Surgical Airway Techniques

Updated: Mar 27, 2018
  • Author: Joshua E Markowitz, MD, FACEP, RDMS, SAIUM; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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A 2002 study of the National Emergency Airway Registry database found that only 0.56% (43 of 7712) of intubations required cricothyrotomy (cricothyroidotomy). [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 cricothyrotomy
  • Needle cricothyrotomy with jet oxygenation
  • Percutaneous cricothyrotomy using the Seldinger technique

Currently, there is some evidence supporting a trend toward open cricothyrotomy and away from needle-based approaches, at least in settings where cricothyrotomy is not frequently performed. [8]




A cricothyrotomy 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. [9]

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


For children younger than 12 years, needle cricothyrotomy 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 cricothyrotomy is difficult in this setting.



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 cricothyrotomy 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


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 cricothyrotomy, but they have demonstrated no significant difference in outcomes or complications.