Needle Cricothyrotomy

As an anesthesiologist and intensivist, the “can’t intubate, can’t ventilate” situation is one of my worst nightmares. Airway rescue procedures like needle cricothyrotomy are essential to know. This rescue technique can be utilized if more conventional airway techniques (e.g., mask ventilation, supraglottic airway, endotracheal intubation) fail. Remember, this is a life-saving but temporizing measure.

The cricothyroid membrane (CTM) should be palpated just inferior to the thyroid cartilage. After prepping the skin, a 3 cc syringe half-filled with fluid is attached to a needle-over-IV catheter, placed in the midline of the CTM, and directed at a 30° angle caudally. The needle is slowly advanced with concurrent aspiration until bubbles are visualized in the syringe upon entering the airway. Similar to peripheral IV placement, the needle is advanced a few more millimeters, and the catheter is threaded into the airway. The plunger is removed from the 3 cc syringe and replaced with an endotracheal tube (ETT) connector from a 7.5 ETT. This creates an adapter for the airway catheter to connect to a standard vent circuit, AMBU, etc.

The delivered tidal volume (VT) is affected by several factors: diameter of the catheter, inspiratory pressure and duration, lung compliance, airway resistance, source of oxygen (bag, jet ventilator, etc.), and the fact that some of the VT will come out through the oro/nasopharynx. As with any type of “jet oxygenation,” expiratory time, chest movement, and barotrauma must all be considered.

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