Surgical Airway Techniques 

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.

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.

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

If time permits and the patient is not unresponsive, injection of the skin and subcutaneous tissue over the cricothyroid membrane with 1% lidocaine solution provides adequate anesthesia.

Cricothyrotomy

• Cuffed, nonfenestrated, No. 4 and No. 5 tracheostomy tubes
• Scalpel, No. 11
• Trousseau dilator
• Tracheal hook
• 4 X 4 gauze/sponges
• Optional equipment - 2 small hemostats, surgical drapes, 1% lidocaine with syringe and needle

Needle cricothyrotomy

• Over-the-needle catheter, 12 or 14 gauge (ga), 8.5 cm
• Over-the-needle catheter, 16 or 18 ga, 8.5 cm (for pediatrics)
• Syringe, 10 mL
• Scalpel, No. 11
• 4 X 4 gauze/sponges
• Nasal cannula or oxygen tubing with Y-connector
• Optional equipment - Surgical drapes, 1% lidocaine with syringe and needle

Percutaneous cricothyrotomy using Seldinger technique

• Cricothyrotome kit
• Scalpel, No. 11
• 4 X 4 gauze/sponges
• Optional equipment - Surgical drapes, 1% lidocaine with syringe and needle

Position the patient supine, with the neck in a neutral position.

Cricothyrotomy

• Assemble and prepare equipment.
• Position the patient supine, with the neck in a neutral position.
• Clean the patient’s neck in a sterile fashion using antiseptic swabs.
• Anesthetize the area locally, if time allows.
• Locate the cricothyroid membrane anteriorly between the thyroid and cricoid cartilage.
• Stabilize the trachea with the left hand until the trachea is intubated.
• Make a 2- to 3-cm midline vertical incision through the skin from the caudal end of the thyroid cartilage to the cephalic end of the cricoid cartilage.
• Make a 1- to 2-cm transverse incision through the cricothyroid membrane.
• Insert the scalpel handle into the incision and rotate 90°. (A hemostat may also be used to open the airway.)
• Insert a tracheal hook into the opening, hooking the caudal end of the opening, and lift, allowing for passage of an appropriately sized cuffed endotracheal or tracheostomy tube (usually No. 5 or No. 6), directing the tube distally.

  • First alternative: Insert the tube through the opening produced by the opened hemostat.
  • Second alternative: Holding the handle of the scalpel straight down in the opening, slide the handle cephalically and insert the tube straight down along the handle until it hits the back of the trachea. Then, angle the tube caudally and advance the tube.
• Inflate the cuff; observe and check for chest rise.
• Secure the airway.
• Caution: Do not cut the thyroid or cricoid cartilage.

Needle cricothyrotomy

• Follow the first 4 steps above.
• Assemble a 12- or 14-ga (No. 16-18 in pediatrics) 8.5-cm over-the-needle catheter to a 10-mL syringe.
• Locate the cricothyroid membrane anteriorly between the thyroid and cricoid cartilage.
• Stabilize the trachea with the thumb and forefinger of one hand.
• Using the other hand, puncture the skin in the midline with the needle over the cricothyroid membrane. (A small incision with a No. 11 blade may be made first to facilitate passage of the needle.)
• Direct the needle at a 45° angle caudally while applying negative pressure to the syringe.
• Maintain needle aspiration as the needle is inserted through the lower half of the cricothyroid membrane. Aspiration of air signifies entry into the tracheal lumen.
• Remove the syringe and needle while advancing the catheter to the hub.
• Attach the oxygen catheter and secure the airway.

Percutaneous cricothyrotomy using Seldinger technique

• This cricothyrotome kit is used similarly to a needle cricothyrotomy but relies on the Seldinger technique. These kits are available in some hospitals and should only be used in patients older than 12 years.
• Follow the first 4 steps of the cricothyrotomy technique.
• Locate the cricothyroid membrane anteriorly between the thyroid and cricoid cartilage.
• Stabilize the trachea with the thumb and forefinger of one hand.
• Using the other hand, puncture the skin in the midline with the finder needle with attached syringe over the cricothyroid membrane. (A small incision with a No. 11 blade may be made first to facilitate passage of the needle.)
• Direct the needle at a 45° angle caudally while applying negative pressure to the syringe.
• Maintain needle aspiration as the needle is inserted through the lower half of the cricothyroid membrane. Aspiration of air signifies entry into the tracheal lumen.
• Remove the syringe, leaving the needle in place, and advance the guidewire through the needle.
• Insert dilator and airway tube combination over the guidewire. Once the airway device is in place, the dilator and guidewire are removed.
• Attach the oxygen catheter and secure the airway.

Percutaneous transtracheal ventilation

• Connect the cannula to oxygen at 15 L/min (40-50 psi) using a Y-connector or through a hole cut in the side of a nasal cannula.
• Intermittent ventilation (1 second on and 4 seconds off) can be achieved by placing a thumb over the open end of the Y-connector or cannula.
• This method can be used for about 30-40 minutes. However, it causes an accumulation of CO₂ and, therefore, must be used sparingly in patients with head trauma.
• A surgical tracheostomy is depicted in the video below.

  Surgical tracheostomy procedure. Video courtesy of Gauri Mankekar, MBBS, MS, PhD.

• Almost no literature is available that compares surgical cricothyrotomy to needle cricothyrotomy.
• Some comparisons have been made between the use of a cricothyrotome kit and the rapid 4-step surgical cricothyrotomy, but they have demonstrated no significant difference in outcomes or complications.

Cricothyrotomy

• Aspiration
• Creation of false passage into the tissue
• Subglottic stenosis
• Laryngeal stenosis
• Hemorrhage/hematoma
• Esophageal/tracheal laceration
• Mediastinal emphysema^[6]
• Vocal cord injury

Needle cricothyrotomy

• Inadequate ventilation/hypoxia
• Aspiration (blood)
• Esophageal laceration
• Posterior tracheal wall perforation
• Subcutaneous emphysema
• Thyroid perforation
• Hypercarbia

Percutaneous transtracheal ventilation

• Pulmonary rupture
• Pneumothorax/tension pneumothorax