C r i c o t h y ro i d Ap p roa c h fo r

E m e r g e n c y Ac c e s s t o t h e
Airway
Alejandro Bribriesco, MDa,*, G. Alexander Patterson, MDb

KEYWORDS
 Cricothyroidotomy  Cricothyrotomy surgical airway  Airway emergency

KEY POINTS
 Surgical access to the airway is established through the cricothyroid membrane in the setting of
cannot-intubate-cannot-ventilate airway emergencies.
 The 3 main techniques for emergent access to the cricothyroid membrane are open, percutaneous,
and needle cricothyroidotomy.
 Providers who manage airway emergencies should be familiar with cricothyroid anatomy and the
techniques of cricothyroidotomy.
 No strong clinical evidence exists to recommend a specific cricothyroidotomy approach or technique.
 Personal experience and familiarity with a particular method of cricothyroidotomy are the most
important factors in selecting which technique should be used.

INTRODUCTION approaches to cricothyroidotomy (also inter-

Immediate evaluation of unstable patients always
begins with the assessment of the airway. This
assessment applies to patients arriving to the
emergency department (ED), in a prehospital
setting, those who are decompensating on the
ward or intensive care unit, as well as patients in
the operating room (OR). Orotracheal intubation
is the mainstay of securing the patients’ airway
and can be achieved in most situations. Although
airway emergencies can occur with some fre-
quency, the need for a surgical airway is rare. A
retrospective study of 30 hospitals in 33 countries
showed that of more than 7000 patients who
required an emergency airway, only 43 required
a surgical airway (0.6%).1 Despite the unlikely
occurrence that a nonsurgical airway fails or is
not possible, providers in this scenario should be
familiar with surgical techniques to gain airway ac-
cess via the cricoid membrane. There are 3 main
changeably referred to as cricothyrotomy): open
cricothyroidotomy, percutaneous cricothyroidot-
omy, and needle cricothyroidotomy.
INDICATIONS/RISK FACTORS
After determining patients are unable to protect
their airway, the first step in managing an airway
emergency is to attempt noninvasive oxygenation
and ventilation.2 The chin-lift, jaw-thrust maneuvers
are important to relieve obstruction caused by the
tongue or soft tissues of the neck. Bag mask venti-
lation with the assistance of a nasopharyngeal or an
oropharyngeal airway should be attempted. These
interventions often stabilize the situation and allow
for a controlled orotracheal intubation. If noninva-
sive methods are not successful, emergent orotra-
cheal intubation should be performed. There are
many additional advanced airway maneuvers and
devices that can be used in these settings and
thoracic.theclinics.com

Disclosure: The authors have nothing to disclose.

a
Department of Thoracic & Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid
Avenue, J4-1, Cleveland, OH 44195, USA; b Division of Cardiothoracic Surgery, Washington University in St.
Louis, 660 South Euclid, Campus Box 8234, St Louis, MO 63110, USA
* Corresponding author.
E-mail address: bribria@ccf.org

