Reviewed and revised on July 21, 2021
- airway rescue procedure allowing transtracheal oxygenation
- also known as needle cricothyroidotomy
- “I can't intubate, I can't oxygenate"scenario
- occasionally performed semi-electively if difficult intubation and/or preoxygenation is anticipated
- local infection
- unrecognizable anatomy (eg, severe obesity, radiation deformity, trauma, edema, or mass lesion)
- previous failed attempts
Technique (as described by Andy Heard and colleagues, see their democannula insertion)
- Extensive patient consent and preparation is not usually possible in an emergency
- extend the patient's neck to optimize recognition of anatomy and ease of procedure
- Identify the cricothyroid membrane and stabilize it with the non-dominant hand. Palpate the membrane with the index finger of the non-dominant hand and stabilize the trachea with the thumb and middle finger.
- Hold a 5 ml syringe (containing 1-2 ml saline) attached to a 14G cannula in the dominant hand, with the fingers between the flange and the plunger. Filling the 5 ml syringe with 1-2 ml of saline allows demonstration of the end point of the bubbles at the entrance of the airway.
- Insert the needle through the skin at a 45 degree angle in a caudal direction. For the cannula to reach the airway, a more vertical approach may be required.
- Aspirate as you continuously advance the needle-cannula assembly into the airway. Stop advancing once air is aspirated, ensuring the tip of the cannula is in the trachea. Do not aspirate when the needle does not advance (can cause false positive atmospheric air aspiration)
- The end point is the free aspirating of air into the entire barrel of the 5 mL syringe.
- Stabilize the cannula hub with your non-dominant hand, then release the syringe plunger held by your dominant hand. If the tip of the cannula is positioned incorrectly, the plunger will be drawn back into the syringe barrel by the vacuum created by the suction out of the airway. The plunger will stay in place if the cannula is correctly placed in the airway.
- Place the dominant hand under the syringe, holding the needle in a pencil grip with the hand resting on the chin or neck to immobilize the cannula.
- Advance the cannula over the needle into the trachea using your non-dominant hand and remove the trowel. It should go in as easily as an IV. Do not remove the needle before advancing the cannula or the cannula will break.
- Make sure the cannula is kept firmly in place at all times.
- Using a syringe with 1-2 mL of saline, connect the cannula and repeat the complete free aspiration of air from the cannula. Again, the lack of piston recoil confirms vent placement. If the initial suction fails, gently remove the cannula while suctioning - free aspirating of air indicates that the tip of the cannula has hit the posterior wall of the trachea.
- Connect an appropriate source of oxygen supply and provide oxygenation
- Technique failure — most commonly due to:
- Bad technique (in a stressful situation)
- Twisting of the cannula
- Blood or vomit in the airway
- Difficult anatomy
- cannula obstruction
- cannula displacement
- injury to local structures (tracheal perforation, esophageal injury, nerve injury, vessel puncture)
- surgical emphysema (if high-flow oxygen is given through a poorly placed cannula)
Advantages of cannula cricothyroidotomy
- relatively safe and simple, fast technique
- The ability to provide oxygenation quickly
- The equipment and technique are more familiar to non-surgically trained professionals
- minimal blood loss
- It allows the situation to stabilize to facilitate further planning
- can be used to allow insertion of a Melker tube
- allows the creation of transtracheal oxygenation
- stabilization buys time to allow further planning
- transtracheal oxygenation may facilitate further laryngoscopic intubation attempts as oxygen escaping cranially through the glottis may allow recognition of
- can be rescued by other techniques (eg scalpel-based emergency surgical airway)
- determined in the NAP4 study to have a higher failure rate than scalpel-based surgical cricothyroidotomy)
- slower than emergency surgical airways using a scalpel (eg
- does not provide a definitive airway
- it does not allow effective ventilation, leads to hypercapnia and necessitates the subsequent provision of a definitive airway
- there may be a time delay of up to 1 minute before SpO2 improves after starting effective transtracheal oxygenation
- risk of surgical emphysema from jet emphysema and other complications (see above)
Cannula comparison (seevideoby Andy Heard and colleagues):
- the 14G Insyte cannula is preferred for cannula cricothyroidotomy as it is wide bore, kink resistant and has memory (recovers shape after deformation)
- other cannulae (eg standard Venflon and Ravussin cannulae) lack these properties
Common mistakes in technique
- Pre-loosening or separation of the cannula from the needle (can lead to false-positive air aspiration)
- Aspiration when removing the syringe from the cannula (also promotes separation of the cannula from the needle and the possibility of false-positive aspiration of atmospheric air)
- Unless it is understood that a steep angle of insertion will increase the possibility of impingement/perforation of the posterior tracheal wall. With a shallow insertion angle there is more depth to traverse and the cannula is more likely to be advanced caudally.
