REVIEW ARTICLE

Conversion of Emergent Cricothyrotomy

to Tracheotomy in Trauma Patients
Peep Talving, MD, PhD; Joseph DuBose, MD; Kenji Inaba, MD; Demetrios Demetriades, MD, PhD

Objectives: To review the literature to determine the
rates of airway stenosis after cricothyrotomy, particu-
larly as they compare with previously documented rates
of this complication after tracheotomy, and to examine
the complications associated with conversion.
Data Sources: We conducted a review of the medical
literature by the use of PubMed and OVID MEDLINE da-
tabases.
Study Selection: We identified all published series that
describe the use of cricothyrotomy, with the inclusion
of the subset of patients who require an emergency air-
way after trauma, from January 1, 1978, to January 1,
2008.
Data Extraction: Only 20 published series of crico-
thyrotomy were identified: 17 retrospective reports and
3 prospective, observational series.
Data Synthesis: Considerable variance in methods and
follow-up periods were noted between examinations. Pub-
lished experiences documented the results of 1134 total
patients for whom cricothyrotomy was performed, in-
cluding 368 trauma patients who underwent emergent
cricothyrotomy. The rate of chronic subglottic stenosis
among survivors after cricothyrotomy was 2.2% (11/
511) overall and 1.1% (4/368) among trauma patients for
follow-up periods with a range from 2 to 60 months. Only
1 (0.27%) of the 368 trauma patients in whom an emer-
gent cricothyrotomy was performed required surgical
treatment for chronic subglottic stenosis. Although the
literature that documents complications of surgical air-
way conversion is scarce, rates of severe complications
of up to 43% were reported.
Conclusions: Cricothyrotomy after trauma is safe for ini-
tial airway access among patients who require the estab-
lishment of an emergent airway. The prolonged use of a
cricothyrotomy tube, however, remains controversial. Al-
though no study to date has demonstrated any benefit
of routine conversion to tracheostomy, considerable de-
ficiencies in existing studies highlight the need for fur-
ther investigations of this practice.
Arch Surg. 2010;145(1):87-91

Author Affiliations: Division of
Trauma and Surgical Critical
Care, Los Angeles County and
University of Southern
California Medical Center,
Los Angeles.
T
HE EARLY ESTABLISHMENT OF
a patent and secure air-
way, in either the field set-
ting or the emergency de-
partment, is a basic tenet of
trauma care.1 Endotracheal intubation re-
mains the initial airway of choice for
trauma patients with a decreased Glasgow
Coma Scale score or airway or ventila-
tory compromise and can be achieved with
a high degree of success in most cases.2-4
During recent years, the laryngeal mask
airway and double-lumen tube (Combi-
tube; Tyco-Kendall Healthcare Products,
Mansfield, Massachusetts) have also gained
popularity because of their simplicity and
demonstrated effectiveness in both pre-
hospital and in-hospital settings.5-7 The es-
tablishment of a surgical airway, how-
ever, remains indicated for those patients
in whom these initial adjuncts fail to pro-
vide adequate airway access or for those
patients with severe facial or neck inju-
ries that preclude the insertion of an en-
dotracheal tube. Cricothyrotomy, which
can be rapidly and successfully per-
formed in both field and hospital settings
by a variety of trained professionals, has
been widely advocated as the initial sur-
gical airway of choice in these emergent
situations.1,7-9
Among patients who require a crico-
thyrotomy and survive their initial inju-
ries, many may require the prolonged use
of a surgically created airway. Tradi-
tional surgical teaching has dictated that
a cricothyrotomy tube placed for emer-
gency purposes should be converted to a
tracheotomy tube within 72 hours in these
patients primarily because the prolonged
use of this airway access is thought to be
associated with a prohibitive risk of sub-
glottic stenosis.10 Although this practice
continues to be advocated by contempo-
rary authors,11,12 the literature on which
this assumption is primarily based is now

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 Table 1. Studies Included in the Review

