Cricothyroidotomy Vs. Tracheostomy
In an emergency situation where intubation is not possible, a surgical airway can be achieved by Cricothyroidotomy or Tracheostomy. Here we compare Cricothyroidotomy vs Tracheostomy w.r.t Applied Anatomy, Technique, Indications, Complications and Success Rates.
CRICOTHYROIDOTOMY[edit | edit source]
Cricothyrotomy is a surgical procedure in which a percutaneous opening of the upper airway is created at the simplest and most quickly accessible cricothyroid membrane, through which a breathing cannula is inserted and linked to the ventilatory system. In rare ‘cannot intubate, can’t oxygenate’ instances, emergency medicine practitioners undertake this life-saving surgery. It is a high-risk, low-frequency procedure. Cricothyrotomy, while still an emergency surgical airway, is an aerosol-producing technique that puts healthcare personnel at risk of infection, especially during epidemics and pandemics. (1) (2)
Cricothyroidotomy Applied Anatomy[edit | edit source]
By palpating the modest depression in the neck skin inferior to the laryngeal prominence, the CTM (Cricothyroid membrane) spanning between the thyroid cartilage and the cricoid cartilage may be recognized. The benefit of this space is that CTM can be easily identified between these two structures. The fibrous nature of the CTM membrane contains minimal vasculature. (1)
Landmarks For Cricothyroidotomy[edit | edit source]
It is very crucial to identify the physical landmarks in all the cases where the cricothyrotomy procedure is going to be applied. The landmarks need to be identified before the practitioner can continue the incision procedure for cricothyroidotomy. The practitioner locates these landmarks by palpating the patient’s skin. The practitioner looks for these landmarks, sternal notch, thyroid, and cricoid cartilage (4). Bordered laterally by cricothyroideus muscles, inferiorly and superiorly by cricoid and thyroid cartilages lie the Cricothyroid Membrane (CTM). The practitioner should start by palpating the laryngeal prominence on the thyroid cartilage, sometimes known as “Adam’s Apple.” The vocal cords are located within the thyroid cartilage. The practitioner should palpate the cricoid cartilage’s circular “signet ring” inferiorly. The Cricothyroid Membrane is about 2 cm underneath the laryngeal prominence and about 2 cm above the cricoid cartilage. and can be felt like a tiny depression between the two cartilaginous structures. (1).
Cricothyroidotomy Indications[edit | edit source]
Cricothyrotomy or tracheostomy are performed in an emergency when a patient is unable to breathe. Cricothyroidotomy is chosen over tracheostomy because it is considered safer, simpler to execute, results in less bleeding, and takes less time in the operating room. Despite the importance of cricothyrotomy, children under the age of 12 are at greater risk because they have a thin larynx, which can be permanently damaged if cricothyrotomy is done. Cricothyrotomy should also be avoided in individuals who have been suspected with laryngotracheal injury as it may aggravate the injury. (6)
Cricothyroidotomy Procedure[edit | edit source]
The procedure on a broad note requires the vertical incision of skin present over the CTM, then horizontal incision of CTM, and then finally placing the ET tube. The procedure includes the following steps in detail:
Cricothyrotomy Procedure: Incision
The incision includes two main phases: vertical skin incision and horizontal cricothyroid membrane incision.
Cricothyrotomy Procedure: Steps
I. Identifying the landmarks using fingers
II. Palpating the cricothyroid membrane
III. Making a vertical incision in the neck skin across the cricothyroid membrane.
IV. Feeling the cricothyroid membrane using the index finger
V. Making a horizontal incision over the cricothyroid membrane
VI. Keeping the incised part open and dilating a little bit using either finger or Kelly forceps
VII. Placing elastic bougie
VIII. Placing an ET tube (Endotracheal Tube) over elastic bougie till cricothyroid membrane is reached
IX. After entering the trachea, ensure removing the elastic bougie and inflating the ET tube cuff
Cricothyrotomy Procedure: Video[edit | edit source]
Video 1 – Surgical Cricothyroidotomy with finger (7)[edit | edit source]
Video 2 – Surgical Cricothyroidotomy with Kelly forceps (8)[edit | edit source]
Video 3 – Needle cricothyroidotomy technique[edit | edit source]
Video 4 – Needle cricothyroidotomy using Yamahi technique (8)[edit | edit source]
Cricothyroidotomy Success Rate and Outcome[edit | edit source]
These outcomes were observed by studying and analyzing the earlier studies done on cricothyroidotomy.
