Cricothyrotomy and Emergency Airway Management

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). It is unclear when the first cricothyrotomy was performed and may originally date back to ancient Egypt. However, the first modern procedure was performed in 1909 by Dr. Chevalier Jackson as a treatment for diptheria. This procedure quickly fell out of favor and didn't return into the medical community until the 1970s. The cricothyrotomy is now the preferred method for establishing an emergent airway when other methods for oxygenation have failed.

Medical workers rushing a gurney down a corridor in an emergency room
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What are the Important Acronyms to Understand?

CICO is an acronym representing "cannot intubate, cannot oxygenate". This is a critical moment when your healthcare provider is not able to provide oxygen to you during an emergency situation. In this situation, non-invasive (CPAP or high-flow nasal cannula), minimally invasive (extraglottic airway devices) and invasive (endotracheal intubation) methods of providing oxygen have failed. While this occurrence is relatively rare, CICO is an emergency and requires immediate intervention because failure to oxygenate the brain can lead to brain injury that can result in death.

ET tube is an acronym representing the endotracheal tube. An endotracheal tube can be inserted through either the oral or nasal cavity. This tube is inserted past the vocal cords into your trachea. The ET tube is then connected to a device that will deliver oxygen directly to your lungs.

FONA is an acronym representing "front of neck airway". FONA forms of airway management include both tracheostomy (surgically placing a hole in the trachea) and cricothyrotomy (surgically placing a hole through the cricothyroid membrane into the trachea). FONA methods are only used when other forms that are less invasive have failed.

Forms of Airway Management

In general there four forms of airway management:

  • Bag-mask involves a facemask connected to a bag that can be squeezed to push oxygen through your nose and mouth into your lungs. This is the least invasive form of airway management. AMBU bag is a common example that you may hear.
  • Extraglottic airway devices (also known as supraglottic airway devices) are breathing tubes that are placed above the vocal cords. Laryngeal airway mask (LMA) is a common example.
  • Intubation places a breathing tube past the vocal cords. This can be inserted by either direct visualization or using video laryngoscopy.
  • Cricothyrotomy

What Is the Cricothyroid Membrane?

The cricothyroid membrane is a ligament that attaches the thyroid cartilage to the cricoid. The thyroid cartilage is located above your thyroid and in front of your larynx that houses your voice box. The top-middle part of the thyroid cartilage forms a "V" known as the laryngeal incisure. During puberty, men's voice boxes tend to grow more than in women, causing the base of the laryngeal incisure to grow. This increased growth creates the Adam's apple, which is also known as the laryngeal prominence. The cricoid is cartilage that surrounds the whole trachea.

How to Locate the Cricothyroid Membrane

Anatomy of the larynx
Anatomy of the larynx.  stock_shoppe

Locating the cricothyroid membrane takes some practice. If you are a clinician it is recommended that when you are doing neck exams you frequently palpate (touch) the structures needed to quickly identify the cricothyroid membrane. If you are just interested in knowing the location of the cricothyroid membrane, you can practice these techniques by yourself.

The laryngeal handshake method is one of the most popular methods to locate the cricothyroid membrane. If you are actually performing the cricothyrotomy, you would perform this method of locating the cricothyroid membrane with your non-dominant hand, as you would be performing the procedure with your dominant hand once the ligament was located.

Laryngeal Handshake Method

  1. Locate the hyoid bone with your thumb and index finger. The hyoid bone is horseshoe-shaped and is located just below your jawline and chin.
  2. Continue to slide your fingers down the side of the neck over the thyroid laminae of the thyroid cartilage. Laminae are thin plates. Where the plates that your thumb and index finger are over, you can feel the thyroid prominence (Adam's apple).
  3. Slide your thumb, index finger, and middle finger down from the thyroid cartilage. Your thumb and middle finger can rest on the hard cricoid (cartilage ring around your trachea) and you will be able to use your index finger to fit into a depression between the cricoid and thyroid cartilage.
  4. Your index finger now rests on the cricothyroid membrane.

Prevalence of Cricothyrotomy

Cricothyrotomy is performed as a result of difficult airways resulting in CICO. In the United States, it is estimated that about 10 to 15 out of 100 cases in the emergency department that require airway management are classified as having difficult airways. Not all difficult airways require a cricothyrotomy to be performed.

Prevalence of cricothyrotomy is not well understood. It varies from facility to facility as well as provider to provider. It is estimated around 1.7 out of 100 cases in the hospital require cricothyrotomy to restore airways in the emergency department while it is estimated that around 14.8 out of 100 cases required cricothyrotomy by paramedics before arriving at a hospital. With advancing technologies such as video laryngoscopy and advanced emergency management training, these numbers are probably actually a little higher than actually seen.

Does Having a Difficult Airway Increase My Risk of a Cricothyrotomy?

Whenever you are having a procedure that requires management of your airway, the anesthesiologist, anesthetist, or another provider will perform an airway assessment. In the United States, a common assessment pattern is known as LEMON, though many may not be familiar with the term but follow the general evaluation.

  • Look externally—an external look of facial features can sometimes provide a general sense of whether or not there may be difficulty managing an airway.
  • Evaluate (3-3-2 rule)—the three numbers are related to the number of fingers that can fit in oral cavity spaces (between incisors, the floor of the mouth, and distance from the base of the tongue to the larynx)
  • Mallampati score—named after an anesthesiologist that created an oral exam with 4 classifications. Class 1 and 2 Mallampati represents easy intubation, while class 3 represents difficult intubation and class 4 is reserved for very difficult intubations.
  • Obstruction and obesity—obesity and any masses in the neck can lead to narrowing airways making the intubation more difficult.
  • Neck mobility—decreased neck mobility reduces visibility during the intubation process.

