplantation, and in response the donor criteria have been expanded. As a result, normothermic ex vivo liver perfusion (NEVLP) has been introduced as a method to evaluate and modify organ function. NEVLP has many advantages in comparison to hypothermic and subnormothermic perfusion including reduced preservation injury, restoration of normal organ function under physiologic conditions, assessment of organ performance, and as a platform for organ repair, remodeling, and modification. Both murine and porcine NEVLP models have been described. We demonstrate a rat model of NEVLP and use this model to show one of its important applications &#8212; the use of a therapeutic molecule added to liver perfusate. Catalase is an endogenous reactive oxygen species (ROS) scavenger and has been demonstrated to decrease ischemia-reperfusion in the eye, brain, and lung. Pegylation has been shown to target catalase to the endothelium. Here, we added pegylated-catalase (PEG-CAT) to the base perfusate and demonstrated its ability to mitigate liver preservation injury. An advantage of our rodent NEVLP model is that it is inexpensive in comparison to larger animal models. A limitation of this study is that it does not currently include post-perfusion liver transplantation. Therefore, prediction of the function of the organ post-transplantation cannot be made with certainty. However, the rat liver transplant model is well established and certainly could be used in conjunction with this model. In conclusion, we have demonstrated an inexpensive, simple, easily replicable NEVLP model using rats. Applications of this model can include testing novel perfusates and perfusate additives, testing software designed for organ evaluation, and experiments designed to repair organs.

A Small Animal Model of Ex Vivo Normothermic Liver Perfusion

There is a significant liver donor shortage, and criteria for liver donors have been expanded. Normothermic ex vivo liver perfusion (NEVLP) has been developed to evaluate and modify organ function. This study demonstrates a rat model of NEVLP and tests the ability of pegylated-catalase, to mitigate liver preservation injury.

There is a significant shortage of liver allografts available for transplantation, and in response the donor criteria have been expanded. As a result, ...

Endoscopy Guided Photoablation of Endometrial Cysts using a 980 nm Laser with a Contact Fiber in Mares

In mares, endometrial cysts are associated with endometriosis and can cause maternal recognition failure or compromise and delay pregnancy diagnoses. Historical treatments were invasive and had adverse effects on the endometrium. Hysteroscopically guided laser therapy is easy and effective for endometrial cysts resection, with no deleterious effects for the endometrium.
A 110 cm long and 1.0 cm wide endoscope is sterilely introduced in the uterus through the open cervix of an estrous mare after vulvar cleaning. The uterus is slowly infused with less than 1 L of physiologic solution and the laser fiber is inserted in the biopsy canal of the endoscope. Cysts are then cauterized with the 980 nm diode laser with a contact fiber set at 20&#8210;2 5W in continuous mode. Each cyst is punctured&#160;until complete voiding of the cyst and shrinking of the cyst wall around the fiber. Uterine lavages with sterile saline solution are performed directly after the surgery and for one or two days as non-inflammatory fluid can be observed.
This procedure is easy and quickly performed, with no obvious deleterious effects. Cysts resection makes ultrasound pregnancy diagnosis easier and, in some cases, could restore proper embryo migration in the uterine horns between day 6.5 and 17. However, this treatment does not improve the underlying histological lesions related to endometriosis. These considerations should be clearly expressed to the breeder before this procedure.

The aim of this report is to describe the photoablation of endometrial cysts in the mare using an endoscopic laser device, and to discuss the interest and limitations of this new approach to deal with low fertility issues.

In mares, endometrial cysts are associated with endometriosis and can cause maternal recognition failure or compromise and delay pregnancy diagnoses. ...

A Large Animal Model for Acute Kidney Injury by Temporary Bilateral Renal Artery Occlusion

Acute kidney injury (AKI) is associated with higher risk for morbidity and mortality post-operatively. Ischemia-reperfusion injury (IRI) is the most common cause of AKI. To mimic this clinical scenario, this study presents a highly reproducible large animal model of renal IRI in swine using temporary percutaneous bilateral balloon-catheter occlusion of the renal arteries. The renal arteries are occluded for 60 min by introducing the balloon-catheters through the femoral and carotid artery and advancing them into the proximal portion of the arteries. Iodinated contrast is injected in the aorta to assess any opacification of the kidney vessels and confirm the success of the artery occlusion. This is furtherly confirmed by the flattening of the pulse waveform at the tip of the balloon catheters. The balloons are deflated and removed after 60 min of bilateral renal artery occlusion, and the animals are allowed to recover for 24 h. At the end of the study, plasma creatinine and blood urea nitrogen significantly increase, while eGFR and urine output significantly decrease. The need for iodinated contrast is minimal and does not affect renal function. Bilateral renal artery occlusion better mimics the clinical scenario of perioperative renal hypoperfusion, and the percutaneous approach minimizes the impact of the inflammatory response and the risk of infection seen with an open approach, such as a laparotomy. The ability to create and reproduce this clinically relevant swine model eases the clinical translation to humans.

This study presents a highly reproducible large animal model of renal ischemia-reperfusion injury in swine using temporary percutaneous bilateral balloon-catheter occlusion of the renal arteries for 60 min and reperfusion for 24 h.

Acute kidney injury (AKI) is associated with higher risk for morbidity and mortality post-operatively. Ischemia-reperfusion injury (IRI) is the most ...

Creation of a High-Fidelity, Low-Cost, Intraosseous Line Placement Task Trainer via 3D Printing

The description of procedural task trainers includes their use as a training tool to hone technical skills through repetition and rehearsal of procedures in a safe environment before ultimately performing the procedure on a patient. Many procedural task trainers available to date suffer from several drawbacks, including unrealistic anatomy and the tendency to develop user-created &#39;landmarks&#39; after the trainer tissue undergoes repeated manipulations, potentially leading to inappropriate psychomotor skill development. To ameliorate these drawbacks, a process was created to produce a high-fidelity procedural task trainer, created from anatomy obtained from computed tomography (CT) scans, that utilize ubiquitous three-dimensional (3D) printing technology and off-the-shelf commodity supplies.
This method includes creating a 3D printed tissue mold capturing the tissue structure surrounding the skeletal element of interest to encase the bony skeletal structure suspended within the tissue, which is also 3D printed. A tissue medium mixture, which approximates tissue in both high-fidelity geometry and tissue density, is then poured into a mold and allowed to set. After a task trainer has been used to practice a procedure, such as intraosseous line placement, the tissue media, molds, and bones are reclaimable and may be reused to create a fresh task trainer, free of puncture sites and manipulation defects, for use in subsequent training sessions.

We describe a procedure to process computed tomography (CT) scans into high-fidelity, reclaimable, and low-cost procedural task trainers. The CT scan identification processes, export, segmentation, modeling, and 3D printing are all described, along with the issues and lessons learned in the process.

The description of procedural task trainers includes their use as a training tool to hone technical skills through repetition and rehearsal of procedures ...