- 7% – Of all intubation cases in the emergency department only 0.27% of adult cases required rescue cricothyroidotomy (9)
- <1% – Of all intubation cases in the emergency department and less than 1% of all paediatric patients required rescue cricothyroidotomy (10)
- 89-100% – Success rate in cricothyroidotomy cases (11) (12) (13) (14) (15) (16) (17) (18) (19)
Complications[edit | edit source]
At an early stage:
- Bleeding can occur
- Incorrect placement, resulting in the possible creation of a false passage through tissue.
- Subcutaneous emphysema
- Oesophageal or mediastinal perforation
- Vocal cord injury
- Laryngeal injury
- Posterior tracheal wall perforation
- Thyroid perforation
- Hypercarbia (Needle Cricothyroidotomy
The later stage of complications
- Persistent stoma
- Glottic or subglottic stenosis
- Laryngeal stenosis
- Tracheoesophageal fistula
- Tracheomalacia (20) (21) (22) (23)
- Minor voice changes
Difference Between Cricothyroidotomy and Tracheostomy[edit | edit source]
- A more straightforward procedure than tracheostomy
- Less bleeding involved
- Less time consuming (24)
- Easier to perform (24) (25)
- Has fewer complications than tracheostomies (26)
- When urgent airway access is required and translaryngeal intubation is not possible, tracheostomy is considered, whereas tracheostomy is performed when the patient requires more than 14 days of ventilator support.
- For cricothyroidotomy, a cut needs to be made 1cm above the superficial cricoid membrane while in tracheostomy a transverse incision of 1cm above the suprasternal notch is required to be made. (27)
TRACHEOSTOMY[edit | edit source]
Tracheostomy Definition[edit | edit source]
The term tracheostomy refers to the creation of a semi-permanent or permanent opening in the cervical trachea and includes the root stom (from Greek stoma) meaning “mouth.” Tracheostomy is a treatment that is commonly used in critically sick patients who require extended mechanical ventilation due to abrupt respiratory collapse or airway problems. Currently, tracheostomy is more usually used for extended mechanical ventilation than for occlusion of the upper airway (28).
Tracheostomy Applied Anatomy[edit | edit source]
Landmarks for Tracheostomy[edit | edit source]
The thyroid notch, cricoid cartilage, and sternal notch are all palpated and identified as anatomic landmarks. To locate a high-riding innominate artery, the surgeon should palpate the sternal notch carefully. A 1 to 2 cm inferior to the carotid cartilage skin incision is then made in the midline anterior neck. An incision can be made horizontally or vertically. (29)
Tracheostomy Layers[edit | edit source]
Layers encountered during tracheostomy[edit | edit source]
The fascia of the neck supports the internal structures and also helps in the compartmentalization of neck structures. Two types of fascia are found in the neck – the superficial cervical fascia and deep cervical fascia.
- Subcutaneous Tissue
- Investing layer of deep cervical fascia
- Strap Muscles (Sternohyoid and Sternothyroid)
- Pretracheal Fascia
- Thyroid Isthmus
Superficial Cervical Fascia (Subcutaneous tissue): It is found between the dermis and deep cervical fascia. The structures associated with the superficial cervical fascia are neurovascular supply to the skin, superficial veins, superficial veins, fat, platysma muscle.
Platysma: Platysma is a paper-like thin superficial muscle lying anterior to the neck.
Deep cervical fascia: This fascial layer lies deep to the superficial fascia and the platysma muscle.
Investing layer: The investing layer surrounds all the structures of the neck and is the most superficial of the deep superficial fascia.
Pretracheal layer: The pretracheal fascia encloses the thyroid gland, and is responsible for its movement during deglutition.
