Endotracheal intubation is first line for securing the airway. In a 'cannot intubate, cannot ventilate' (CICV) situation, cricothyroidotomy can buy time (minutes) while expert help or definitive treatment is organised.
The aim is to insert the largest diameter tube in the least amount of time with the fewest complications.
The 4th National Audit Project 2011 (NAP4) of the Royal College of Anaesthetists reported that:
- Needle cricothyroidotomy and Mini-trach (Seldinger) techniques are quick but have a higher failure rate
- Once help arrives, the open technique takes only slightly longer and has a lower failure rate
More recently, the Royal College of Anaesthetists and ENT UK have developed a consensus statement available here. The recommendation is that the standard 'front of neck airway' or FONA should be a scalpel-bougie cricothyroidotomy.
Do not hesitate to call for expert help or equipment.
Below is a generic description of this procedure for reference purposes. You should seek specific advanced airway training (eg ALS, ATLS) rather than use this page as a manual.
Widest bore simple IV cannula (eg orange/brown 14G): this will not work with a safety needle
10ml sterile saline or water
plenty of assistance
1. Half-fill a 20ml syringe with sterile saline or water.
2. Take both white and clear plastic ends off the cannula and attach the 20ml syringe.
3. Attach a long piece of oxygen tubing to the oxygen supply. Take the unattached end, bend the tubing back on itself and cut a hole in the side.
3. Extend the neck (unless C-spine immobilised).
4. Feel for the thyroid cartilage (Adam's apple). About 1cm inferior to this there is a horizontal recess. The cricothyroid membrane is in this recess (red asterisks in the photo).
5. With your non-dominant hand, hold both sides of the airway to be sure of your position.
6. In the midline, insert the cannula into the crycothryoid recess, drawing back on the plunger.
7. Bubbles indicate that you are in the airway.
8. Remove the syringe and get an assistant to attach the oxygen tubing to the cannula. Take care not to let go of the cannula at any time.
9. With the oxygen flow at maximum, occlude the hole in the tubing for about 1 second and release for about 3-4 seconds. Repeat.
A Mini-Trach kit can also be used to get temporary access to the airway. It uses a modified Seldinger technique (incision/dilatation/railroading). Use the same anatomical landmarks for the cricothyroid membrane.
Page last reviewed: 23 September 2017