Needle Cricothyroidotomy Summary

Indication

  • Can't intubate, can't oxygenate scenario
  • Emergency airway access

Advantages

  • Quick and easy to perform
  • Recommended in children
  • Less risk to cricoid cartilage

Disadvantages

  • Temporary measure only
  • Requires high-pressure oxygen
  • Risk of barotrauma
  • Prone to kinking/failure
  • Unsuitable for patient transfer

Equipment

  • 14+ gauge cannula (adults)
  • 20mL syringe
  • High-pressure oxygen source
  • 400 kPa pressure required

Duration

  • 30-45 minutes maximum
  • CO₂ buildup occurs
  • Transition to definitive airway needed

Ventilation Parameters

  • Adults: 1 second ON, 4 seconds OFF
  • 15 L/min flow rate
  • Children: Age in years = initial flow rate
  • Adjust until chest rises

Complications

  • Barotrauma/pneumothorax
  • Cannula kinking/obstruction
  • Bleeding/hematoma
  • Esophageal/tracheal injury
  • Subcutaneous emphysema

Needle Cricothyroidotomy

Emergency airway access procedure for can't intubate, can't oxygenate scenarios

Definition

Needle cricothyroidotomy involves insertion of a wide-bore non-kinking cannula through the cricothyroid membrane to provide oxygen on a short-term basis until a definitive airway can be placed.

CRICOTHYROID MEMBRANE ANATOMY DIAGRAM

Anatomy of the cricothyroid membrane and surrounding structures

Indications

Primary Indication

Can't intubate, can't oxygenate scenario - a true emergency situation where conventional airway management has failed and the patient cannot be ventilated or intubated.

Advantages vs Disadvantages

Advantages

  • Quick and easy to perform
  • Recommended in failed airway in child where surgical cricothyroidotomy is relatively contraindicated because of risk of damaging cricoid cartilage
  • Less invasive than surgical cricothyroidotomy
  • Can be performed with minimal equipment

Disadvantages

  • Only a temporary measure - not a definitive airway
  • Requires high-pressure oxygen source (at 400 kPa)
  • May cause barotrauma, particularly in the presence of expiratory obstruction
  • Particularly ineffective in patients with chest trauma
  • Prone to failure because of kinking of the cannula
  • Unsuitable for maintaining oxygenation during patient transfer
  • CO₂ elimination is inadequate leading to hypercapnia

Procedure

Step-by-Step Procedure
  1. Attach a syringe (preferably 20 mL) to a stiff cannula and needle (minimum 14 gauge in adults)
  2. Identify the cricothyroid membrane between the thyroid cartilage and cricoid cartilage
  3. Insert the cannula through the cricothyroid membrane into the airway at an angle of 45 degrees aiming caudally in the midline
  4. Confirm cannula position by aspiration of air with the syringe and advance cannula fully over the needle into the trachea
  5. Remove the needle, and aspirate air from the cannula to confirm position
  6. Hold the cannula in place, attach the ventilation system and commence ventilation
  7. One second of oxygen supplied at a pressure of 400 kPa (4 bar) and flow of 15 L/min should be sufficient to inflate adult lungs adequately
  8. This is followed by a 4 second pause to enable expiration via the upper airway (expiration does not occur via the cannula)
  9. In children the initial flow rate should equal the child's age in years, and this is increased in 1 L/min increments until one second of oxygen flow causes the chest to rise
  10. Look carefully for adequate exhalation through the upper airway (chest falls adequately with each expiration)
  11. The patient can be adequately oxygenated for 30 - 45 mins using this technique (because of inadequate exhalation, build up of CO₂ occurs)
  12. If ventilation fails, or complications occur, proceed immediately to surgical cricothyroidotomy

Important Notes

This is a temporary oxygenation technique, not a definitive airway. The patient will develop hypercapnia due to inadequate CO₂ elimination. A definitive airway must be established within 30-45 minutes.

Complications

  • Barotrauma from high pressure ventilation including pulmonary rupture with tension pneumothorax
  • Inadequate ventilation due to kinking or obstruction of the cannula
  • Aspiration of blood
  • Oesophageal laceration
  • Haematoma formation
  • Perforation of posterior tracheal wall
  • Subcutaneous and/or mediastinal emphysema
  • Thyroid perforation
  • Infection at insertion site
  • Failure to secure adequate oxygenation

Clinical Anatomy

SITE OF AIRWAY PROCEDURES DIAGRAM

Anatomical landmarks for needle cricothyroidotomy procedure

Key Anatomical Points

Pediatric Considerations

In children under 12 years, the cricoid cartilage is the narrowest part of the airway (compared to the vocal cords in adults). Surgical cricothyroidotomy is relatively contraindicated in children due to risk of damaging the cricoid cartilage and subsequent subglottic stenosis, making needle cricothyroidotomy the preferred emergency surgical airway technique in this population.