Chapter 13

In 1799, as George Washington lay dying of life threatening upper airway obstruction, one of his physicians, Elisha Cullen Dick, argued against further bloodletting and for tracheotomy. In retrospect this was the only lifesaving option available. It was not attempted and the President succumbed.1

Indications for surgical airway access vary from the elective through to impending airway compromise, and finally to the true emergency cannot intubate, cannot oxygenate scenario. This chapter will deal primarily with techniques of surgical airway access that the practitioner can use to deal with the difficult airway that presents either in the form of impending airway compromise or, the life-threatening emergency.

### 13.1.1 Why Cricothyrotomy and Not Tracheotomy?

The higher complication rate of emergency tracheotomy, compared to cricothyrotomy,2 results from the fact that the trachea is situated deeper in the neck, the posterior tracheal wall lacks the protection of a circumferential cricoid cartilage (increasing the risk of esophageal perforation), there is a greater abundance of adjacent vascular structures, and there is a proximity of the thyroid gland and lung. The palpable, often visible, surface landmarks of the thyroid and cricoid cartilages and the ability to accomplish the task faster, with a minimum of equipment, make emergency cricothyrotomy more attractive than tracheotomy, for the surgeon and nonsurgeon alike.3

As a consequence, all of the techniques to be discussed with the exception of percutaneous dilational tracheotomy (see Chapter 31) and possibly needle insufflation in children will involve access to the airway through the cricothyroid membrane (CTM).

### 13.1.2 What Is the History of Cricothyrotomy?

Surgical access to the airway has its origins in ancient times but it was the pandemic of morbus strangulatorius in Europe at the beginning of the 19th century that began its modern evolution. The French surgeon, Pierre Bretonneau, first attempted to relieve the laryngeal obstruction of this infectious laryngo-tracheal bronchitis by tracheotomy in 1818, finally meeting with success in 1825.4 His paper, published in 1826, gave the disease entity the name diphtheria,5 from the Greek diphthera meaning leather. This was in recognition of the thick, leathery, blue-white upper respiratory tract membranes characteristic of the disease.6 In the 20 years that followed, Armand Trousseau, Joseph Récamier, and MP Guersant, honed the technical aspects of bronchotomy7—laryngotomy and tracheotomy—and by 1851 Trousseau published his experience in 222 cases, 127 of whom survived.8

In the United States, Chevalier Jackson published further refinements to the technique in 1909.9 Ten years later (1921), he published a paper attributing the devastating complication of subglottic stenosis to high tracheotomy, concluding that the only acceptable point of access to the airway was below the first tracheal ring and that high tracheotomy should be abandoned.10 Jackson was a figure of immense authority11 and it is not surprising that high tracheotomy, or cricothyrotomy, was relegated to almost total ...

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