INTRODUCTION

 Establishing a surgical airway by front-of-neck access is an indicated intervention in patients who cannot be intubated
via the oral or nasal routes and also when faced with a cannot intubate–cannot oxygenate scenario.
 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-gauge catheter is inserted into the trachea through the CTM and connected to a high-pressure (35 to 50 psi)
oxygen source for both oxygenation and ventilation.

PATIENT SELECTION
 The primary indication for surgical airway placement is a cannot intubate–cannot oxygenate scenario, often following
failed attempts to establish an oral/nasal endotracheal airway.

 Cricothyrotomy and jet ventilation 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.

 Attempting tracheal intubation prior to cricothyrotomy may increase the risk of harm to the patient by delaying
oxygenation or increasing the risk of failure of a surgical airway. If standard intubation seems unlikely to succeed, it is
not always necessary to attempt it prior to establishing a surgical airway.

 Establishing a traditional endotracheal airway

 Trauma can distort the neck anatomy by hematoma (e.g., cervical fracture, major vessel injury), create aspiration of
blood or active oropharyngeal bleeding (facial trauma), or lessen the integrity of supporting structures (e.g., mandible
fracture, LeForte fractures). Look for these features and have a preplanned difficult airway algorithm to include
surgical airway to mitigate impending or actual respiratory failure.

 Clinical signs and symptoms of airway obstruction—one common reason to perform a surgical airway
 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 tissue. 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
(Figure 30-2B). In a patient with a short, obese neck, the membrane may be hidden at the level of the manubrium. In a patient
with a thin, long neck, it may be midway between the chin and the manubrium. The thyroid gland overlies the trachea; both
structures are difficult to palpate. One easy way to find the cricoid membrane is to slowly palpate the trachea as you move up
toward the head from the sternal notch; when your fingers “fall off” after a firm structure, you have palpated the thyroid cartilage.
Next, slowly palpate back toward the feet, and the first “soft spot” after that thyroid cartilage is the cricoid membrane.
Additionally, a very rough approximation of where to find the CTM should landmarks be skewed is to take your outstretched
four fingers held together and place your fifth finger on the superior aspect of the manubrium. With the rest of your fingers
directed cephalad, the most superior aspect of the index finger is roughly juxtaposed to the CTM.
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

The equipment needed to perform a surgical cricothyrotomy is listed in Table 30-3

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

The procedure summary for performing a surgical cricothyrotomy is provided in Table 30-4. (See Video: Cricothyrotomy.)

Locate the cricothyroid membrane.

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.

SURGICAL CRICOTHYROTOMY USING SELDINGER TECHNIQUE

This method (Figure 30-8) 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 cau dally (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 tracheos tomy 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. (See Video: Needle Cricothyrotomy.)
COMPLICATIONS

Acute complications after emergency cricothyrotomy occur in up to 15% of cases. 13 Venous bleeding usually occurs from small
veins and stops spontaneously. Arterial bleeding can be from the thyroidea ima
artery or from a small artery at the base of the CTM. The first step in controlling ongoing bleeding is to apply pressure. If
bleeding persists, topical hemostatic agents or ligation may help stop it. A small amount of bleeding usually creates no
hemodynamic concerns, but it can make the procedure more challenging.
In an obese patient, it is possible to place the tube anterior to the lar ynx and trachea into the mediastinum (false passage),
making ventilation impossible. Signs of an incorrectly positioned tube are high airway pressures, absent breath sounds, and
massive subcutaneous emphysema. If suspected, remove the tube and make a second attempt at insertion. Surgical consultation is
recommended quickly as revision can be even more challenging than the initial approach. 12
Laceration of the trachea, esophagus, or recurrent laryngeal nerves is rare and often occurs when the procedure is performed by
someone unfamiliar with the neck anatomy. Pneumothorax is usually secondary to barotrauma caused by ventilation initiated
immediately after tube placement.
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 cartilages degrade and scar, leading to stenosis and loss of the function of the larynx. Because
cricothyrotomy has a high incidence of airway stenosis, 13 a change to tracheotomy is common after 2 to 3 days. In addition, if
using an endotracheal tube, right mainstem intubation is common after a surgical airway given the relatively longer tube length.
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 confirmation of
placement above the carina follow.

PERCUTANEOUS CRICOTHYROTOMY AND TRANSTRACHEAL JET INSUFFLATION

If percutaneous access is pursued by “needle cricothyrotomy”—a poor but common term that is defined as a 12- to 16-
gauge needle catheter inserted into the trachea—the catheter must be attached to a higher-pressure oxygen source (≥35
psi); it cannot simply be attached to a standard wall oxygen outlet and be turned up or to wide open.

Attachment of a 12- to 16-gauge catheter directly to a wall oxygen source or bag-valve mask will not reverse ventilation gaps
and may only modestly aid oxygen delivery.14-16
The proper equipment for jet ventilation must exist and be maintained, and the procedure requires practice, just like other surgical
interventions.9 Do not perform jet ventilation without the correct equipment ready in advance and without antecedent
practice; one cannot simply “put this together” at the time of critical need.
Jet ventilation uses a small catheter attached to either a pressure regulator attached directly to a wall oxygen source or cylinder
via pressure tubing. Jet ventilation can also be done using the VBM Manujet III or a commercial oxygen insufflator attached to
high-flow oxygen (≥15 L or greater), such as the ENK® Oxygen Flow Modulator or the Rapid O2 Insufflator® (Figure 30-9).9 Set
the oxygen pressure at 35 to 50 psi; if setting pressure for a small adult or child, use 0.5 psi/kg body mass and observe. In jet
ventilation, the catheter and high-pressure gas provide volume for inhalation, and the native airway is the passive exhalation
route. With proper jet ventilation, adequate oxygenation and ventilation occur. 10 Duration is limited only by airway
desiccation from nonhumidified gas, an effect that takes hours to a day to occur. Properly performed jet ventilation does not
create hypercarbia or the need for rapid reestablishment of another airway; only poorly performed or “needle cricothyrotomy”
low-pressure techniques create those situations.

ANATOMY, INDICATIONS, AND CONTRAINDICATIONS

Anatomy and general indications were described earlier in this chapter. The only absolute contraindication is complete airway
obstruction (i.e., expiration is blocked); this is exceptionally rare because most upper airway obstruction is inspiratory, including
obstruction from masses. Relative contraindications are unfamiliarity, not having the equipment ready, and local infection at
puncture site.
EQUIPMENT NEEDED

Equipment needed for transtracheal jet ventilation is listed in Table 30-5. Do not try to use standard oxygen tubing, three-way
stopcocks, or bag-valve devices or attach to wall outlets turned to highest liter flow.

PROCEDURE
The steps of performing jet ventilation are listed in Table 30-6. Optimize preprocedural oxygenation and ventilation when
possible (although often failure is the reason for the procedure).
COMPLICATIONS

Damage to the trachea during insertion may occur, including perforation of the lateral or posterior wall, particularly in
children.8,17 Failure to secure the catheter can lead to displacement. Bleeding at the puncture 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. Finally, delivery

of excessive ventilatory force is associated with barotrauma, and equipment used in jet ventilation requires constant surveillance
of chest rise and appropriate exhalation.16 Even if the cricoid membrane is not used (from misidentification), jet 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.