Just because you are identified as someone that has a difficult airway does not necessarily mean that you are at high risk for a cricothyrotomy. Extraglottic airway devices such as the LMA have helped to reduce the need for more invasive procedures like the cricothyrotomy.

Indications for Cricothyrotomy

Only patients that are unable to manage their own airway, or have their airway managed by an anesthesiologist need to have a cricothyrotomy. When airway management cannot be achieved and CICO occurs, cricothyrotomy is required to ensure proper oxygenation of the brain. While cricothyrotomies are rarely required to manage an airway, here are the three most common categories of injuries that may require cricothyrotomy (listed in order of prevalence):

  1. Facial fractures
  2. Blood or vomit in the airways—massive hemorrhage, extreme vomiting
  3. Trauma to the airways or spine

Other reasons that may increase your risk for cricothyrotomy includes:

While some conditions can be linked as at-risk for requiring cricothyrotomy there are instances that cannot be anticipated. The urgency of performing a cricothyrotomy will differ in each circumstance based on how well you are able to maintain oxygen. Sometimes multiple attempts to perform intubation or try other techniques may be allowed, while other times, oxygenation will be the limiting factor requiring rapid advancement to performing a cricothyrotomy. It is important that hospitals and emergency services have difficult airway carts available with a cricothyrotomy kit.

Contraindications for Cricothyrotomy

In adults, there really are not any reasons to not perform a cricothyrotomy in an emergent situation. However, in children, there are some considerations that should be evaluated. Children's airways are smaller and more funnel-shaped than adults. This causes a narrowing around the cricothyroid membrane. Trauma to this can cause subglottic stenosis (or narrowing below the vocal cords) to occur as a result, which can lead to long-term breathing difficulties.

The guidelines on children are not as clear as adults. When considering whether or not a cricothyrotomy is appropriate, the anesthesiologist will consider age, size of the child, and physical findings of the neck. Age recommendations range from 5 to 12 years of age in performing a cricothyrotomy. If cricothyrotomy is not an option for the child, a tracheostomy will be surgically placed instead. This is performed below the level of the cricoid and towards the lower portion of the thyroid.

What is Included in a Difficult Airway Cart and Cricothyrotomy Kit?

It is important to have access to a difficult airway cart and a cricothyrotomy kit if you are in a hospital department that sees frequent airway emergencies such as the emergency department or the intensive care unit. Typically a difficult airway cart will contain:

  • Oral airways
  • Intubation supplies—laryngoscope, endotracheal tube, introducers, stylets, etc.
  • Different style blades for the laryngoscope
  • Extraglottic airway devices—LMA
  • Fiberoptic bronchoscope
  • Airway anesthetic products—Xylocaine, atomizers, etc...
  • Cricothyrotomy kit

A cricothyrotomy kit typically contains:

  • Scalpel
  • Yankauer suction
  • Small-bore endotracheal tube (ET)
  • ET holder or twill tape to secure tube once placed
  • 10-12 mL syringe
  • Trach hook
  • Dilator
  • Gauze

While all difficult airway carts and cricothyroid kits will be different, they will be very similar to what is listed above.

How Is a Cricothyrotomy Performed?

Since cricothyrotomy is a procedure that is not typically anticipated it is important to have a difficult airway cart and cricothyrotomy kit available in high-risk areas. There are several techniques that are used in performing a cricothyrotomy:

  • Standard technique
  • Rapid four-step technique
  • Seldinger technique

In general the standard technique is fast and safe enough to perform, however, it is believed that the rapid four-step approach may offer some time savings. Both the standard and rapid four-step technique utilizes a horizontal incision to break through the cricothyroid membrane, while the Seldinger technique uses a needle to penetrate and then using a guidewire to progress with the rest of the procedure.

Potential Complications Related to Cricothyrotomy

Since there are many structures close in proximity to the cricothyroid membrane, there are several complications that can unintentionally occur:

  • Unintentional laceration of other structures (thyroid cartilage, cricoid cartilage, or tracheal rings)
  • Tearing through the trachea other than the intended hole for the cricothyrotomy
  • Misplacement of the tube outside of the trachea
  • Infection

Is a Cricothyrotomy Permanent?

A cricothyrotomy is not usually permanent. After breathing function has been restored, your anesthesiologist will determine when it is safe to remove the breathing tube. Trials may be required, where the tube is left in place but the cuff (balloon) is deflated allowing you to breathe around the tube.

Once removed the hole that remains will either heal on its own or may require surgical repair to close the hole. The severity of the obstruction will determine whether or not you can have the tube removed while in the hospital or if you will need to have it at home for a period of time. If you will have cricothyrotomy in place, you will be taught how to care for the tube to prevent breathing problems or other complications.

2 Sources
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  1. Approach to the difficult airway in adults outside the operating room. (subscription required).

  2. Emergency cricothyrotomy (cricothyroidotomy). (subscription required).

Additional Reading

By Kristin Hayes, RN
Kristin Hayes, RN, is a registered nurse specializing in ear, nose, and throat disorders for both adults and children.