Source: James W Bonz, MD, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA

A surgical airway procedure is indicated when other forms of endotracheal intubation have failed and ventilation is worsening or not possible. This is the feared "can't intubate, can't ventilate" scenario, and in the emergency setting, cricothyrotomy is the surgical procedure of choice.

Cricothyrotomy is preferred over tracheotomy because of the lower risk of complications, the predictable anatomy of the cricothyroid membrane, and the comparative rapidity with which the procedure can be performed—even by less experienced practitioners. Cricothyrotomy traditionally has been done in an "open" form; however, percutaneous cricothyrotomy using standard Seldinger technique has been advanced as a more successful approach when identification of the relevant anatomic landmarks is more difficult. Seldinger technique involves the introduction of a device into the body through the use of an introducer needle and a guide wire. The needle is used to locate the target; a guide wire is then fed through the thin-walled needle into the target, acting as a "placeholder" for the device, which is fed over the guide wire and into the target.

In the case of percutaneous cricothyrotomy, the practitioner first identifies the cricothyroid membrane by physical landmarks and makes a small vertical skin incision. A thin-walled 18-gauge needle (attached to a syringe) pierces the membrane, and the airway is positively identified when air is aspirated in the syringe. A guide wire is then fed through the needle. Standard cricothyrotomy sets include an airway catheter (similar to a tracheostomy tube) with a stiff dilator within its lumen. The catheter/dilator combination is fed onto the guide wire and the catheter/dilator is placed within the airway. The dilator and guide wire are subsequently removed, and the catheter is attached to a bag-valve device for ventilation.