No. of No. of Follow-up No. With No. Level

Source Study Design Cricothyrotomies Survivors Time, mo Chronic SGS Operated On of Evidence
Boyd et al,13 1979 Retrospective 147 103 6.0 2 1 III
Weymuller and Cummings,14 1982 Prospective, observational 15 15 2.0 0 0 II
Greisz et al,15 1982 Retrospective 61 31 3.0 0 0 III
McGill et al,16 1982 Retrospective 38 12 Not stated 0 0 III
Holst et al,17 1985 Retrospective 203 61 6.0 0 0 III
Miklus et al,9 1989 Retrospective 20 8 Not stated 0 0 III
Spaite and Joseph,18 1990 Retrospective 20 3 Not stated 0 0 III
Boyle et al,19 1993 Retrospective 69 5 Not stated 0 0 III
Sise et al,20 1984 Prospective, observational 76 30 8.5 2 1 II
O´Connor et al,21 1985 Retrospective 49 30 17.0 0 0 III
Esses and Jafek,22 1987 Retrospective 78 46 Not stated 3 3 III
DeLaurier et al,23 1990 Retrospective 34 20 2.0 0 0 III
Salvino et al,25 1993 Retrospective 30 15 Not stated 2 0 III
Hawkins et al,24 1995 Retrospective 66 26 60.0 0 0 III
Jacobson et al,8 1996 Retrospective 47 10 24.0-60.0 0 0 III
Gillespie and Eisele,26 1999 Retrospective 20 11 23.0 1 1 III
Isaacs,27 2001 Retrospective 65 27 37.0 0 0 III
Rehm et al,28 2002 Retrospective 18 11 12.0-24.0 0 0 III
Wright et al,29 2003 Retrospective 46 15 6.0 0 0 III
François et al,30 2003 Prospective, observational 32 32 6.0 1 1 II
Total No. (%) 1134 (100.0) 511/1134 (45.1) 16.0 11/511 (2.2) 7/11 (63.6)

Abbreviation: II indicates prospective clinical study or retrospective analysis of reliable data, including observational, cohort, prevalence, or case-control
studies; III, retrospective study, including database or registry reviews, a large series of case reports, and expert opinion; SGS, subglottic stenosis.

older than 80 years. A growing body of more contem-
porary literature has suggested that the risk associated
with the prolonged use of a cricothyrotomy tube, par-
ticularly that of airway stenosis, may be much lower than
previously believed.8,9,13-30 The risk of conversion, al-
though less well examined, may also be associated with
underappreciated risk.29,31 The aims of the present re-
view are to review the literature to determine the rates
of airway stenosis after cricothyrotomy, particularly as
they compare with previously documented rates of this
complication after tracheotomy, and to examine the com-
plications associated with conversion.
METHODS
We conducted a search of the medical literature using the key-
word cricothyrotomy in PubMed (http://www.pubmed.gov; ac-
cessed May 6, 2008), a service of the National Library of Medi-
cine of the National Institutes of Health and OVID MEDLINE
databases. A total of 153 publications that pertain to cricothy-
rotomy performed from January 1, 1978, to January 1, 2008,
were identified. A consensus panel of 3 reviewers (P.T., J.D.,
and K.I.) reviewed each study and their references to extract
all studies that addressed open cricothyrotomy in human pa-
tients who require airway access (Table 1). Twenty studies
were identified and analyzed to abstract the following data: pa-
tient population type, nature of cricothyrotomy tube place-
ment, clinical outcomes, and follow-up. An additional sub-
group of trauma patients was also identified for examination
(Table 2).
RESULTS
Twenty published series and studies were identified. Sev-
enteen of these consisted of retrospective reports, and
3 were prospective, observational series. Considerable
variance in methods and follow-up among these inves-
tigations was noted. In these reports, 1134 total crico-
thyrotomies were documented, with 511 survivors avail-
able for follow-up (Table 1). Follow-up periods ranged
overall from 2 to 60 months, with a mean of 16 months.
Chronic subglottic stenosis was documented in 11 of 511
overall survivors (2.2%). Surgical intervention to cor-
rect stenosis was required in 7 of the 511 survivors (1.4%).
Among trauma patients, 452 cricothyrotomies were
performed. Adequate documentation that these proce-
dures were performed for emergent airway access was
available in 368. The overall rate of chronic subglottic
stenosis in this setting was 0.9% (4/452) and 1.1%
(4/368) when cricothyrotomy was used to establish
emergent airway access. Only 1 of 368 trauma patients
(0.27%) required surgical treatment for chronic sub-
glottic stenosis after emergent cricothyrotomy for
trauma (Table 2).
The examination of complications directly related to
conversion to tracheotomy was limited to only 2 iden-
tified case series consisting of 15 total patients.29,31 The
overall complication rate from these 2 reports was 53.3%
(8/15), with a mortality rate of 28.6% in 1 series.31
COMMENT
In the late 19th century, Chevalier Jackson began to es-
tablish surgical airway operative techniques as standard-
ized procedures. During his investigations, he con-
ducted extensive examinations of the complications
associated with the performance of these interventions.
In a 1921 publication,10 he reported on a series of 200
cases of subglottic stenosis after the surgical creation of

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 Table 2. Studies With Available Data That Pertain to Trauma Patients

