Open Cricothyrotomy

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

Open cricothyrotomy is an emergent surgical procedure. It is performed to establish an airway access by passage of a tube through an incision in the cricothyroid membrane. This is a procedure of choice in the feared "can't intubate, can't ventilate" scenario - when all other forms of endotracheal intubation have failed and the spontaneous ventilation is worsening or has become impossible.

The airway access is established via the tracheostomy tube. The tracheostomy tube consists of three parts: an outer cannula (or the tracheostomy tube itself), an inner cannula, and an obturator. During the procedure, the obturator is placed within the tracheostomy tube to guide the insertion, while the inner cannula is removed. The distal end of the obturator is rounded and protrudes through the end of the tracheostomy tube, allowing the practitioner to easily guide the tube into place without it being caught on the surrounding structures. In addition, the obturator prevents the tube clogging with tissue or the fluids during an insertion. Once the tube is placed, the obturator is removed and the inner cannula is placed within the tracheostomy tube. Alternatively, the procedure can be performed using the modified the endotracheal tube, which will be demonstrated in this video.

Cricothyrotomy is associated with significant complications and is performed only when less invasive measures have failed. However, it is preferred over tracheotomy (a procedure in which an opening is created between two tracheal rings), because of the lower risk of associated complications, relative rapidity with which it can be performed, and the predictable anatomy of the region.

Young age is considered a contraindication to open cricothyrotomy, as this procedure is associated with an increased risk of developing subglottic stenosis in children. However, there is disagreement among experts as to which age this procedure becomes acceptable. Opinions vary from 5 years to 12 years of age, and many consider this a relative contraindication. In young children, tracheotomy is preferred, and patients may be temporized with transtracheal jet ventilation through a needle cricothyrotomy for long enough to perform this more involved procedure. Other contraindications include fractured larynx or severe injury to the cricoid cartilage.