Carotid sheath: Found on both sides of the neck enclosing important neurovascular bundle of the neck. The component of the carotid sheath includes the common carotid artery, internal jugular vein, vagus nerve, cervical nodes. (43)
Tracheostomy Procedure Video in a Pediatric Patient[edit | edit source]
Tracheostomy Indications[edit | edit source]
General indications for the placement of tracheostomy include the following conditions:
- Acute respiratory failure that will necessitate the use of mechanical ventilation for an extended period of time,
- Failure to wean from mechanical ventilation,
- Upper airway obstruction,
- Difficult airway, and
- Copious secretions (28)
Tracheostomy Procedure[edit | edit source]
- The neck of the patient undergoing tracheostomy is hyperextended by placing sandbags under the shoulder.
- Then a vertical (midline) or horizontal incision is made.
- The deep fascia is opened.
- Strap muscles are retracted laterally.
- Isthmus is divided or retracted below.
- 2nd and 3rd tracheal rings are opened, and a circular opening is made. (32)
- The tracheostomy tube is placed.
- Tiding of the tracheostomy tube around the neck
Types of Tracheostomy tube[edit | edit source]
- Fuller’s bivalved tracheostomy tube
- Jackson’s tracheostomy tube
- Red Rubber tracheostomy tube
- Polyvinylchloride tracheostomy tube
Tracheostomy Success Rate and Outcome[edit | edit source]
On studying and analyzing 44,124 patients, 4,476 (10.8%) patients underwent tracheostomy. It was obtained that the morality was high in all these patients (20.6%). An analysis of death rates in tracheostomy patients from some old clinical trials shows that this patient population has a significant mortality rate, with most studies showing 1-year mortality rates of 50 percent or more.(28) (34)
In a similar research study on 60 patients, it was observed that patients with amyotrophic lateral sclerosis show high chance of long-term survival after tracheostomy for Acute Respiratory Failure. The outcomes of the study were:
Patients died in the hospital: 0 patient
Discharged Mechanical Ventilation dependent patients: 42 (70%)
Partially Mechanical Ventilation dependent patients: 17 (28.3%)
Patients liberated from Mechanical Ventilation: 1 (1.63%)
Median survival post tracheostomy was 21 months with survival rate 1 and 2 years after tracheostomy: 65% and 45%
Survival rates with hazard ratio of dying, in patients older than 60 years at tracheostomy: 2.1 (38)
In a similar study done by Milo Engoren 1, Cynthia Arslanian-Engoren, Nancy Fenn-Buderer, a total of 429 patients were studied. Of all them, 19% showed hospital mortality. The number of survivors of mechanical ventilation was 57%. Hospital survivor patients dying percentage after the time period of 100 days was 24%, 6 months was 30%, 1 year was 36% and 2 years was 42%. (35)
Complications of Tracheostomy[edit | edit source]
The complications of a tracheostomy can be considered in 3-time frames:
Immediate complications can include:
- Structure damage to the trachea
- Failure of procedure
- Aspiration event
- Air embolism
- Loss of airway
- Hypoxemia, hypercarbia
Early complications can include:
- Tube displacement
- Subcutaneous emphysema
- Stomal infection
- Stomal ulceration
- Accidental decannulation
Late complications can include:
- Tracheal stenosis
- Granulation tissue
- Aspiration event
- Tracheoarterial fistula
- Tracheoesophageal fistula
- Accidental decannulation
- Dysphagia (28)
Advantages of Tracheostomy Vs. Cricothyroidotomy[edit | edit source]
|Less comfortable for patients than tracheostomy||Improved patient comfort|
|Oral care and suctioning is compromised||Easier oral care and suctioning|
|Low patient mobility due to emergency||Enhanced patient mobility (36) (37)|
|Takes longer time than tracheostomy||Less time consuming than CTT|
|Easier than tracheostomy||More complex than CTT|
|No difference in damage and difficulty scores||No difference in damage and difficulty scores|
|Requires minimal instruction and practise to achieve optimal results||Requires more instruction and practise to achieve optimal results in comparison to CTT|
