Surgical Airway Techniques Technique

Updated: Mar 27, 2018
  • Author: Joshua E Markowitz, MD, FACEP, RDMS, SAIUM; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Technique

Cricothyrotomy (Cricothyroidotomy)

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

Open cricothyrotomy

Steps in the procedure are as follows:

  • 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 the 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.
  • One alternative to the preceding step is to insert the tube through the opening produced by the opened hemostat; a second alternative is to hold the handle of the scalpel straight down in the opening, slide the handle cephalically, insert the tube straight down along the handle until it hits the back of the trachea, angle the tube caudally, and advance the tube
  • Inflate the cuff; observe and check for chest rise
  • Secure the airway
  • Take care not to cut the thyroid or the cricoid cartilage

A surgical tracheostomy is depicted in the video below.

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

Needle cricothyrotomy

Steps in the procedure are as follows:

  • Follow the first four steps listed above for surgical cricothyrotomy
  • Assemble a 12- or 14-gauge (16- or 18-gauge in children) 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

The cricothyrotome kit for this procedure is used in much the same way as in 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. (See the video below.)

Cricothyroidotomy (Seldinger technique). Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.

Steps in the procedure are as follows:

  • Follow the first four steps listed above for surgical cricothyrotomy
  • Locate the cricothyroid membrane anteriorly between the thyroid and the 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 guide wire through the needle
  • A small incision with a No.11 blade may be needed to enlarge the hole before insertion of the dilator; it is recommended to make this incision before removing the needle so as not to accidentally cut the guide wire
  • Insert the dilator–airway tube combination over the guide wire; once the airway device is in place, remove the dilator and the guide wire
  • 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 s on, 4 s 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 carbon dioxide and therefore must be used sparingly in patients who have sustained head trauma.

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Complications

Complications associated with open cricothyrotomy include the following:

  • Creation of false passage into the tissue
  • Subglottic stenosis
  • Laryngeal stenosis
  • Hemorrhage/hematoma
  • Esophageal/tracheal laceration
  • Mediastinal emphysema [10]
  • Vocal cord injury

Complications associated with needle cricothyrotomy include the following:

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

Ultrasound guidance may reduce the incidence of airway damage. [2]  Whether airway injury is present after the procedure may be determined by means of fiberoptic bronchoscopy, radiography, or computed tomography (CT). [11]

Complications associated with percutaneous transtracheal ventilation include the following:

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