eMedicine Specialties > Clinical Procedures > Respiratory Management

Tracheal Intubation, Surgical Airway Techniques

Author: Joshua E Markowitz, MD,, Fellow and Clinical Instructor, Department of Emergency Medicine, Emergency Ultrasound, Drexel University College of Medicine
Coauthor(s): Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Contributor Information and Disclosures

Updated: Apr 5, 2009

Introduction

A 2002 study of the National Emergency Airway Registry database found that only 0.56% (43 of 7,712) of intubations required crycothyrotomy.1 This percentage may be driven even lower by increasing adoption of rapid sequence intubation techniques, increased use of video-assisted intubation and other "difficult airway" devices, and increased prevalence of residency-trained emergency practitioners.2 However, some patients still require a surgical airway.3,4

An emergent surgical airway can be accomplished by using one of several different methods, including a surgical cricothyrotomy, needle cricothyrotomy with jet oxygenation, or percutaneous cricothyrotomy using the Seldinger technique.

Indications

Adults

  • A cricothyrotomy is indicated when a patient’s airway cannot be secured using nonsurgical methods or when other devices or rescue techniques (ie, intubating laryngeal mask airway, fiberoptic scope, lighted stylet) have failed or are not available.
  • A cricothyrotomy is indicated when an airway is required immediately in a patient who is not a candidate for orotracheal or nasotracheal intubation (ie, in the case of severe facial trauma).5
Pediatrics
  • For children younger than 12 years, needle cricothyrotomy with percutaneous transtracheal (jet) ventilation is the surgical airway of choice. A child’s larynx and cricoid cartilage are very soft, mobile, and pliable, making a surgical cricothyrotomy difficult.

Contraindications

Absolute contraindications

  • Pediatrics - Children younger than 12 years, unless of teenage or adult size

Relative contraindications

  • Airway obstruction distal enough to the cricoid membrane that a cricothyrotomy would not provide a secure airway with which to ventilate the patient 
  • Presence of a SHORT neck, which includes S urgery (history or prior neck surgery), H ematoma, O besity, R adiation (evidence of radiation therapy), or T rauma/burns, making it difficult to locate the patient’s anatomical landmarks or producing an increased risk of further complications
  • Tumor, infection, or abscess at site of incision
  • Lack of operator expertise

More on Tracheal Intubation, Surgical Airway Techniques

Overview: Tracheal Intubation, Surgical Airway Techniques
Treatment & Medication: Tracheal Intubation, Surgical Airway Techniques
References
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References

  1. Bair AE, Filbin MR, Kulkarni RG, et al. The failed intubation attempt in the emergency department: analysis of prevalence, rescue techniques, and personnel. J Emerg Med. Aug 2002;23(2):131-40. [Medline].

  2. Friedman Z, You-Ten KE, Bould MD, Naik V. Teaching lifesaving procedures: the impact of model fidelity on acquisition and transfer of cricothyrotomy skills to performance on cadavers. Anesth Analg. Nov 2008;107(5):1663-9. [Medline].

  3. McIntosh SE, Swanson ER, Barton ED. Cricothyrotomy in air medical transport. J Trauma. Jun 2008;64(6):1543-7. [Medline].

  4. Liess BD, Scheidt TD, Templer JW. The difficult airway. Otolaryngol Clin North Am. Jun 2008;41(3):567-80, ix. [Medline].

  5. Verschueren DS, Bell RB, Bagheri SC, Dierks EJ, Potter BE. Management of laryngo-tracheal injuries associated with craniomaxillofacial trauma. J Oral Maxillofac Surg. Feb 2006;64(2):203-14. [Medline].

  6. Barkhuysen R, Merkx MA, van Damme PA, Buyne OR, van den Hoogen FJ. Acute upper airway failure and mediastinal emphysema following a wire-guided percutaneous cricothyrotomy in a patient with severe maxillofacial trauma. Oral Maxillofac Surg. May 2008;12(1):35-8. [Medline].

  7. American College of Surgeons, Committee on Trauma. Advanced Trauma Life Support For Doctors. 7th ed. Chicago: American College of Surgeons; 2004:1-2, 10.

  8. Koltai PJ, Kispert PH. Principles of trauma. In: Bailey BF, Healy GB, et al. Head and Neck Surgery - Otolaryngology. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2001:61.

  9. Murphy, MF, Walls, RM. Identification of the Difficult and Failed Airway. In: Walls RM, Murphy MF, Luten RC, Schneider RE. Manual of Emergency Airway Management. 2nd. Philadelphia: Lippincott Williams & Wilkins; 2004:70.

  10. Vissers RJ, Bair AE. Surgical airway techniques. In: Walls RM, Murphy MF, Luten RC, Schneider RE. Manual of Emergency Airway Management. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2004:1-6, 15.

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Further Reading

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Keywords

intubation, tracheal intubation, airway, emergency airway, airway emergency, pediatric airway, immediate airway, emergency intubation, cric, cric tray, surgical airway, surgical airway techniques, surgical cricothyrotomy, needle cricothyrotomy, percutaneous cricothyrotomy, intubation, intubate, Seldinger technique, percutaneous transtracheal ventilation

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Contributor Information and Disclosures

Author

Joshua E Markowitz, MD,, Fellow and Clinical Instructor, Department of Emergency Medicine, Emergency Ultrasound, Drexel University College of Medicine
Joshua E Markowitz, MD, is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

Medical Editor

Michael R Filbin, MD, Clinical Instructor, Department of Emergency Medicine, Massachusetts General Hospital
Michael R Filbin, MD is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

 
 
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