Overview of Cricothyrotomy
Surgical airways, or procedures done to help a person breathe, aren’t a new idea in medicine. Ancient Egyptian art suggests that these types of surgeries have been done for thousands of years. The first known surgical airway was done back in 100 B.C. by a person named Asclepiades of Bithynia. Fast forward to 1546, Antonio Mus Brassavola was recognized for performing the first successful surgical airway. Later, in 1649, the term “tracheotomy” was introduced by Thomas Fienus.
Although this procedure has a long history, it wasn’t officially termed a surgical process until 1909. During this year, Dr. Chevalier Jackson, a throat doctor at Jefferson Medical School in Philadelphia, defined a procedure which later, he called the “high tracheostomy.” This technique was used for inflammatory diseases like diphtheria. However, after seeing around 200 cases of trachea narrowing due to this procedure, Dr. Jackson spoke out against it, and as a result, it became less popular.
In the 1970s, the procedure made a comeback. Doctors Brantigan and Grow found that the procedure had a low complication rate, based on a study of over 655 patients. Nowadays, when an adult’s airway fails, the go-to rescue method is an emergency surgical airway. This procedure is considered simpler than a tracheostomy.
There have been several techniques developed over the last century to get control of the airway via the cricothyroid membrane, which is a band of tissue in the throat. Today, there are three main methods used:
1. The first technique involves the use of a small caliber cannula, a thin tube that is inserted through the cricothyroid membrane. High-pressure oxygen is then inserted into the trachea using a method known as “jet ventilation.”
2. The second technique involves the use of larger caliber cannulas that are inserted through the cricothyroid membrane, often using the Seldinger technique over a guide wire. These cannulas are typically at least 4 mm in internal diameter, which allows for low-pressure ventilation.
3. Lastly, there’s open surgical cricothyrotomy which is typically done in emergencies. Despite the numerous techniques described over the last century, the rapid “Scalpel-Finger-Bougie” technique is preferred by emergency medicine experts due to its simplicity and speed.
Few people end up needing this procedure. Research shows that of the 17,583 adult intubations performed in emergency departments over ten years, only about 80 people (0.39 percent) needed a surgical airway. In the remainder of this article, we’ll discuss the scalpel-finger-bougie technique used in emergent cricothyroidotomy for situations where it’s impossible to insert a breathing tube or supply oxygen (known as “cannot intubate, cannot oxygenate” situations).
Anatomy and Physiology of Cricothyrotomy
A cricothyrotomy is a medical procedure where a tube is inserted into your neck via a small cut in a part called the cricothyroid membrane. This membrane is located in the neck and its location is essential for doctors doing this procedure especially in emergency cases.
Think of the cricothyroid membrane as a gate located between two walls. The wall above it is the thyroid cartilage, also known as the “Adam’s Apple.” The wall below is called the cricoid cartilage, which feels like a small rounded ring. On both sides of this gate or membrane are the cricothyroideus muscles.
When the doctor does the procedure, he or she will first feel for your Adam’s Apple. Then, the doctor will move their hand down to find the round signet ring, which is the cricoid cartilage. The small depression or dip they feel in between these two structures is the cricothyroid membrane, which is usually about 2 cm below the Adam’s Apple. That’s where the cut is made to insert the tube.
Why do People Need Cricothyrotomy
An emergency cricothyrotomy is a last resort procedure used in managing emergency breathing situations. This procedure becomes crucial when traditional methods of administering oxygen don’t work, a situation often referred to as “Cannot Intubate, Cannot Oxygenate” or CICO. Not addressing a CICO situation promptly can lead to a lack of oxygen in the brain and could potentially cause the patient’s death. In such instances, an immediate alternative airway must be established, and that’s where an emergency cricothyrotomy comes in.
Certain situations may cause a CICO scenario and require an emergency cricothyrotomy. These include:
- Oral or facial trauma: This refers to any injury to the mouth or face.
- Cervical spine trauma: This is an injury to the neck part of the spine.
- Profuse oral hemorrhage: This means severe bleeding from the mouth.
- Copious emesis: This means severe vomiting.
- Anatomic abnormalities that prevent endotracheal intubation: Sometimes, the shape or structure of a person’s throat or airway might make it impossible to insert a tube to assist with breathing.