Thorac Surg Clin 28 (2018) 435–440

https://doi.org/10.1016/j.thorsurg.2018.04.009
1547-4127/18/Ó 2018 Elsevier Inc. All rights reserved.
436 Bribriesco & Patterson
are successful in approximately 99% of ED airway
emergencies.3 If orotracheal or nasotracheal intu-
bation cannot be achieved, a cannot-intubate-
cannot-ventilate (CICV) scenario has developed,
which demands immediate intervention before pa-
tients die. It is in this rare but fatal situation that
emergent surgical access to the airway via the cri-
cothyroid membrane is necessary. Settings in
which cricothyroidotomy is required or should be
highly anticipated include difficult patient anatomy;
bleeding or swelling of the oropharynx that ob-
scures visualization; food bolus obstruction, such
as with an unsuccessful Heimlich maneuver; maxil-
lofacial trauma; and airway obstruction, such as
angioedema or inhalational burns.4
ANATOMY
Thorough understanding of anterior neck and
airway anatomy is essential to safely perform surgi-
cal access to the cricothyroid membrane (Fig. 1).
With the neck extended, the notch of the thyroid
cartilage (known as the laryngeal prominence) is a
key landmark. The cricothyroid membrane in an
Fig. 1. The upper airway anatomy. Thyroid cartilage
with laryngeal prominence (thyroid notch) serves as
an important surface landmark. The cricothyroid
membrane is also known as the median cricothyroid
ligament. (From Drake RL, Vogl AW, Mitchell AWM.
Head and neck. In: Gray’s anatomy for students. 3rd
edition. Philadelphia: Elsevier; 2015; with permission.)
adult is approximately 8.0 mm in width and
10.4 mm in height.5 It is roughly one finger breadth
inferior to the laryngeal prominence and is appre-
ciable as a small indentation. One technique for
locating the cricothyroid membrane is to place
the index finger on the laryngeal prominence and
gently roll the tip of middle finger along the thyroid
cartilage until it falls into the cricothyroid mem-
brane. The other hand can stabilize the airway to
facilitate proper identification. Cephalad to the thy-
roid cartilage is the hyoid bone. The inferior border
of the hyoid bone and the palpable step-off onto
the thyrohyoid ligament can be misidentified as
the cricothyroid membrane. This pitfall leads to
misplacement of a tube or needle above the vocal
cords and can cause significant injury. In the setting
of difficult surface anatomy, the location of the cri-
cothyroid membrane can be approximated as 4 fin-
gerbreadths above the sternal notch. Placing 4
fingers vertically along the neck with the small
finger in the sternal notch is a useful estimate for
the position of the cricothyroid membrane.6
HOSPITAL SETTINGS AND PREPARATION FOR
CRICOTHYROIDOTOMY
The ED is the most common location for airway
emergencies. The ED team is the primary airway
service and has training in a wide range of intuba-
tion techniques including cricothyroidotomy.7 In
the setting of trauma, often the ED and surgical
team work in concert to secure the airway as part
of the primary survey.1 In CICV situations, both
open percutaneous and needle approaches to cri-
cothyroidotomy can be performed by either ED
physicians or surgeons. For airway emergencies
on the ward, many centers have devised a difficult
airway team or an algorithm that guides manage-
ment. Depending on the institution, this team can
include an anesthesiologist, an otolaryngologist, a
general surgeon, and personnel from respiratory
therapy. The OR is the most controlled setting for
airway issues and, therefore, the least likely loca-
tion for an emergent surgical airway. The anes-
thesia team is well trained in different techniques
for establishing endotracheal intubation, and the
necessary equipment is readily available in the
OR. Surgeons are also present if emergent surgical
access by cricothyroidotomy is necessary, and the
OR provides the ideal setting in terms of lighting
and access to instruments. In some hospitals, an-
esthesiologists perform cricothyroidotomy usually
by a percutaneous approach.
It is essential that any provider who may be
required to perform a cricothyroidotomy has a thor-
ough understanding of the tools and instruments
required (Fig. 2). This understanding begins with
 Cricothyroid Approach for Emergency Access 437

Fig. 2. Instruments for open and percutaneous cricothyroidotomy. (A) Instruments for open cricothyroidotomy.
Variations in technique of open cricothyroidotomy may use different combinations of instruments. For example,
some techniques for the open approach omit the use of a tracheal hook or Trousseau dilator. A gum-bougie (not
shown) is an additional tool that can be used. (B) Percutaneous cricothyroidotomy (Melker kit). An example of
the contents of a percutaneous cricothyroidotomy kit based on the guidewire Seldinger technique. (Adapted
from Hebert RB, Thomas D. Cricothyrotomy and percutaneous translaryngeal ventilation. In: Roberts JR, Custalow
CB, Thomsen TW, editors. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th edi-
tion. Philadelphia: Elsevier; 2018. p. 127–41; with permission.)