No. of No. With Emergent No. With No. Level of

Source Cricothyrotomies Airway Established Chronic SGS Operated On Evidence
McGill et al,16 1982 26 26 0 0 III
Miklus et al,9 1989 19 19 0 0 III
Spaite and Joseph,18 1990 19 19 0 0 III
Boyle et al,19 1993 69 69 0 0 III
Sise et al,20 1984 40 1 2 1 II
DeLaurier et al,23 1990 31 31 0 0 III
Salvino et al,25 1993 30 30 2 0 III
Hawkins et al,24 1995 66 66 0 0 III
Jacobson et al,8 1996 47 47 0 0 III
Gillespie and Eisele,26 1999 10 10 Not stated Not stated III
Isaacs,27 2001 4 4 0 0 III
Rehm et al,28 2002 36 0 0 0 III
Wright et al,29 2003 46 46 0 0 III
François et al,30 2003 9 Not stated Not stated Not stated II
Total No. (%) 452 (100.0) 368/452 (81.4) 4/452 (0.9) 1/4 (25.0)

Abbreviations: See Table 1.

airways. Among these cases, Jackson determined that 30
of the lesions were secondary to laryngeal inflammation
and cartilage necrosis owing to diphtheria or other causes
of inflammation. Of the remaining 170 patients with sub-
glottic stenosis, 158 (92.9%) had undergone cricothy-
rotomy. After noting that the preponderance of patients
with subglottic stenosis had a history of cricothy-
rotomy, he concluded that the use of this type of surgi-
cal airway was associated with a prohibitive risk of ste-
nosis compared with tracheotomy. Largely on the basis
of the report by Jackson, surgical dogma that advises
against elective cricothyrotomy and supports the prac-
tice of early conversion to tracheotomy after emergent
cases gained widespread acceptance. Even today, au-
thors continue to recommend adherence to these prin-
ciples to avoid the risk of subglottic stenosis after crico-
thyrotomy.11
Several subsequent examinations, however, have re-
futed the findings of Jackson. Brantigan and Grow32 were
among the first to challenge the dogma against cricothy-
rotomy in 1976. These investigators reported their ex-
perience with the use of elective cricothyrotomy in 655
cardiovascular patients, without a single subglottic ste-
nosis in their series. In our review of reports that fol-
lowed, we identified 20 series with similar findings. From
20 studies we noted a chronic subglottic stenosis rate of
2.2% among survivors of hospitalization for follow-up
periods that ranged from 2 to 60 months. In the largest
of the prospective series of cricothyrotomy, Sise et al20
documented only 2 cases of subglottic stenosis after the
use of this airway approach among 76 critically ill pa-
tients. Both of the patients with stenosis in this report
were adolescent trauma patients. Each underwent cri-
cothyrotomy only after complications associated with an-
tecedent endotracheal intubation. As Weymuller and
Cummings14 have previously shown, the performance of
cricothyrotomy after previous endotracheal intubation
is known to be associated with stenosis rates in excess
of 30%.
In a prospective, observational study, François and col-
leagues30 compared outcomes of critically ill patients who
underwent cricothyrotomy with a cohort undergoing tra-
cheotomy. The investigators found that both the inci-
dence and severity of complications between the 2 groups
were similar. Overall, our finding of a 2.2% rate of chronic
subglottic stenosis, the most commonly voiced concern
that pertains to cricothyrotomy tube use, compares favor-
ably with a recently reported series of survivors of open
surgical33 and dilatational tracheotomy.34 In a prospec-
tive, observational examination of 58 cardiothoracic sur-
gery survivors who underwent open tracheostomy, Walts
et al33 found that 9.2% of patients had tracheal stenosis as
verified by direct fiberoptic endoscopy visualization dur-
ing a mean follow-up period of 2.1 years. In another pro-
spective, observational study of 146 patients who under-
went either open or dilatational tracheotomy, Koitschev
and colleagues34 found that the severe suprastomal steno-
sis (grade II, ⬎50% of the lumen) was present in 19.2%
of patients via endoscopy at a mean follow-up of 75 days.
In addition to the risk of chronic subglottic stenosis,
several other concerns that pertain to the prolonged use
of a cricothyrotomy tube have also been proposed. Even
among advocates of the technique, concerns that per-
tain to the use of this form of surgical airway for chil-
dren and adolescents have been voiced. In the aforemen-
tioned prospective series by Sise et al,20 the only 2 patients
found to develop stenosis were adolescents, although both
of these individuals had been previously intubated via
an endotracheal route. On the basis of these findings, the
authors of this report recommended the avoidance of cri-
cothyrotomy in younger patients. In a recent report by
Parrilla et al,35 however, total complication rates of 42%
were noted after tracheotomy in a large population of
pediatric patients, which suggests that any surgical
manipulation of the pediatric airway may be likely to
predispose patients to stenosis and other airway compli-
cations. The explanation for this, as Parrilla and col-
leagues point out, is likely multifactorial. Currently, the
role of cricothyrotomy in children and adolescents re-
mains ill-defined.
Less morbid complications of cricothyrotomy have also
been raised as a concern, including voice change and dys-