In these situations, a physician might need to perform an emergency cricothyrotomy to ensure the patient continues to receive oxygen.
When a Person Should Avoid Cricothyrotomy
In some extreme emergencies when it’s very hard to breathe (known as a CICO situation), a procedure called cricothyrotomy might be needed right away. This procedure involves creating an opening through the neck and into the windpipe to assist with breathing. There’s no situation where one absolutely cannot have cricothyrotomy.
However, there are some situations where cricothyrotomy might not be the best choice. If a person might be having, or has previously had, surgery on their windpipe, that could be a problem. If a person has a broken voice box (larynx), or other damage to the area where the voice box connects to the windpipe, these are also situations to be cautious. Lastly, it’s not the first choice in children.
Patients with an urgent disease of the voice box may be at increased risk of a condition called subglottic stenosis. This is a narrowing in the windpipe just below the voice box, making a planned cricothyrotomy a bit risky.
For children between 5 to 12 years old, cricothyrotomy can be tricky. Children’s airways are shaped more like a funnel, and performing cricothyrotomy could increase the risk of their windpipe narrowing in the future, just like subglottic stenosis mentioned before.
Equipment used for Cricothyrotomy
If a treatment called a cricothyrotomy is needed, there’s a specific list of equipment that the doctor must have on hand. This treatment involves making an incision in your neck and inserting a tube into your windpipe to help you breathe. Here’s what the doctors will use:
First, they use something called a Yankauer suction. This tool helps clear fluids from your mouth or throat. Following this, the doctor will use a scalpel, specifically a number 20 blade if possible, to make the necessary incision. A scalpel is a small sharp knife that doctors use in surgery.
Then, they will need a Gum elastic bougie. This long, thin piece of equipment is used to guide the tube into the right spot in your windpipe. The actual tube used is known as a cuffed tracheostomy tube 6.0. This tube helps you breathe when it’s hard to do so on your own.
After the tube is placed, a ten cc syringe is used to inflate the cuff on the tube which helps keep it in place. Next is the securement device, which is used to keep the tube firmly in position. Lastly, the tube is connected to a ventilator and associated tubing. A ventilator is a machine that moves breathable air into and out of the lungs, to help a patient breathe.
Who is needed to perform Cricothyrotomy?
A doctor, often known as a physician, is the main person who takes care of your health. They diagnose and treat illnesses, and help you stay healthy. They are like the captain of your healthcare team.
Nurses are another crucial part of your healthcare team. They provide a variety of care depending on your health needs. This can include help with medications, wound care, and answering any questions you might have about your health or treatment.
A respiratory therapist is a specialist who takes care of your lungs and breathing. If you have problems with your lungs or breathing, they can help you. They are especially important if you have conditions like asthma or pneumonia, or if you’re in the hospital and need help breathing.
Preparing for Cricothyrotomy
Getting a patient’s permission and explaining them, the risks, benefits and any possible problems of a procedure are important parts of any treatment. However, under emergency situations, such as during breathing crises, there’s often no time for detailed explanations. Ideally, the doctor should discuss all this beforehand with patients who might face problems in managing their airways.
It’s worth noting that performing emergency procedures such as getting access to the windpipe in a breathing emergency, is as straightforward as other emergency treatments. However, there can be a mental block when doctors think of terms like “failed airway” or “cannot insert a breathing tube or supply oxygen”. This can create a false sense of personal failure, which could result in a delay in acting. Practicing on training models can help doctors be more comfortable with these techniques and therefore, respond swiftly and confidently when they are actually needed.
Before starting any procedure that involves inserting a breathing tube, especially for difficult cases, a doctor should follow a series of steps aimed at managing breathing problems. This can reduce the stress and difficulty associated with performing an emergency procedure to open the airways. It’s important to share the planned actions with the healthcare team so everyone knows what’s expected.
The doctor should also be able to identify key parts of the neck in case it becomes necessary to perform an emergency procedure to open the airways. Lastly, all the required equipment should be accessible at a moment’s notice.
