Cricothyrotomy

Excerpt

The surgical airway is not a new concept in the world of medicine. Ancient Egyptian hieroglyphics indicate that surgeons may have performed this procedure thousands of years ago. In 100 B.C., Asclepiades of Bithynia completed the first documented elective surgical airway. In 1546, Antonio Mus Brassavola was the first to record a successful surgical airway, and Thomas Fienus first coined the term “tracheotomy” in 1649.

Despite 5,000 years of history, the surgical airway was not a formal surgical technique until 1909, when Dr. Chevalier Jackson, a laryngologist at Jefferson Medical School in Philadelphia, detailed a procedure he called the “high tracheostomy.” The high tracheostomy was utilized for inflammatory processes such as diphtheria. However, Dr. Jackson later condemned his procedure, having reviewed nearly 200 cases of tracheal stenosis secondary to cricothyrotomy, and the cricothyrotomy fell out of favor.

It wasn’t until the 1970s that cricothyrotomy returned to mainstream practice when physicians Brantigan and Grow published a low complication rate on a series of 655 patients undergoing elective cricothyrotomy. This review showed a low complication rate in 655 patients undergoing elective cricothyrotomy for prolonged mechanical ventilation, with only 0.01% of patients developing subglottic stenosis. Today, the emergency cricothyrotomy is now the surgical rescue technique of choice for the failed airway in adults. It is considered a more straightforward procedure than tracheostomy. Brantigan and Grow ultimately concluded that cricothyroidotomy is a delicate, well-tolerated procedure.

Over the last 100 years, several techniques have been described to obtain airway control via the cricothyroid membrane. Essentially, three different methods ultimately arrive at a controlled airway and are in use today.

1. A small caliber cannula (i.e., IV angiocath) can be inserted through the cricothyroid membrane percutaneously. High-pressure oxygen can then be insufflated into the trachea in a technique called “jet ventilation.” This technique requires an unobstructed upper airway for passive expiration and does not prevent hypercapnia. This technique is not suitable for long-term ventilation.

2. Large caliber cannulas developed by many medical companies can be inserted percutaneously through the cricothyroid membrane, often using the Seldinger technique over a guide wire. These cannulas are typically at least 4 mm in internal diameter, allowing for low-pressure ventilation.

3. Open surgical cricothyrotomy is the final pathway to the emergent airway. Over the last century, multiple techniques have been described, often complex and time-consuming, utilizing any number of specialized tools. However, given the time-sensitive nature of the emergent cricothyrotomy, the technique should be simple and rapid. The rapid “Scalpel-Finger-Bougie” technique is the preferred technique taught by airway experts across the field of emergency medicine.

The rate of performing cricothyrotomy varies among different settings. The National Emergency Airway Registry (NEAR) indicates that over ten years, 17,583 adult intubations were performed in emergency departments, of which about 25 patients (0.14 percent) received a primary surgical airway and about 55 patients (0.31 percent) received a rescue surgical airway. Another study on emergency medical services reported that, of the 57,209 patients requiring advanced airway management in the prehospital setting, only 286 patients (0.5 percent) underwent cricothyrotomy.

For the rest of this article, we will discuss the scalpel-finger-bougie technique when speaking of emergent cricothyroidotomy in the “cannot intubate, cannot oxygenate” (CICO) situation.