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phagia. It has been hypothesized that injury to the cri-
cothyroid muscle may contribute to alterations in vocal
tenor and phonation. Although human data are lacking,
animal studies17 have failed to demonstrate electromy-
elographic or muscle morphologic changes after pro-
longed use of a cricothyrotomy tube. In addition, this se-
quela may not be unique to this particular form of surgical
airway. Walts and colleagues,33 in a report on the fol-
low-up of 58 survivors of tracheotomy for respiratory fail-
ure after cardiovascular surgery, noted that 24% of pa-
tients reported voice changes. The true incidence of
alterations in voice after cricothyrotomy is unknown. The
incidence of dysphagia after cricothyrotomy, likewise, has
not been defined. It has previously been appreciated that
prolonged ventilation is associated with higher rates of
swallowing abnormalities,36-39 particularly at extremes of
age.40,41 Although the prolonged use of an emergently
placed airway tube may predispose patients to alter-
ations of deglutination, the particular risk of cricothy-
rotomy for this morbidity, compared with that of trache-
otomy or orotracheal intubation, has not been defined.
The risk of conversion itself has not been well estab-
lished but is most certainly a concerning entity. In an ex-
amination by Wright et al,29 investigators found that,
among 8 patients who underwent conversion, compli-
cations occurred in 5 (62.5%). They also noted that pa-
tients who underwent conversion required a signifi-
cantly greater subsequent length of hospital stay compared
with their counterparts who had continued use of their
cricothyrotomy tube for airway access. In another re-
port by Altman and colleagues,31 3 of 7 patients (43%)
who underwent conversion at a mean of 6.1 days expe-
rienced severe complications, which resulted in 2 deaths
and 1 patient with permanent neurologic impairment.
Unfortunately, the existing literature that pertains to
routine conversion of cricothyrotomy to tracheotomy
may raise more questions than it answers. Although the
aforementioned figures are interesting, they are based
largely on retrospective studies and class III studies that
used mixed methods and uncontrolled patient selec-
tion. The type and size of endotracheal cannula used are
also poorly documented or highly variable among exist-
ing investigations. Given that the diameter and materi-
als of cannula involved may affect the type and rate of
subglottic stenosis, the absence of this information is
significant.
The diagnosis of subglottic stenosis among these
studies is, unfortunately, also not universally well docu-
mented. The methods and indications for evaluation of
stenosis are unclear. Follow-up procedures are highly
variable and poorly documented, with no standardiza-
tion. Once diagnosed, the optimal modality and timing
for treatment are, likewise, not defined. The percentage
of patients who require surgical correction of stenosis is
also questionable because confounding comorbidities
may preclude consideration for such procedures in
many patients.
Because of the lack of evidence that supports manda-
tory conversion of emergently established cricothy-
rotomy to a subsequent surgical or percutaneous trache-
otomy, a prospective, randomized validation of this
practice is warranted. The primary end point of such trial
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should be designed to evaluate clinically significant sub-
glottic stenosis that requires treatment as evaluated by
endoscopic examination of the larynx, vocal cords, and
trachea before intensive care unit discharge and decan-
nulation and during the postdecannulation follow-up.
Secondary end points would include complications as-
sociated with the second procedure, such as tracheoin-
nominate fistula, incidence of aspiration and pneumo-
nia, acute respiratory failure owing to inadvertent
decannulation, tracheoesophageal and tracheocutane-
ous fistula, chronic dysfunction of the vocal cords, de-
glutination abnormalities, and voice alterations. Other
important end points would be markers of efficacy, such
as length of stay in the intensive care unit and the hos-
pital, time to decannulation, and cost analysis. Given the
small number of emergently established cricothyroto-
mies at a single institutional level, a multi-institutional
trial is necessary to validate the practice.
In conclusion, several class III studies have sug-
gested that there is no benefit associated with conver-
sion of cricothyrotomy to tracheotomy. Conversely, no
existing literature supports the routine use of this prac-
tice. In the absence of adequate evidence on which to base
practice, however, the role of routine conversion of emer-
gent cricothyrotomy to tracheotomy remains a matter of
contention. Prospective investigation designed to settle
this debate is warranted.
Accepted for Publication: January 14, 2009.
Correspondence: Joseph DuBose, MD, Los Angeles
County and University of Southern California Medical
Center, 1200 N State St, Room IPT4N123, Los Angeles,
CA 90033-4525 (jjd3c@yahoo.com).
Author Contributions: Study concept and design: Talving,
DuBose, Inaba, and Demetriades. Acquisition of data:
Talving. Analysis and interpretation of data: Talving,
DuBose, and Inaba. Drafting of the manuscript: Talving,
DuBose, and Inaba. Critical revision of the manuscript for
important intellectual content: Inaba and Demetriades. Study
supervision: Demetriades.
Financial Disclosure: None reported.
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