- Cannula mishandling (loss of control of syringe or cannula, disconnection or separation of cannula from needle leading to false positive air aspiration)
- Inserting the cannula too deeply (air aspiration will fail if the trachea becomes stuck before aspiration is attempted)
- Failure to advance the cannula from the needle, rather than withdrawing the needle from the cannula (increases the risk of kinking of the cannula)
- Failure to use a slow "suction as you go" technique instead of the "yoke back and forth" cannula insertion technique (risk of needle-cannula separation, compression of the tracheal lumen, and tracheal grafting)
- A 5 ml syringe is preferred, as using a 10 or 20 ml syringe is more difficult to control, with the hand too far from the cricothyroid membrane, and a 3 ml syringe has insufficient barrel volume to facilitate effective aspiration and the endpoint confirmation.
References and links
- CCC —Surgical cricothyroidotomy
- CCC —Cricothyroidotomy kit
- CCC —ENK oxygen flow delivery system
- CCC —I can't intubate, I can't ventilate
FOAM and web resources
- Cannula insertionby Andy Heard and colleagues (video, highly recommended)
- Cannula comparisonby Andy Heard and colleagues (video, highly recommended)
Chris is an Intensivist and ECMO specialist atAlfred ICUin Melbourne. It is also aAssociate Clinical Assistant Professor at Monash University.He is a co-founder ofAustralian and New Zealand Clinical Educators Network(ANZCEN) and is the lead for theANZCEN Clinician Educator Incubatorprogram. He is a member of the Board of Directors forIntensive Care Foundationand is a First Party Examiner for theCollege of Intensive Care. He is an internationally recognized Clinician Educator with a passion for helping clinicians learn and improve the clinical performance of individuals and teams.
After completing his medical degree at the University of Auckland, he continued his postgraduate training in New Zealand as well as Australia's Northern Territory, Perth and Melbourne. He has completed fellowships in both critical care and emergency medicine, as well as postgraduate training in biochemistry, clinical toxicology, clinical epidemiology and health professional education.
He is actively involved in the use of translational simulation to improve patient care and process and systems design at Alfred Health. Coordinates Alfred ICU training and simulation programs and manages the unit's training website,INTENSIVE. He created the Critically Ill Airway course and teaches many courses around the world. He is one of its foundersFOAMmovement (Free Open-Access Medical Education) and is its co-creatorlitfl.com,TheRAGE podcast, TheRefreshingcourse, and theSMACCconference.
One of his great achievements is that he is a father of three amazing children.
On Twitter, it is@precordialthump.
Hello. I think where it says Rasmussen cannulae it means Ravussin
Right! Thanks - I fixed the error.