knowing exactly where these supplies can be found
expeditiously. Depending on the location that an
airway emergency occurs, assisting providers
may not be able to readily acquire the materials
needed without direct instruction. The ED and OR
are areas where equipment is most easily acces-
sible. On the ward, emergency airway teams carry
a bag or container with all of the necessary supplies
for easy transport to any location given the often
unpredictable nature of airway emergencies.
TECHNIQUE
Open Cricothyroidotomy
The patients should be placed supine with the neck
extended if possible. Skin prep should be per-
formed expeditiously with betadine, chlorhexidine,
or any readily available product. Given the emer-
gent nature of the procedure, prepping the neck
should not delay establishing airway access. The
neck is examined and palpated to define the anat-
omy of the thyroid cartilage, cricoid cartilage, crico-
thyroid membrane, and sternal notch. The airway is
held fixed with the nondominant hand to maintain
its midline position during initial incision and
throughout the procedure. The location of the crico-
thyroid membrane should be repeatedly confirmed
with the index finger of the hand stabilizing the
airway. A vertical incision over the cricothyroid
membrane is performed. Vertical orientation is
preferred to horizontal because it avoids injury to
lateral vascular structures, such as the anterior ju-
gular veins. In addition, a vertical incision can be
easily extended in either direction to best expose
the cricothyroid membrane if the initial incision is
in a suboptimal location. After the initial incision
through the skin and subcutaneous tissue, the
nondominant hand spreads the incision to expose
deeper tissue for division. Caution should be taken
to avoid injuring the airway with the scalpel. Once
the cricothyroid membrane is visible or easily
palpable, a horizontal incision is made with enough
length to insert the tip of the fifth finger or the
scalpel handle into the cricothyroidotomy. Effort
should be made to make this incision along the su-
perior border of the cricoid cartilage rather than the
inferior border of thyroid cartilage. This incision min-
imizes the risk of injury to the vocal cords or
crossing vessels from cricothyroid vessels. Either
the finger or scalpel handle serves to maintain ac-
cess to the cricothyroidotomy. The cricothyroidot-
omy can be spread with a hemostat or a
Trousseau dilator as necessary with exposure
maintained with the nondominant hand, although
this requires an additional instrument to be avail-
able. A tracheal hook can be used to provide trac-
tion to optimize the cricothyroidotomy for
intubation. A tracheostomy tube or a small endotra-
cheal tube (6.0 mm) can be inserted directly or with
the aid of a gum-bougie in a Seldinger fashion.8 The
tube is connected to an Ambu bag (Ambu A/S,
Copenhagen, Denmark) and ventilation initiated.
Symmetric chest rise and bilateral breath sounds
should be present. A carbon dioxide monitor should
be connected to further confirm endotracheal
placement of the tube.
438 Bribriesco & Patterson
One variation of this technique is the rapid four-
step technique.9 The first step is palpation of the
cricoid membrane with the index finger while sta-
bilizing the airway with the thumb and middle fin-
gers. Step 2 is making a horizontal incision with a
No. 20 scalpel through the skin and cricothyroid
membrane simultaneously. The scalpel is held in
place within the airway allowing for insertion of a
tracheal hook to provide inferior traction (step 3).
The final step is insertion of a tracheostomy or
endotracheal tube into the incision over the
tracheal hook. Yet another option is the 3-step
technique initially described by MacIntyre and col-
leagues,10 which involves incision through the cri-
cothyroid membrane, insertion of a gum elastic
bougie into cricothyroidotomy, and tube place-
ment over the bougie.10,11
Early complications include delay in insertion,
creation of a false passage, injury to the membra-
nous portion of the airway, laceration or fracture of
the cricoid or thyroid cartilages, and injury to major
vascular structures.3,12,13 The rate of complica-
tions is higher when cricothyroidotomy is per-
formed in a prehospital setting.3
Percutaneous Cricothyroidotomy
Many providers who may be required to establish
a surgical airway will have limited surgical training.
Commercial cricothyroidotomy kits (Table 1)14
have been developed to simplify the procedure
and build on common clinical skills widely used
Table 1
Commercially available percutaneous
cricothyroidotomy kits
Seldinger Based Non-Seldinger Based
Arndt (Cook, Airfree (FRC Medizintechnik,
Bloomington, Holzheim am Forst,
IL, USA) Germany)
Melker (Cook, Patil’s airway (Cook,
Bloomington, Bloomington, IL, USA)
IL, USA) Pertrach (Pulmodyne,
Mini-Trach II Indianapolis, IN, USA)
(Smiths PCK (Portex
Medical Ltd, Cricothyroidotomy Kit)
Hythe, UK) (Smiths Medical Ltd,
Hythe, UK)
QuickTrach 1 and 2 (VBM
Medizintechnik GmbH,
Sulz, Germany)
TracheoQuick (Teleflex
Medical GmbH, Kernen,
Germany)
Data from Langvad S, Hyldmo PK, Nakstad AR, et al. Emer-
gency cricothyrotomy–a systematic review. Scand J Trauma
Resusc Emerg Med 2013;21:43.
by health care providers, such as the Seldinger
guidewire technique.15 The surface anatomy of
the airway is established as described for open cri-
cothyroidotomy. A small skin incision is made over
the cricothyroid membrane, and a needle with a
fluid-filled syringe is inserted and aspirated to
confirm entry into the airway. A guidewire is intro-
duced through the needle, and a specially
designed endotracheal tube is inserted over the
wire. In addition, there are kits available that do
not rely on a guidewire-based technique. These