How is Cricothyrotomy performed
Before a procedure that may cause a difficult breathing situation, it’s important to locate a part of your throat called the cricothyroid membrane (CTM). This can be especially crucial in emergencies, as accessing the CTM can help prevent complications like incorrect placement of medical devices, injury to nearby structures, or trauma to the airway. It should be located in all patients, particularly before using any medication that puts you to sleep (anesthesia), or when necessary in critical care situations. There are several ways to find the CTM. Looking at the front of your neck is effective about half the time, so you shouldn’t depend on this method alone. The other way is by feeling (palpating); however, this can vary depending on one’s gender, position, and body type. It is often more challenging to find it in women, compared to men.
The Difficult Airway Society recommends a three-step technique known as the “laryngeal handshake” technique. In situations when physical examination isn’t enough, ultrasound can be used to confirm the position of the CTM. It can be particularly helpful in patients with severe obesity.
Medical literature describes many techniques and tools to access the trachea (windpipe) using the CTM. One widely supported method within the Emergency Medicine and Critical Care community is the “Three-Step Method,” which combines crucial steps from different established techniques. This process aims to provide a simple process to increase success in high-stress situations when this procedure is often performed.
1. Start by using the fingers of your less dominant hand to find the CTM, while using your thumb and middle finger to keep the throat steady.
2. Make a small vertical cut over the CTM.
3. Carefully feel through the tissue under the skin until you can identify the CTM, ignoring any bleeding.
Next, use a scalpel to cut the CTM horizontally, insert your finger through the cut, then insert a narrow rubber device called a bougie through the cut and into the windpipe for airway management. Afterward, pass a cuffed tube over the bougie and inflate the cuff. Finally, confirm the placement using a bag valve mask (a device used to provide breaths) and secure the tube in place using a securement device.
The other standard method involves physically feeling the CTM, making a vertical cut in the skin over the CTM, then making a horizontal cut through the membrane. Tools such as a tracheal hook and a dilator are used to extend the cut, after which a tube is inserted into the windpipe.
In a procedure called Needle Cricothyroidotomy, the CTM is stretched across the skin using the thumb and middle finger. An angiocatheter (a flexible tube) attached to a syringe filled with saltwater is used to puncture the CTM. Air bubbles in the syringe indicate placement in the windpipe. The instrument is then advanced, the needle is removed, and the position is confirmed with the saline syringe. The tube is kept in place by holding it at all times and is not to be held by stitches. It’s then connected to a device providing high-pressure oxygen. The patient is given breaths at a rate of 10-12 per minute, with a 1:4 inhalation to exhalation ratio.
Possible Complications of Cricothyrotomy
An emergency cricothyrotomy, which is the final step of the “Can’t Intubate, Can’t Oxygenate” (CICO) method, is typically performed to save a patient’s life when they can’t breathe. Although it’s a drastic procedure, the immediate need to help the patient breathe far outweighs any potential risks involved. However, like all medical procedures, it can bring about certain complications.
The frequency of these complications varies a lot between studies, from none at all to over half of cases having some kind of issue. The dependability of these reports mainly depends on the unique circumstances of the patient, the experience of the medical team, and where the procedure takes place. Bleeding is the most common difficulty encountered, but this is somewhat expected during the process. If severe bleeding happens, the medical team will apply pressure or pack the site to control it.
There can also be other complications right after the procedure, such as damaging the tracheal cartilages, which form the structure of the windpipe, creating the hole in the wrong place, or causing an infection. In rare instances, a tube might accidentally be placed in the wrong location, creating a false path instead of entering the windpipe.
In the long-term, patients might undergo changes to their voice or have narrowing of the airway below the vocal cords, often referred to as subglottic stenosis. Throat discomfort while swallowing, unintentional creation of a permanent breathing hole in the throat (tracheostomy), an ongoing hole where the incision was made, and continued infection are other potential long-term complications of the procedure.
What Else Should I Know About Cricothyrotomy?
Cricothyrotomy is a procedure performed in emergency situations when a healthcare professional can’t open up a patient’s airway using the usual methods – this is known as a “CICO situation,” which stands for “can’t intubate, can’t oxygenate.” This situation is the last step in the difficult airway algorithm, which is a sequence of strategies used when it’s challenging to establish an airway. If the airway can’t be opened, it can be life-threatening for the patient.
That’s why preparing for a cricothyrotomy is so crucial. Even though the procedure itself is relatively straightforward, it requires a high level of mental focus and is extremely critical in such emergency situations. Proper preparation can truly mean the difference between life and death for a patient who urgently needs their airway opened.
