Cricothyrotomy

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Cricothyrotomy is the creation of an opening in the cricothyroid membrane (CTM) to establish an effective airway. The primary indication is a cannot intubate-cannot ventilate scenario with actual or impending airway compromise and respiratory failure. Cricothyrotomy may be performed by passing a large bore cannula or needle through the CTM into the trachea (needle cricothyrotomy) or creating an opening through the CTM and passing an endotracheal tube or tracheostomy tube into the trachea (surgical cricothyrotomy). A needle cricothyrotomy is typically paired with jet ventilation to maintain oxygenation and is a temporizing measure because ventilation is often inadequate. Surgical cricothyrotomy is a definitive airway that allows the usage of conventional modes of mechanical ventilation. Contraindications to cricothyrotomy include tracheal transection, tracheal or laryngeal trauma, and/or anatomic distortion. Surgical cricothyrotomy is also contraindicated in infants and young children. Complications include bleeding, airway trauma, and/or incorrect placement.

See also “Surgical airway management.”

• Needle cricothyrotomy: the passage of a large-bore cannula through the cricothyroid membrane (CTM) into the trachea
  • Not a definitive airway: supports oxygenation, but the ability to ventilate is limited ^[2][3]
  • Most commonly used with jet ventilation. ^[2][3]
• Surgical cricothyrotomy: the passage of a tube into the trachea via an incision through the skin, cervical fascia, and CTM; provides a definitive airway.

The most common indication is a cannot intubate-cannot ventilate (CICV) scenario (e.g., after failed intubation), however, emergency surgical airways can be considered early in difficult airway management in select situations.

• Needle cricothyrotomy
  • CICV scenario in young children (in whom surgical cricothyrotomy is contraindicated)
  • CICV scenario in adults if the practitioner is not comfortable performing a surgical cricothyrotomy
• Surgical cricothyrotomy ^[2]
  • CICV scenario
  • Secure airway required (e.g., for emergency surgery) but unsuccessful oral intubation

Needle cricothyrotomy ^[3]

• Absolute
  • Tracheal transection
  • Severe laryngeal injury
• Relative
  • Distorted anatomy or massive edema
  • Coagulopathy
  • Complete upper airway obstruction

Surgical cricothyrotomy ^[2][4][5]

• Absolute
  • Infants and young children ^[2][6]
  • Tracheal transection
  • Laryngeal fracture
  • Obstruction distal to the CTM
• Relative
  • Infection at the site
  • Distorted anatomy

The ability to perform safe and timely endotracheal intubation is a contraindication to cricothyrotomy.

Tracheostomy is preferred for patients who need a permanent surgical airway without imminent signs of airway compromise, or if surgical cricothyrotomy is absolutely contraindicated.

We list the most important contraindications. The selection is not exhaustive.

The following applies to stab-twist-bougie-tube cricothyrotomy technique: ^[2][7]

• Sterile gloves and PPE
• Antiseptic solution
• Sterile drape
• Local anesthetic with epinephrine
• Syringe and small-gauge needle for local anesthetic
• Scalpel (e.g., No. 11, 20, or 10)
• Angled gum elastic bougie
• Appropriately sized tube
  • Adults: No. 4 Shiley tracheostomy tube or 6.0 cuffed ET tube
  • Large older children and adolescents: cuffless tubes are preferred; size depends on age ^[6][8]
• Lubricant
• Sterile gauze
• ETCO₂ detector
• Self-inflating manual ventilation bag

• Position the patient supine with their neck extended.
• Provide oxygen to the mouth and nose.
• Identify the CTM landmarks: the depression between the thyroid cartilage and cricoid cartilage
• Don PPE and sterile gloves.
• Perform skin preparation.
• Apply sterile drape (if time permits).
• Additional steps for surgical cricothyrotomy:
  • Administer local anesthesia (if the patient is conscious and time permits).
  • Apply a small amount of lubricant to the inside of the tube.

Surgical cricothyrotomy ^[2][7][11]

There are multiple techniques, e.g., open and percutaneous (using a type of Seldinger technique). The following technique is recommended in the 2015 Difficult Airway Society guidelines: ^[7]

Surgical cricothyrotomy is contraindicated in infants and very young children. ^[12]

Stab-twist-bougie-tube cricothyrotomy ^{[2][4][9][10][11]}

1. Grasp the cricoid cartilage between the middle finger and thumb of the nondominant hand.
2. Locate the CTM with the index finger.
3. Make an ∼ 1.5 cm-wide transverse incision through the skin, subcutaneous tissue, and CTM.
4. Turn the scalpel 90° to open the incision.
5. Insert the bougie (angled end first) directed toward the patient's feet.
6. Advance the bougie 10–15 cm.
7. Withdraw the scalpel.
8. Thread the lubricated tube over the bougie.
9. Advance the tube just until the cuff is no longer visible.
10. Inflate the tracheal tube cuff.
11. Remove the bougie and attach a self-inflating bag.
12. Verify intratracheal placement with positive EtCO₂.

Assessment of breath sounds, peak airway pressures, and capnography will help differentiate between common causes of hypoxia and/or inadequate ventilation after a cricothyrotomy.

• ET tube or tracheostomy tube secured
• Correct tube placement verified clinically
• CXR obtained
• Surgical team consulted for a definitive airway

• Bleeding
• Incorrect tube placement
• Mainstem intubation
• Pneumothorax
• Injury to laryngotracheal structures

We list the most important complications. The selection is not exhaustive.