kits use variations of an endotracheal tube pre-
loaded on a sharp trocar or needle that allows
rapid intubation of the airway once the cricothyroid
membrane is punctured. Mechanisms for safe en-
try and avoidance of injury to the membranous
portion of the airway have been devised. One
example is the Portex Cricothyroidotomy Kit
(Smiths Medical Ltd, Hythe, UK), which uses a
specialized needle that indicates when the tip is
against tissue (cartilage or posterior membranous
wall) or when it is in free space (airway lumen).
Complications of the percutaneous approach
include pretracheal or paratracheal tube place-
ment, subcutaneous emphysema, bleeding, and
injury to the posterior wall of the trachea or esoph-
agus.16–21 Most studies evaluating complications
were performed in experimental settings using
cadaver, animal, or manikin models. However,
given the extremely rare need for a surgical airway,
the true incidence and variety of clinical complica-
tions are difficult to determine for any cricothyroi-
dotomy approach.
Needle Cricothyroidotomy
Needle cricothyroidotomy is the most simple and
rapid method to obtain access to the airway but
has many limitations. It affords for oxygenation
through a small-caliber angio-catheter (12–14
gauge) but does not allow effective removal of car-
bon dioxide. The angio-catheter cannot be well
secured and so it should be emphasized that this
is a temporizing maneuver until a more secure
airway can be established. The procedure is per-
formed in a similar fashion to the percutaneous
Seldinger cricothyroidotomy approach. A 12- or
14-gauge needle with angio-catheter is attached
to a 5-mL syringe partially filled with saline. Sur-
face landmarks guide needle insertion into the cri-
cothyroid membrane at a 45 angle. The syringe is
gently aspirated during insertion until the airway is
entered as indicated by the appearance of air bub-
bles. The needle is removed leaving the angio-
catheter in place. Oxygen can be continuously
administered through the catheter, but exhalation
must occur to allow for ventilation and avoid
 Cricothyroid Approach for Emergency Access
barotrauma. For this purpose, a stopcock with one
port open to the atmosphere can be attached in
line with the angio-catheter and oxygen source
(Fig. 3). When the open port is occluded with a
finger, oxygen flows into the lungs. Uncovering
the open port stops the flow of oxygen and allows
limited ventilation. Alternatively, a syringe with a
side hole or a jet ventilator can be attached to
the angio-catheter. To avoid overinflation of the
lungs and allow ventilation, a ratio of 1 second of
inspiration to 3 seconds of expiration is recom-
mended. Chest rise and fall is a useful visual aid
to guide ventilation in this setting.
The complications associated with needle crico-
thyroidotomy are similar to the percutaneous
approach. As noted earlier, the appropriate inspi-
ration to expiration ratio must be maintained to
avoid barotrauma. Additionally, kinking of the
angio-catheter is a unique pitfall of this approach,
Fig. 3. Oxygenation and ventilation with needle crico-
thyroidotomy. One example of a system used for
oxygenation and ventilation via needle cricothyroi-
dotomy. Oxygen is delivered when the open port of
the stopcock is occluded with a finger, which allows
gas flow into the lungs. Exhalation and ventilation oc-
curs when the port is uncovered. (From Hebert RB,
Thomas D. Cricothyrotomy and percutaneous translar-
yngeal ventilation. In: Roberts JR, Custalow CB, Thom-
sen TW, editors. Roberts and Hedges’ clinical
procedures in emergency medicine and acute care.
7th edition. Philadelphia: Elsevier; 2018. p. 127–41;
with permission.)
439
and more rigid commercially available catheters
have been designed to address this problem.
RESULTS
The infrequency of CICV situations leading to crico-
thyroidotomy limits the ability to study and compare
outcomes of different techniques in the clinical
setting. Similarly, the low incidence of performing
the procedure limits providers from gaining real-
world experience and expertise. Most studies on
cricothyroidotomy are aimed at evaluating how
various groups of providers perform the procedure
using animal, cadaver, or manikin models. Metrics,
such as speed, learning curve, and injury to the
airway model, are used to estimate the efficiency
and safety of a particular approach. Many groups
feel strongly about the superiority of one technique
or a particular percutaneous kit over another. How-
ever, there is no strong evidence to definitively sup-
port open versus percutaneous cricothyroidotomy
or endorse a specific percutaneous kit. A recent
systematic review of 24 studies comparing different
approaches or kits concluded that the limited avail-
able evidence of low quality precluded any recom-
mendations.14 Interestingly, 17 of 24 studies
analyzed included the open surgical technique but
no surgeons or surgical residents were participants.
SUMMARY
Cricothyroidotomy is the final option for establishing
an airway in an emergency that has developed into
a CICV situation. Needle, open, and percutaneous
techniques have been developed and refined to
optimize the performance and success of the pro-
cedure. Paramedics, surgeons, ED physicians,
and anesthesiologists are some of the groups who
respond to airway emergencies and should be
familiar with the anatomy of the cricothyroid mem-
brane and the conduct of at least one approach to
emergency cricothyroidotomy. The particular tech-
nique or kit is not the key to success, but rather
the experience and training of the provider perform-
ing the procedure are the crucial factors for estab-
lishing emergency surgical airway access.
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