Airway – Cricothyroidotomy (needle)

Procedure, instructions and discussion

Needle Cricothyroidotomy when unable to oxygenate and ventilate with (BVM, LMA, ETT) and age <10years

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Instructions

Indications

• Inability to oxygenate and ventilate by other means (BVM, LMA, ETT)

and

• Age under 10 years

Contraindications (ABSOLUTE/relative)

• Tracheal rupture or transection
• Laryngeal fracture

Alternatives

• Bag-Valve-Mask (BVM )Ventilation
• Supraglottic Airway Device intubation (SAD, LMA)
• Endotracheal intubation
• Surgical cricothyroidotomy
• Tracheostomy

Informed consent

NOT REQUIRED

• Consent is not required.
• This is an emergency procedure to save a life

Potential complications

• Coughing
• Failure (incorrect position, blockage/kink, dislodgement)
• Neurovascular, oesophageal, and laryngeal injury
• Bleeding (with potential aspiration)
• Barotrauma (pneumothorax and acute lung injury)
• Hypercapnia
• Infection

Infection control

• Standard precautions
• Aseptic non-touch technique
• PPE: non-sterile gloves, aprons, surgical mask and protective eyewear or face shield

Area

• Resuscitation bay

Staff

• Procedural clinician
• Airway assistant (at least one)

Equipment

• 5ml Luer syringe (containing 2ml or saline)
• 5ml Luer lock syringe (empty)
• 16-18g non-safety cannula
• Oxygen tubing and supply Tape (to secure)

Positioning

• Patient supine with neck extended
• Assistant maintains head positions midline
• Procedural clinician lateral to patient
• Dominant hand towards head (patient’s left side if right-handed)

In children, the laryngeal prominence (thyroid cartilage) is not developed. Palpate the trachea above the suprasternal notch and move superiorly until the prominence of the cricoid cartilage is felt. The needle should be placed just above the cricoid cartilage in the midline.

Medication

• 2ml lignocaine 1% with adrenaline (1:100,000)

Never apply local anaesthetic in a time critical emergency. It can be considered before predicted difficult intubations where the chance of failure is high and infiltrated after induction in the minute before the first attempt at intubation.

Sequence

Needle cricothyroidotomy

• Brief team ‘I’m performing a needle cricothyroidotomy now’ and allocate roles
• Identify cricothyroid membrane
• Connect the 5ml syringe with 2ml water to the non-safety cannula
• Stabilise larynx with thumb and middle finger of non-dominant hand ‘laryngeal handshake’
• Palpate cricothyroid membrane with index finger
• Insert cannula into cricothyroid membrane caudally at 30-45 degrees from skin with dominant hand
• Advance cannula applying negative pressure to syringe until bubbles appear confirming intratracheal placement
• Anchor the needle and advance cannula over needle into airway, until hub rests on skin surface
• Remove the needle and syringe
• Connect the second 5ml syringe to the cannula and aspirate tracheal air to 5ml to re-confirm position
• Perform jet insufflation (below)
• Allocate an assistant to hold the cannula hub at the skin until a definitive airway is placed
• Secure cannula hub at skin with tape after first inflation and place NPA and OPA to aid exhalation

Jet insufflation

• Allocated assistant continues to hold cannula hub at skin
• After aspiration of 5ml tracheal air with syringe, remove plunger from syringe
• Turn on oxygen attached to oxygen tubing at 1l/min/year of age maximum (10l/min)
• Place oxygen tubing deeply into secured syringe without plunger (syringe helps transfer pressure to cannula)
• Inflate for 2-4 seconds, watch for chest rise then remove oxygen tubing from syringe
• Observe for 20 seconds, noting improvement in saturations
• Further inflation of two seconds when saturations fall 5% from maximum reached

Failure to aspirate air on insertion

• Repeat insertions progressing laterally and alternating side until you have five punctures
• Vertical cut down through skin followed by blunt finger dissection to larynx or trachea followed by repeat puncture

Post-procedure care

DOCUMENT PROCEDURE

• Definitive airway (Anaesthetic/ENT urgently required)
• Dedicated team member continues to hold cannula at hub until definitive airway placed
• Provide ongoing sedation and paralysis
• Monitor for barotrauma (pneumothorax) and failure (blocking, kinking, dislodgement)
• Document after definitive airway placed (completion, complications)

Tips

• Avoid safety cannulas that cannot be connected to a syringe
• If cricothyroid anatomy uncertain or injured aim for palpable tracheal rings with identical technique
• Wall oxygen can easily cause barotrauma, avoid prolonged inflation
• Jet insufflation may be possible for hours despite hypercarbia (unless total upper airway obstruction)
• In complete upper airway obstruction, inspiratory to expiratory ratios greater than 1:8 is required to reduce risk of barotrauma
• Ultrasound may be used in preparing to intubate a difficult airway to locate the cricothyroid membrane

Discussion

We outline an approach using equipment available in all emergency departments. Regular physical practice of your chosen method is recommended, unfamiliar equipment is best avoided in an emergency.

Needle cricothyroidotomy is preferable to surgical cricothyroidotomy in infants and children as the cricothyroid membrane is small and undeveloped at a younger age. This makes a needle procedure anatomically easier to perform with less potential damage to the larynx and surrounding structures.

There is no clear evidence on the age cut off for transitioning from a needle to a surgical cricothyroidotomy, expert consensus guidelines most commonly suggest age ranges from 10-12 years old. The size of the child is probably more important than the age.

The cricothyroid membrane has a mean height of 2.6mm (SD: 0.7) and width of 3mm (SD: 0.6) in neonatal cadavers (mean height of 44.9cm and a mean weight of 2kg). This suggests an 18g cannula is still appropriate in this age group

References

• Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM; Difficult Airway Society; Intensive Care Society; Faculty of Intensive Care Medicine; Royal College of Anaesthetists. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth. 2018 Feb;120(2):323-352.
• Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, O’Sullivan EP, Woodall NM, Ahmad I; Difficult Airway Society intubation guidelines working group. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48
• Greater Sydney Area Helicopter Emergency Medical Service. Prehospital emergency anaesthesia manual. (Ver.3.) Sydney: NSW Ambulance; 2018
• Begley JL, Butson B, Kwa P. The emergency surgical airway. Emerg Med Australas. 2017 Oct;29(5):570-575.
• Chrimes N. The vortex approach to the difficult airway. 2016.

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