Percutaneous Cricothyrotomy

Vinay Bangalore, MD, MPH
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Introduction

The protection and maintenance of a patent’s airway is extremely important. Airway maintenance procedures are highly useful skills to possess for all clinicians. They permit ventilation and oxygenation and prevent further complications in an emergency. 
Oral endotracheal intubation is the most common method of obtaining a secure airway. However, in certain situations, definitive airway control by means of intubation may be contraindicated or extremely difficult to perform. In such situations, cricothyrotomy may be the best way to establish an airway. 
Cricothyrotomy is a procedure that makes an opening in the cricothyroid membrane to obtain an airway. It differs from a tracheostomy, which is a procedure that makes an opening in the trachea between the second and fourth tracheal rings. The cricothyroid membrane is immediately subcutaneous in location. There are no overlying muscles and no major arteries, veins, or nerves in the region. These anatomic considerations make the cricothyroid membrane an ideal choice for gaining access to the airway when endotracheal intubation is not possible. 

Equipment

  • Melker emergency cricothyrotomy catheter set (Cook Medical), which includes these items:

  • Cricothyrotomy tube

  • Tapered curved dilator

  • Syringe

  • Disposable scalpel

  • Polytetrafluoroethylene (Teflon, PTFE, TFE) coated catheter needle

  • Guidewire with flexible tip

  • Trach tape

Indications

  • Inability to perform oral or nasal endotracheal intubation

  • Massive oral, nasal, or pharyngeal hemorrhage

  • Massive emesis

  • Laryngospasm

  • Mass effect (cancer, tumor)

  • Structural deformities of the oropharynx

  • Upper airway stenosis

  • Oropharyngeal edema

  • Foreign-body obstruction

  • Maxillofacial injuries

  • Cervical spine instability

Contraindications

  • Fractured larynx or significant damage to the cricoid cartilage (absolute contraindication)

  • Endotracheal intubation can be accomplished easily and quickly

  • Infants and children younger than 5 years old (relative contraindication)

  • Bleeding diathesis (relative contraindication)

  • Massive neck edema (relative contraindication)

The Procedure

Step 1

Place the patient in a supine position. Prep and drape the anterior neck using usual sterile precautions if time permits. Open the Melker emergency cricothyrotomy catheter set. 

Step 2

Advance the tapered end of the curved dilator into the connector end of the provided cricothyrotomy tube until the handle of the dilator stops against the connector. Lubrication may be used on the surface of the dilator to facilitate this step. 

Step 3

Identify and palpate the cricothyroid membrane between the thyroid and cricoid cartilages. Stabilize the thyroid cartilage with one hand, and make a vertical skin incision over the cricothyroid membrane using the scalpel with the other hand. Attach the syringe filled with 3 mL of saline to the catheter needle, and advance the needle through the incision into the airway. The tip of the needle should be directed at a 45-degree angle to the frontal plane in a caudal direction. Entrance into the airway will be confirmed by aspiration on the syringe, resulting in return of free air. 
  • Pearl: Make sure that the incision is large enough to allow passage of the dilator and the cricothyrotomy tube.

Step 4

Once in the airway, remove the syringe and needle, leaving the catheter in place. Advance the flexible end of the guidewire through the catheter into the airway. 

Step 5

Remove the catheter, leaving the guidewire in place. Advance the cricothyrotomy tube/dilator assembly over the guidewire until the proximal stiff end of the guidewire is completely through and visible at the handle end of the dilator. While maintaining the position of the guidewire, continue to advance the tube/dilator combination over the guidewire with a rotating motion until it is completely into the trachea. 
  • Pearl: Make sure to have control of the guidewire at all times to prevent its inadvertent loss into the trachea.

Step 6

Remove the guidewire and dilator simultaneously. Connect the airway catheter to a ventilator using its standard 15-mm connector. 

Step 7

Fix the cricothyrotomy catheter in place with tracheostomy tape strip in the standard fashion. 

Complications

Immediate or Early Complications

  • Common

    • Bleeding, hematoma

    • Incorrect/unsuccessful tube placement

    • Subcutaneous emphysema

  • Infrequent

    • Esophageal perforation

    • Mediastinal perforation

    • Pneumothorax, pneumomediastinum

    • Vocal cord injury

Late Complications

  • Common

    • Dysphonia

    • Persistent stoma

  • Infrequent

    • Subglottic or glottic stenosis

    • Tracheoesophageal fistula

    • Tracheomalacia

Pediatric Considerations

Although not an absolute contraindication, the procedure is not recommended in infants and children younger 10 years of age because of the difficulty in palpating and identifying important neck landmarks. 

Postprocedure Instructions

General tracheostomy care is given as for regular tracheostomy and consists of suctioning respiratory secretions and keeping the stomal wound and tube flanges clean with sterile saline. Tube ties that have been contaminated with secretions should be changed. 

Coding Information and Supply Sources

ICD-9 Codes

Supplier

Cook Medical, Inc., P.O. Box 4195, Bloomington, IN 47402-4195. Phone: 1-800-457-4500. Web site: http://www.cookmedical.com/

Bibliography

Cook Medical. Melker universal cricothyrotomy catheter set: instructions for use. http://www.cookmedical.com/cc/content/mmedia/C-T-UTCCSB304.pdf. Accessed January 2008.
Goldenberg D, Bhatti N. Management of the impaired airway in the adult. In: Cummings CW, ed. Otolaryngology: Head and Neck Surgery. 4th ed. Elsevier, Mosby; Philadelphia 2005. http://www.mdconsult.com. Accessed January 2008.
Mace SE, Hedges JR. Cricothyrotomy and translaryngeal jet ventilation. In: Roberts JR, ed. Clinical Procedures in Emergency Medicine. 4th ed. Saunders; Philadelphia 2004. http://www.mdconsult.com. Accessed January 2008.
Walls RM. Airway. In: Marx JA, ed. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 6th ed. Mosby; Philadelphia 2006. http://www.mdconsult.com. Accessed January 2008.
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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