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There are 3 main approaches to cricothyroidotomy: needle cricothyroidotomy, percutaneous cricothyroidotomy using the Seldinger technique, and surgical cricothyroidotomy (see the videos below).What is the difference between cricothyrotomy and cricothyroidotomy? ›
Cricothyrotomy (also called cricothyroidotomy) is a procedure that involves placing a tube through an incision in the cricothyroid membrane (CTM) to establish an airway for oxygenation and ventilation.Why is tracheostomy preferred over cricothyroidotomy? ›
Tracheostomy is preferably done in an operating room by a surgeon. In emergencies, the procedure has a higher rate of complications than cricothyrotomy and offers no advantage. However, it is the preferred procedure for patients requiring long-term ventilation.What is the difference between open cricothyrotomy and needle cricothyrotomy? ›
1 With needle cricothyrotomy, a needle or small cannula is passed percutaneously through the cricothyroid membrane to permit translaryngeal jet ventilation (TLJV),1–3 whereas an open, or surgical, cricothyrotomy is the use of surgical means (eg, scalpel) to create the opening in the cricothyroid membrane,1–4 and a ...What are the two types of intubation? ›
Direct and video laryngoscopy are the two most common approaches utilized for endotracheal intubation.What are the three types of airway devices? ›
The different types of medical devices used to maintain or open an individual's airway include the oropharyngeal airway (OPA), nasopharyngeal airway (NPA), and endotracheal airway (ETA).Which is better tracheotomy or cricothyroidotomy? ›
surgical cricothyroidotomy is preferable to a tracheostomy for most patients who require the establishment of an emergency surgical airway, because it is easier to perform, associated with less bleeding, and requires less time to perform than an emergency tracheostomy."Can Emts perform cricothyrotomy? ›
Prehospital Surgical Airway - EMTprep. One of the most invasive airway procedures that can be performed by a paramedic is a surgical cricothyrotomy. Although infrequent, this procedure could mean the difference between life and death for a patient when there are no other means of securing their airway.Can nurses perform cricothyrotomy? ›
Surgical cricothyrotomy in the field Can be performed reliably by specially trained nurses.What is the most common complication of cricothyrotomy? ›
A systematic review by DeVore et al found that the most frequent early complication after emergency surgical cricothyroidotomy was failure to obtain an airway; the most common long-term complication was airway stenosis.
The single most important contraindication for cricothyroidotomy is laryngeal pathology.What are the absolute contraindications for cricothyrotomy? ›
Contraindications to cricothyrotomy include tracheal transection, tracheal or laryngeal trauma, and/or anatomic distortion. and young children. Complications include bleeding, airway trauma, and/or incorrect placement. See also “Surgical airway management.”Do anesthesiologists do cricothyroidotomy? ›
Cricothyroidotomy, a technique which is faster and requires less surgical skill, can be performed by anesthesiologists, and is the preferred procedure.How do you ventilate a cricothyroidotomy? ›
Airway management and ventilation—needle cricothyroidotomy. A 14 G intravenous cannula, or preferably a purpose made cricothyroidotomy cannula, is attached to a high-pressure oxygen supply and ventilation achieved by occluding the open limb of a 3-way tap with a finger.Is cricothyrotomy horizontal or vertical? ›
A cricothyrotomy is generally performed by making a vertical incision on the skin of the throat just below the laryngeal prominence (Adam's apple), then making a horizontal incision in the cricothyroid membrane which lies deep to this point.Which lung is easier to intubate? ›
Accidental intubation of a bronchus is more common on the right because the right main bronchus is more vertically orientated than the left main bronchus.What are the 4 drugs for intubation? ›
 Common sedative agents used during rapid sequence intubation include etomidate, ketamine, and propofol. Commonly used neuromuscular blocking agents are succinylcholine and rocuronium. Certain induction agents and paralytic drugs may be more beneficial than others in certain clinical situations.What is the best paralytic for intubation? ›
To this day, succinylcholine is the only depolarizing agent used for rapid sequence induction. Because of its rapid onset, ultrashort duration of action, and safety, it is the paralytic of choice in almost all cases of rapid sequence induction in adults.What is a 3 way airway maneuver? ›
The triple airway manoeuvre is used to maintain a patent upper airway and combines head tilt, jaw thrust and mouth opening. It must be remembered that the simple act of positioning a patient in a lateral position is a form of basic airway management.What are the 3 ways to open an airway? ›
- Head Tilt. Tilting the head back tends to allow the larynx to rise away from the posterior pharyngeal structures, opening the airway. ...
- Jaw Thrust. ...
- Triple Airway Maneuver. ...
- Head and Neck Neutral. ...
- Head and Neck Fully Flexed. ...
- Head and Neck Fully Extended.
