Open Scalpel-Bougie Cricothyroidotomy

Endotracheal intubation is first line for securing the airway. In a 'cannot intubate, cannot oxygenate' (CICO) 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. 



Disinfectant wipe/liquid

Personal protective equipment


Scalpel and blade

Gum elastic bougie

Good light - preferably headlight

Tracheostomy dilator or artery forceps

Retractors eg small Langenbecks

Selection of tracheostomy tubes (eg size 4 to 8) and endotracheal tubes including paediatric sizes

Large suture (eg 0 or 1 gauge)

Ventilator, tubing, connectors - check with anaesthetist

Tube ties etc. 

Plenty of assistance

You may have access to diathermy and other equipment



1. Aseptic technique insofar as possible given the situation. Quickly disinfect the skin.

2. Hold the larynx firmly in your non-dominant hand to stabilise it. 

3. Make a horizontal stab incision into the cricothyroid recess (red asterisks in the photo below). When making a stab incision, avoid cutting from side to side to minimise bleeding. The blade can be turned 90 degrees to help open the cricothyroidotomy. Alternatively make a vertical cut over the recess and dissect down through the cricothyroid membrane. 

4. With retractors, a tracheostomy dilator, and/or a cricoid hook, dilate the hole.

5. Insert a gum elastic bougie, angled caudally into the airway.

6. Railroad a tracheostomy or endotracheal tube over the bougie under direct vision. Inflate the cuff. Someone must hold the tracheostomy tube in position. They must not let go until it has been secured. If unable to locate a tracheostomy tube or the smallest size does not fit, consider using a small oral endotracheal tube, taking care not to push the tube past the carina. 

7. Check capnography, oximetry, chest signs etc. to confirm tube position.

8. Secure haemostasis.

9. Suture the tube flange (sutures can be removed when the situation is under control).

10. Pass tube ties through the tube flange.

11. Ventilate and reassess. 

12. Perform a formal tracheostomy.




Page last reviewed: 23 September 2017