|Less dissection and fewer steps required than tracheostomy||More dissection and more steps are required than CTT|
|Rapidity does not diminish its success||Little more complex so rapidity might diminish its success as compared to CTT|
|Easier to learn||Require more practise to master the technique than CTT (39)|
|CTT is done during emergencies||Performed when longer ventilator support required (40)|
|Done in adults||In adults and children|
|Provide a temporary airway access||Long term airway maintenance|
|CTT involves less bleeding and complications||Tracheostomy requires more expertise to perform|
Acknowledgements[edit | edit source]
Base Version of Article Written By: Jaud Ansari BSc (Zoology), MSc (Biophysics) Jamia Milia Islamia University
Medically Reviewed By: Dr.Sandeep Moolchandani MS, MHA, DrNB
Read Similar Articles[edit | edit source]
References[edit | edit source]
(1) – Hughes, Kate E et al. “Evaluation of an Innovative Bleeding Cricothyrotomy Model.” Cureus 10,9 e3327. 18 Sep. 2018, doi:10.7759/cureus.3327
(2) – Issa, Nabil et al. “Emergency cricothyrotomy during the COVID-19 pandemic: how to suppress aerosolization.” Trauma surgery & acute care open 5,1 e000542. 6 Aug. 2020, doi:10.1136/tsaco-2020-000542
(3) – Image Attribution – Olek Remesz (wiki-pl: Orem, commons: Orem) – Own work based on: Gray951.png, CC BY-SA 2.5, https://commons.wikimedia.org/w/index.php?curid=3492701
(4) – Katos, M. G., & Goldenberg, D. (2007). Emergency cricothyrotomy. Operative Techniques in Otolaryngology – Head and Neck Surgery, 18(2), 110-114. https://doi.org/10.1016/j.otot.2007.05.002
(5) – Image attribution – S Bhimji MD, CC BY 4.0 <https://creativecommons.org/licenses/by/4.0>, via Wikimedia Commons
(6) – Patel SA, Meyer TK. Surgical airway. Int J Crit Illn Inj Sci. 2014;4(1):71-76. doi:10.4103/2229-5151.128016
(7) – Video Attribution: Arif Alper Çevik, CC BY 3.0 <https://creativecommons.org/licenses/by/3.0>, via Wikimedia Commons
(8) – Video Attribution: Arif Alper Çevik, CC BY 3.0 <https://creativecommons.org/licenses/by/3.0>, via Wikimedia Commons
(9) – Sagarin MJ, Barton ED, Chng YM, Walls RM; National Emergency Airway Registry Investigators. Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. Ann Emerg Med. 2005;46(4):328-336. doi:10.1016/j.annemergmed.2005.01.009
(10) – Sagarin MJ, Chiang V, Sakles JC, et al. Rapid sequence intubation for pediatric emergency airway management. Pediatr Emerg Care. 2002;18(6):417-423. doi:10.1097/00006565-200212000-00004
(11) – Fortune JB, Judkins DG, Scanzaroli D, McLeod KB, Johnson SB. Efficacy of prehospital surgical cricothyrotomy in trauma patients. J Trauma. 1997;42(5):832-838. doi:10.1097/00005373-199705000-00013
(12) – Erlandson MJ, Clinton JE, Ruiz E, Cohen J. Cricothyrotomy in the emergency department revisited. J Emerg Med. 1989;7(2):115-118. doi:10.1016/0736-4679(89)90254-0
(13) – McGill J, Clinton JE, Ruiz E. Cricothyrotomy in the emergency department. Ann Emerg Med. 1982;11(7):361-364. doi:10.1016/s0196-0644(82)80362-4
(14) – Spaite DW, Joseph M. Prehospital cricothyrotomy: an investigation of indications, technique, complications, and patient outcome. Ann Emerg Med. 1990;19(3):279-285. doi:10.1016/s0196-0644(05)82045-1
(15) – Wendy L Nugent, Kenneth J Rhee, David H Wisner, Can nurses perform surgical cricothyrotomy with acceptable success and complication rates?, Annals of Emergency Medicine, Volume 20, Issue 4, 1991,Pages 367-370,ISSN 0196-0644, https://doi.org/10.1016/S0196-0644(05)81656-7.
(16) – Miklus RM, Elliott C, Snow N. Surgical cricothyrotomy in the field: experience of a helicopter transport team. J Trauma. 1989;29(4):506-508.
(17) – Jacobson LE, Gomez GA, Sobieray RJ, Rodman GH, Solotkin KC, Misinski ME. Surgical cricothyroidotomy in trauma patients: analysis of its use by paramedics in the field. J Trauma. 1996;41(1):15-20. doi:10.1097/00005373-199607000-00004
(18) – Roberts, Hedges. Surgical cricothyroidotomy. Clinical Procedures in Emergency Medicine. 5th ed. Phildelphia: Saunders Elsevier; 2010. Chapter 6.
