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A transcutaneous or surgical airway is indicated following unsuccessful orotracheal or nasotracheal intubation attempts in the context of an inability to mask ventilate and the presence of an immediate need for definitive airway management. The placement of a surgical or transcutaneous airway is the final endpoint for the “unsuccessful arm” of the emergency pathway for the American Society of Anesthesiologists (ASA) Difficult Airway algorithm. Once the presence of a “can’t intubate, can’t ventilate” situation is clear, a surgical or transcutaneous airway should be immediately considered. A delay can increase the patient’s risk of hypoxic brain injury and death. A surgical or transcutaneous emergent airway can be achieved using different methods, including a surgical cricothyrotomy, needle cricothyrotomy with jet oxygenation, and percutaneous cricothyrotomy using the Seldinger technique.


Cricothyrotomy is the creation of a surgical opening in the airway through the cricothyroid membrane (CTM) with the subsequent placement of a tube for ventilation. In an emergency situation, the speed, lower complication rate, and relative ease of performance make a cricothyrotomy preferable to a tracheostomy.

All difficult airway carts should contain the necessary instruments for the cricothyrotomy, which include a scalpel and a 5.0-7.0 cuffed endotracheal tube (ETT). Forceps and hemostats are optional. Briefly, the skin is prepared with standard antiseptic technique, the CTM is identified just superior to the cricoid cartilage, the trachea and larynx is stabilized with the nondominant hand, and a generous vertical incision is made over the membrane. The pretracheal tissue and fascia is rapidly divided, a horizontal incision is made through the CTM, the incision is dilated using an instrument or finger, and an ETT is inserted with the aid of a stylet to a depth of approximately 5 cm.

This procedure can be conducted in less than 30 seconds and provides a stable airway for up to 72 hours. Acute complications include procedure failure, hemorrhage, pneumothorax, pneumomediastinum, subcutaneous emphysema, and misplaced ETT. Tracheal stenosis and infection are the most common late complications. The only absolute contraindication is age less than 12 years. Traditionally, a needle cricothyrotomy is recommended for children younger than 12 years of age.

Percutaneous Cricothyrotomy

Because anesthesiologists are often hesitant to perform unfamiliar surgical procedures, other methods of establishing airway access are commercially available. These kits contain components that are based on the insertion of a needle and wire, followed by insertion of a cannula using a modified Seldinger technique. Although this procedure is considered simpler by nonsurgeons, it requires the execution of more steps than a surgical cricothyrotomy and is limited by the relatively small lumen of the cannula. This technique is preferred in children younger than 12 years as incision of the CTM can produce irreparable damage in this population.

Needle Cricothyrotomy with Jet Ventilation

This method of establishing a surgical ...

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