An endotracheal tube is the definitive method to secure a compromised airway, limit aspiration, and initiate mechanical ventilation in comatose patients, in patients who cannot protect their own airways, and in patients who need prolonged mechanical ventilation Overview of Mechanical Ventilation Mechanical ventilation ...Why would you do a tracheostomy instead of intubation? ›
A tracheostomy (trach) is a procedure in which a doctor surgically makes an incision in the trachea, sometimes called the “windpipe.” Tracheostomy procedures are performed when there is an obstruction in the airway and intubation is medically not possible, a patient has inefficient oxygen delivery or has problems with ...What is an emergency tracheotomy called? ›
In an emergency situation, the more appropriate term is a cricothyroidotomy—an opening in the membrane below the Adam's apple and before the firmer cartilage of the trachea begins.What is an alternative to tracheal intubation? ›
An alternative device is the specifically designed intubating laryngeal mask airway (iLMA). Using this method the insertion of the tracheal tube is blind, increasing the potential for traumatising the airway and successful intubation is not guaranteed at first pass.How long is the incision for a cricothyrotomy? ›
Movement of the cricothyroid membrane on transition from the neutral to extended neck position varied from 15 mm caudad to 27 mm cephalad. The minimum incision required in the extended position was 70 mm in males and 80 mm in females, commencing 30 mm above the suprasternal notch.Can you intubate in an ambulance? ›
Field intubation is the placement of an advanced airway or endotracheal tube (ET) by emergency medical services (EMS) personnel outside the hospital setting. Endotracheal tube intubation (ETI) has long been the standard for airway control in the prehospital setting and is the focus of this activity.Can you intubate as a paramedic? ›
Paramedics are trained to perform endotracheal intubation (ETI), though a step-wise airway management approach has led to the use of supraglottic airway devices (SGAs), often in place of ETI.Should the nurse suction a patient with a tracheotomy? ›
Nurses must ensure that everything remains sterile during the process to prevent potential infections. A nurse knows when a patient needs tracheostomy suctioning when the patient is coughing, having difficulty breathing, gurgling, breathing quickly, or making bubbly sounds.What is the minimum training required for successful cricothyroidotomy? ›
While clinical correlates are not known, the authors recommend that providers of emergency airway management be trained on mannequins for at least five attempts or until their cricothyroidotomy time is 40 s or less.How long can a cricothyroidotomy last? ›
Traditional surgical teaching has dictated that a cricothyrotomy tube placed for emergency 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 subglottic stenosis.
Cricothyrotomy, whether traditional surgical cricothyrotomy or percutaneous cricothyrotomy using a guidewire, uses an incision through the skin and cricothyroid membrane through which an artificial airway is inserted into the trachea.Can nurses perform surgical cricothyrotomy with acceptable success and complication rates? ›
Finally, two patients developed subglottic stenosis. Conclusion: Surgical cricothyrotomy in the field can be performed reliably by specially trained nurses.What are the risks of cricoid pressure? ›
The recommended pressure to prevent gastric reflux is between 30 and 40 Newtons (N, equivalent to 3-4 kg), but pressures greater than 20 N cause pain and retching in awake patients and a pressure of 40 N can distort the larynx and complicate intubation.What structures must be penetrated in an emergency cricothyroidotomy? ›
Cricothyrotomy is an elective or emergency procedure to establish an airway outside of the oral cavity by creating an incision in the cricothyroid membrane to access the trachea with either a small or large bore tube (cannula).Why cricothyroidotomy is not done in children? ›
AIRWAY ANATOMY IN CHILDREN AND CURRENT GUIDELINES
A percutaneous technique can result in tracheal compression and posterior wall perforation, while surgical cricothyroidotomy is discouraged due to the risk of fracturing the laryngeal cartilage.
The procedure involves inserting a hollow needle into the throat just below the thyroid cartilage and should only be performed by a medical professional.What is the smart mnemonic for difficult cricothyrotomy? ›
Assessment for difficult cricothyrotomy can be performed by patient history and physical examination. The mnemonic “SMART” is a tool that can used to assess for difficulties that may occur: S: Surgery; M: Mass; A: Access or Anatomy; R: Radiation; and T: Tumor.What is a relative contraindication of cricothyrotomy? ›
Relative contraindications for the creation of an emergency surgical airway include the following: Airway obstruction distal enough to the cricoid membrane that a cricothyroidotomy would not provide a secure airway with which to ventilate the patient.Is there a tube down your throat during anesthesia? ›
Once you're asleep, the anesthesiologist or CRNA may insert a flexible, plastic breathing tube into your mouth and down your windpipe. The tube ensures that you get enough oxygen. It also protects your lungs from oral secretions or other fluids such as stomach fluids.Can paramedics do cricothyrotomy? ›
One of the most invasive airway procedures that can be performed by a paramedic is a surgical cricothyrotomy. Although infrequent, this procedure could mean the difference between life and death for a patient when there are no other means of securing their airway.