(19) –Holcroft JW, Anderson JT, Sena MJ. Shock and acute pulmonary failure in surgical patients. Doherty GM, ed. Current Diagnosis & Treatment: Surgery. 13th ed. McGraw-Hill Companies; 2010. Chapter 12.
(20) – Tintinalli JE, Kelen GD, Stapczynski JS, MA OJ, Cline DM. Surgical airway management. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 6th ed. McGraw-Hill Companies; 2004. Chap 20.
(21) – Rehm CG, Wanek SM, Gagnon EB, Pearson SK, Mullins RJ. Cricothyroidotomy for elective airway management in critically ill trauma patients with technically challenging neck anatomy. Crit Care. 2002;6(6):531-535. doi:10.1186/cc1827
(24) – McKenna P, Desai NM, Morley EJ. Cricothyrotomy. [Updated 2021 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537350/?report=classic
(25) – François B, Clavel M, Desachy A, Puyraud S, Roustan J, Vignon P. Complications of tracheostomy performed in the ICU: subthyroid tracheostomy vs surgical cricothyroidotomy. Chest. 2003;123(1):151-158. doi:10.1378/chest.123.1.151
(26) – Zasso, Fabricio & You-Ten, Kong & Ryu, Michelle & Losyeva, Khrystyna & Tanwani, Jaya. (2020). Complications of cricothyroidotomy versus tracheostomy in emergency surgical airway management: A systematic review. 10.21203/rs.3.rs-18196/v1.
(27) – Heffner JE. The technique of tracheotomy and cricothyroidotomy. When to operate–and how to manage complications. J Crit Illn. 1995;10(8):561-568.
(28) – Cheung NH, Napolitano LM. Tracheostomy: epidemiology, indications, timing, technique, and outcomes. Respir Care. 2014;59(6):895-919. doi:10.4187/respcare.02971
(29) – Raimonde AJ, Westhoven N, Winters R. Tracheostomy. [Updated 2021 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559124/
(30) – Jeremykemp, Copyrighted free use, via Wikimedia Commons
(31) – National Heart Lung and Blood Institute (NIH), Public domain, via Wikimedia Commons
(32) – SRB’s Manual of surgery 5th edition
(33) – Tracheostomy Tube Cuffed Tenbergen, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons
(34) – Freeman BD, Stwalley D, Lambert D, et al. High resource utilization does not affect mortality in acute respiratory failure patients managed with
(35) – Engoren M, Arslanian-Engoren C, Fenn-Buderer N. Hospital and long-term outcome after tracheostomy for respiratory failure. Chest 2004;125(1):220–227.
(36) – Bice T, Nelson JE, Carson SS. To Trach or Not to Trach: Uncertainty in the Care of the Chronically Critically Ill. Semin Respir Crit Care Med. 2015;36(6):851-858. doi:10.1055/s-0035-1564872
(37) – Heffner JE. The role of tracheotomy in weaning. Chest. 2001;120(6 Suppl):477S-81S. doi:10.1378/chest.120.6_suppl.477s
(38) – Vianello A, Arcaro G, Palmieri A, et al. Survival and quality of life after tracheostomy for acute respiratory failure in patients with amyotrophic lateral sclerosis. J Crit Care. 2011;26(3):. doi:10.1016/j.jcrc.2010.06.003
(39) – Hardjo S, Croton C, Woldeyohannes S, Purcell SL, Haworth MD. Cricothyrotomy Is Faster Than Tracheostomy for Emergency Front-of-Neck Airway Access in Dogs. Front Vet Sci. 2021;7:593687. Published 2021 Jan 11. doi:10.3389/fvets.2020.593687
(40) – https://slidetodoc.com/infraglottic-invasive-airways-dr-s-a-rajkumar-intensivist/
(42) – Mikael Häggström.When using this image in external works, it may be cited as:Häggström, Mikael (2014). “Medical gallery of Mikael Häggström 2014”. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.008. ISSN 2002-4436. Public Domain.orBy Mikael Häggström, used with permission., Public domain, via Wikimedia Commons
(43) – Tikaa, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons