Chapter 30  Attempting tracheal intubation prior

to cricothyrotomy may increase the

Surgical Airway risk of harm to the patient by delay-
ing oxygenation or increasing the
INTRODUCTION risk of failure of a surgical airway. If
 Establishing a surgical airway by standard intubation seems unlikely to
front-of-neck access is an indicated succeed, it is not always necessary to
intervention in patients who cannot attempt it prior to establishing a
be intubated via the oral or nasal surgical airway.
routes and also when faced with a
cannot intubate–cannot oxygenate  Establishing a traditional
scenario. endotracheal airway
 Surgical cricothyrotomy uses the
cricothyroid membrane (CTM) as an
insertion route, inserting a tracheal
tube either directly through an
incision or by using the Seldinger
technique after puncture.
 Percutaneous transtracheal jet
ventilation/oxygenation is an
alternative to surgical airway
establishment whereby a 12- to 16-
 Trauma can distort the neck anatomy
gauge catheter is inserted into the
by hematoma (e.g., cervical fracture,
trachea through the CTM and
major vessel injury), create aspira-
connected to a high-pressure (35 to
tion of blood or active oropharyngeal
50 psi) oxygen source for both
bleeding (facial trauma), or lessen
oxygenation and ventilation.
the integrity of supporting structures
PATIENT SELECTION (e.g., mandible fracture, LeForte
fractures). Look for these features
 The primary indication for surgical and have a preplanned difficult
airway placement is a cannot airway algorithm to include surgical
intubate–cannot oxygenate scenario, airway to mitigate impending or
often following failed attempts to actual respiratory failure.
establish an oral/nasal endotracheal
airway.  Clinical signs and symptoms of
airway obstruction—one common
 Cricothyrotomy and jet ventilation reason to perform a surgical airway.
can be used before laryngoscopy and
direct glottic intubation if the latter is
likely to fail because of anatomic
distortion or any other cause that
impedes visualization, notably blood,
secretions, vomitus, swelling, or
foreign matter.

 Pregnant patients, specifically at or
near term, are at increased risk of
regurgitating gastric contents
secondary to reduced lower
esophageal sphincter tone, will
desaturate faster by virtue of having
a decreased functional reserve
capacity (reduced by 20% near
term), will have edematous tissues
secondary to increased total body
water and decreased oncotic
pressure, and may be malpositioned
for ideal intubation if lying in a
lateral tilt. Children are another
special population with limited
surgical options, especially when
younger than 12 years old.
PATIENT AGE
 Inserting any airway into the trachea
in children under age 12 years has
specific challenges including a
shorter neck, more relative soft tis-
sue. more compressible proximal
airway structures, and less distinctive
thyroid and cricoid cartilages.
Hyperextension of the neck to
increase the sagittal length of the
CTM may mitigate some of these
factors.
 Cricothyrotomy is more challenging
in children, leading to increased risk
of laryngeal and tracheal injuries.6-8
Due to these complications,
tracheotomy is preferred in
children under 12 years old,
particularly those under age 8.
 The American Heart Association and
others recommend attempting
percutaneous transtracheal jet
ventilation first, with surgical
cricothyrotomy as a second-line
option.
 The key to successful rescue
airway placement in children is
advance planning and training for
this specific scenario.
INJURIES REQUIRING
CRICOTHYROTOMY
 Trauma is a common reason to
consider a surgical airway.
 Penetrating trauma to the neck
affecting a major artery (carotid,
vertebral, or thyroid) may create an
expanding hematoma and obstruct
the airway.
 Blunt trauma to the neck or face may
cause hemorrhage of the soft tissues
or injury to the trachea/larynx,
including rupture. If the trachea or
larynx is disrupted, do not attempt
cricothyrotomy
TYPE OF EMERGENCY AIRWAY
AND TUBE SELECTION
 Cricothyrotomy is preferred over
percutaneous approaches (except for
children <12 years old).

 Tracheostomy tube because it has
an obturator to ease insertion, is
shorter and easier to suction, and is
easier to secure
 Endotracheal tubes placed during
cricothyrotomy may be inadvertently
directed cephalad or advanced too
deeply and are more difficult to
secure. To avoid endotracheal tube
malposition, many use a gum elastic
bougie to ensure tracheal placement
and the correct tube direction.12 If a
standard endotracheal tube is used,
many prefer to change later to a
tracheostomy tube. Use a gum
bougie or endotracheal tube stylet as
an obturator for endotracheal tube
removal and tracheostomy tube
insertion.
 The diameter of the tube inserted is
crucial. A common choice for an
adult is a 6-mm tracheostomy or 5-
to 6-mm endotracheal tube. Do not
choose a larger (≥7 mm) tube or
one smaller than 4 mm, the latter
excepted in pediatric patients.
SURGICAL (OPEN)
CRICOTHYROTOMY
ANATOMY
 The CTM is located between the
thyroid and cricoid cartilages
(Figure 30-2A). Both structures are
easily palpated but are not directly
seen because they are covered with
the pretracheal fascia. In men, the
thyroid cartilage is prominent and
creates the “Adam’s apple”; in
women and children, the thyroid and
cricoid cartilages can be hard to
distinguish from each other.
 The CTM is found approximately
one third of the distance from the
manubrium to the chin in the midline
in patients with normal habitus
 The vascular structure often injured
during cricothyrotomy is the
thyroidea ima artery, a branch of the
aorta running up to the thyroid gland
in the midline. This vessel
infrequently reaches the level of the
CTM. A carotid injury usually
results from attempts using poor
landmarks (either indistinct or not
carefully sought) or when technique
is poor. The first step after
recognizing any vascular injury
during cricothyrotomy is immediate
direct pressure to stop the bleeding
and avoid catastrophe.
EQUIPMENT
PATIENT PREPARATION AND
POSITIONING
 Place the patient supine, with the
neck slightly hyperextended if no
cervical trauma is present
(neutral if there is suspected
trauma); this optimizes neck
structure palpation and
recognition. If time permits,
apply antiseptic solution to the
 skin. Ventilate with a bag-valve
mask connected to 100% oxygen
while preparing. For the patient
in extremis, do not delay
initiating the procedure to
achieve any of these
preparations.
PROCEDURE
SURGICAL CRICOTHYROTOMY
USING SELDINGER TECHNIQUE
The procedure summary for performing a
surgical cricothyrotomy
 Locate the cricothyroid membrane.
COMPLICATIONS
 Make a midline vertical incision. The
pretracheal fascia is seen through the
incision. Bleeding is less likely with
a vertical incision.
 Perforate the cricoid membrane with
a horizontal incision.
 Widen the opening.
 Insert a tracheostomy tube with
obturator.
 This method uses a kit most often
and starts with a small vertical
incision through the skin at the
CTM. Next, insert the needle at a 30-
to 45-degree angle pointing to the
feet and aspirate air to make sure the
needle is in the trachea.
 Once air aspiration is free, pass the
guidewire through the needle,
directing the guidewire caudally
(toward the feet).
 Place a tracheostomy tube over the
dilator, and make another “nick” in
the skin to ease penetration.
 Pass the dilator, with the
tracheostomy tube, over the
guidewire into the trachea.
 Once the dilator is in the trachea,
remove the guidewire, direct the
tracheostomy tube into the trachea,
and verify correct placement.
 Indications and complications are
similar to the open method. Multiple
different commercial kits exist, but
proper use depends more on
deliberate, repetitive training.
 Acute complications after emergency
cricothyrotomy occur in up to 15%
of cases.
 Venous bleeding usually occurs from
small veins and stops spontaneously.
 Arterial bleeding can be from the defined as a 12- to 16-gauge needle
thyroidea ima artery or from a small catheter inserted into the trachea
artery at the base of the CTM. —the catheter must be attached to
a higher-pressure oxygen source
 The first step in controlling ongoing (≥35 psi); it cannot simply be
bleeding is to apply pressure. If attached to a standard wall oxygen
bleeding persists, topical hemostatic outlet and be turned up or to wide
agents or ligation may help stop it. A open.
small amount of bleeding usually
creates no hemodynamic concerns,
CONTRAINDICATIONS
but it can make the procedure more
challenging.  The only absolute contraindication is
complete airway obstruction (i.e.,
expiration is blocked); this is
 Laceration of the trachea, esophagus,
exceptionally rare because most
or recurrent laryngeal nerves is rare
upper airway obstruction is
and often occurs when the procedure
inspiratory, including obstruction
is performed by someone unfamiliar
from masses. Relative
with the neck anatomy.
contraindications are unfamiliarity,
Pneumothorax is usually secondary
not having the equipment ready, and
to barotrauma caused by ventilation
local infection at puncture site.
initiated immediately after tube
placement.
EQUIPMENT NEEDED
 A tube left in the narrow space
between the cricoid and thyroid
cartilages can erode both cartilages
over time, and bacterial chondritis
may occur.
 The key when using a standard
endotracheal tube is to only insert
deep enough to inflate the balloon
within the trachea and achieve a seal;
then, careful auscultation of breath
sounds, assessment of carbon
dioxide in expelled gas, and  Do not try to use standard oxygen
confirmation of placement above the tubing, three-way stopcocks, or
carina follow. bag-valve devices or attach to wall
outlets turned to highest liter flow.
PERCUTANEOUS
CRICOTHYROTOMY AND
TRANSTRACHEAL JET
INSUFFLATION
 If percutaneous access is pursued
by “needle cricothyrotomy”—a
poor but common term that is
PROCEDURE punctures rarely cause long-term
airway complications, which is an
advantage over cricothyrotomy.

DEVICE REMOVAL

 Jet ventilation allows a more

controlled approach to airway
management; one can plan the next
step(s) carefully and without fear of
ventilation failure if done properly,
avoiding any rush to another
procedure. Often, a better
laryngoscopic attempt or a formal
tracheostomy can occur once time
pressures are abated with jet
ventilation.

COMPLICATIONS

 Damage to the trachea during

insertion may occur, including
perforation of the lateral or posterior
wall, particularly in children. Failure
to secure the catheter can lead to
displacement. Bleeding at the punc-
ture site and infection may occur.
 Massive subcutaneous emphysema
can develop during ventilation,
especially if the catheter is
improperly inserted or misplaced in
the soft tissues of the neck.
 Delivery of excessive ventilatory
force is associated with barotrauma,
and equipment used in jet ventilation
requires constant surveillance of
chest rise and appropriate exhalation.
 Even if the cricoid membrane is not
used (from misidentification), jet