Enhancing Healthcare Team Outcomes
surgical cricothyroidotomy is preferable to a tracheostomy for most patients who require the establishment of an emergency surgical airway, because it is easier to perform, associated with less bleeding, and requires less time to perform than an emergency tracheostomy."
In the emergency setting, a cricothyroidotomy can be created using one of three techniques . A 'needle airway' using a 12–14-gauge cannula can be inserted into the trachea via the cricothyroid membrane (Fig.What are the absolute contraindications for cricothyroidotomy? ›
The only absolute contraindication to surgical cricothyroidotomy is age, although the exact age at which a surgical cricothyrotomy can be safely performed is controversial and has not been well defined.Is cricothyroidotomy above or below the vocal folds? ›
A cricothyroidotomy enters the larynx in the midline just below the vocal cords.What are the different types of tracheostomy procedure? ›
- Surgical tracheotomy can be performed in an operating room or in a hospital room. ...
- Minimally invasive tracheotomy (percutaneous tracheotomy) is typically performed in a hospital room.
The Melker® and Quicktrach 2® devices appear to hold particular promise as alternatives to surgical cricothyroidotomy. Further studies, in more clinically relevant models, are required to confirm these initial positive findings.What are the different types of intubation? ›
- Endotracheal intubation- This is broad term that encompasses a tube going from the oropharynx to the trachea. ...
- Orogastric intubation.
- Nasogastric intubation.
- Fiberoptic intubation.
- Surgical Airway.
There are four variations of the laryngeal tube: standard laryngeal tube, disposable laryngeal tube, laryngeal tube-Suction II and disposable laryngeal tube-Suction II. The design of the device has been revised several times. Insertion of the standard laryngeal tube is as easy as with the laryngeal mask airway classic.What is the difference between the inner and outer cannula for a tracheostomy? ›
With this type of tracheostomy, the outer tube acts as a permanent tube which remains in the stoma. The inner cannula acts as a removable liner. The inner cannula can be removed and cleaned, or discarded and replaced.What are the two most common types of tracheostomy tube in terms of design? ›
Tracheostomy tubes can be cuffed or uncuffed. Uncuffed tubes allow airway clearance but provide no protection from aspiration. Cuffed tracheostomy tubes allow secretion clearance and offer some protection from aspiration, and positive-pressure ventilation can be more effectively applied when the cuff is inflated.
One person holds the tracheostomy tube securely in place. The second person removes the existing Velcro ties and then inserts the clean Velcro ties through one side of the flange, passing the tie around the back of the patient's neck and inserting the Velcro tie through the other side of the flange.Is cricothyrotomy better than tracheostomy? ›
surgical cricothyroidotomy is preferable to a tracheostomy for most patients who require the establishment of an emergency surgical airway, because it is easier to perform, associated with less bleeding, and requires less time to perform than an emergency tracheostomy."What is the difference between trach tube and intubation? ›
An endotracheal tube is an example of an artificial airway. A tracheostomy is another type of artificial airway. The word intubation means to "insert a tube". Usually, the word intubation is used in reference to the insertion of an endotracheal tube (Image 1).What are three types of intubation tubes? ›
The three types of intubation stylets inserted in the tracheal tube: (a) Arcuate shape malleable stylet, (b) McGrath MAC- shaped malleable stylet and (c) McGrath MAC-shaped rigid stylet.What is the best intubation technique? ›
Hold the preselected tube in your right hand like a pencil, curve forward. Pass the tube into the larynx through the cords in one smooth motion. If the patient is breathing, time the forward thrust for inspiration when the cords are fully open.What is the difference between LMA and ET tube? ›
The LMA has many advantages over the ETT, such as having no direct contact with the tracheal mucosa, no need for direct laryngoscopy during inserting, and less adverse events such as lower frequency of coughing and decreased oxygen saturation during emergence, and lower incidence of sore throat in adults .What is an intubating LMA called? ›
The LMA Fastrach, also called the ILMA is specifically designed to facilitate blind intubation. It is available in both reusable and disposable forms and has a handle designed to allow for optimal positioning and a bar designed to elevate the epiglottis out of the way to facilitate intubation.What are the names of intubation tubes? ›
Types of endotracheal tubes include oral or nasal, cuffed or uncuffed, preformed (e.g. RAE (Ring, Adair, and Elwyn) tube), reinforced tubes, and double-lumen endobronchial tubes.