Cricothyroidotomy

Excerpt

Surgical airway techniques have been described for thousands of years, evolving significantly over time. Hieroglyphics indicate that ancient Egyptian surgeons may have practiced some form of this intervention. In 100 BC, Asclepiades of Bithynia completed the first documented elective surgical airway, though the term “tracheotomy” was not introduced until 1649 by Thomas Fienus.

Despite its 5,000-year history, the surgical airway remained an informal practice until the 20th century. In 1909, Dr. Chevalier Jackson, a laryngologist at Jefferson Medical School in Philadelphia, described a procedure he termed “high tracheostomy.” The method bore similarities to cricothyroidotomy and was used for patients with inflammatory airway conditions such as diphtheria. After reviewing nearly 200 cases of tracheal stenosis, Dr. Jackson ultimately discouraged the use of his technique, leading to its decline in practice.

In the 1970s, cricothyroidotomy returned to mainstream practice when Brantigan and Grow published a series involving 655 patients undergoing elective cricothyroidotomy. The review demonstrated a low complication rate, with only 0.01% of patients developing subglottic stenosis during prolonged mechanical ventilation. Emergency cricothyroidotomy currently remains the preferred surgical rescue technique for adolescents and adults.

Over the last 100 years, various methods have been developed to establish airway control through the cricothyroid membrane (CTM). Three primary approaches are presently in use.

Jet ventilation involves the percutaneous insertion of a small-caliber cannula, such as an intravenous angiocatheter, through the CTM. High-pressure oxygen is then insufflated into the trachea. However, because this technique relies on an unobstructed upper airway for passive expiration, it does not prevent hypercapnia and is unsuitable for prolonged ventilation.

The Seldinger technique utilizes commercially available kits containing large-caliber cannulas, typically at least 4 mm in internal diameter, which are inserted percutaneously over a guidewire. These devices allow for low-pressure ventilation and are available from various manufacturers.

The open surgical approach, specifically the rapid "scalpel-finger-bougie" technique, is the preferred method in emergency medicine. This technique requires minimal equipment and is readily available in the emergency department. The procedure involves making an incision through the CTM with a scalpel, inserting a finger into the trachea as a placeholder, and advancing a bougie to guide the placement of a cannula.

The incidence of surgical airway placement in prehospital and emergency department settings has declined over time. Recent data estimate cricothyroidotomy rates in prehospital care between 0.06% and 0.72%, while rates in emergency departments range from 0.14% to 1.4%.