Surgical Airway Techniques

Updated: Feb 13, 2020
  • Author: Joshua E Markowitz, MD, FACEP, RDMS, SAIUM; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Overview

Background

A 2002 study of the National Emergency Airway Registry database found that only 0.56% (43 of 7712) of intubations required cricothyroidotomy (cricothyrotomy). [1, 2, 3]  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. [4]  However, some patients still require a surgical airway. [5, 6, 7]

An emergency surgical airway can be accomplished by using one of several different methods, including the following:

  • Open cricothyroidotomy [8]
  • Needle cricothyroidotomy with jet oxygenation
  • Percutaneous cricothyroidotomy using the Seldinger technique

Some evidence has supported a trend toward open cricothyroidotomy and away from needle-based approaches, at least in settings where cricothyroidotomy is not frequently performed. [9]

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Indications

Adults

A cricothyroidotomy is indicated when a patient’s airway cannot be secured by using nonsurgical methods or when other devices or rescue techniques (ie, intubating laryngeal mask airway, fiberoptic scope, or lighted stylet) have failed or are unavailable. It is also indicated when an airway is required immediately in a patient who is not a candidate for orotracheal or nasotracheal intubation (see the video below)—for instance, in the case of severe facial trauma. [10]

Fiberoptic-assisted tracheal intubation. Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.

Children

For children younger than 12 years, needle cricothyroidotomy with percutaneous transtracheal (jet) ventilation is the surgical airway of choice. Because a child’s larynx and cricoid cartilage are very soft, mobile, and pliable, a surgical cricothyroidotomy is difficult in this setting.

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Contraindications

An absolute contraindication for the creation of an emergency surgical airway is as follows:

  • Patient younger than 12 years, unless the child is of teenage or adult size

Relative contraindications for the creation of an emergency surgical airway include the following:

  • Airway obstruction distal enough to the cricoid membrane that a cricothyroidotomy would not provide a secure airway with which to ventilate the patient
  • Presence of a SHORT neck (ie,  Surgery [history of prior neck surgery], Hematoma, Obesity, Radiation [evidence of radiation therapy], or Trauma/burns), making it difficult to locate the patient’s anatomic landmarks or causing an increased risk of further complications
  • Tumor, infection, or abscess at the incision site
  • Lack of operator expertise
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Outcomes

Almost no literature is available comparing surgical cricothyrotomy with needle cricothyrotomy. Some comparisons have been made between the use of a cricothyrotome kit and the rapid four-step surgical cricothyroidotomy, but they have demonstrated no significant difference in outcomes or complications.

Kwon et al assessed the incidence and outcomes of cricothyroidotomy in a "cannot intubate, cannot oxygenate" (CICO) situation. [11] A total of 10,187 tracheal intubations were attempted, and 23 patients received cricothyroidotomy (22 in the emergency department [ED] and one in the endoscopy room). The survival rate at hospital discharge was 47.8% (11/23). Aside from cases of cardiac arrest at admission, the survival rate was 62.5% (10/16). Cricothyroidotomy was successful in 17 patients (73.9%), nine (52.9%) of whom survived; it failed in six (26.1%), two (33.3%) of whom survived. After failed cricothyroidotomy, airways were secured via tracheal intubation, nasotracheal intubation, or tracheostomy.

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