Emergency surgical airway access - is there a best way?

Todd Fraser on 30-09-2012

The subject of emergency surgical airway technique is one of the favourite topic of emergency, critical care, anaesthetic and pre-hospital bloggers these days.  So why shouldn't Crit-IQ join in?  Here's your chance to describe what you do.

There are a number techniques described.  Its one of the most feared procedures in clinical medicine, and with good reason - the outcomes from these events are often not good.  Many of us have had, and will have, no experience with it in practice, so almost no one can claim to be proficient in any of these methods.

This topic comes up this week because of the release of a head to head comparison of a percutaneous method versus knife-to-skin in a simulated enviroment.  The results of the study suggest that a surgical method improves times to secure access and was favoured by the 30 practitioners studied.

Of all the methods described, the one that sits most comfortably with me is the knife-dilators-bougie method.  This appears to have the support of the literature, and in my hands in a similated environment, it feels easiest.  The equipment required is readily available and familiar, so when the heat is on, is more likely to be familiar.

So what do you do?


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Peter from Queensland wrote 10-02-2012 08:54:39 am
My approach is horizontal incision, trachy dilators run along southern edge of blade, open vertically, size 6 tube between the tips. Tube needs to be well lubed. I've used this only once pre-hospital and it went as smoothly as I could have hoped. Hope never to have to do it again.

Georgie Parks wrote 10-06-2012 09:26:26 am
I guess it depends on what you're comfortable with. The technique for perc trachy is not too dissimilar, and in parts of the world like Australasia we're a bit more accustomed to this - that might explain the results in the paper you referred to.

Needle jet insufflation is a good first step - you can fairly rapidly regain saturations and buy some time when it works. You can reattempt to gain access from the top, and if this doesn't work, you can convert to seldinger method.

klaus wrote 11-20-2012 09:17:09 am
How would you secure an airway in a patient who is a grade 3 airway and is now intubated and ventilated on ICU following aspiration pneumonitis and ARDS. She is recovering well. Because of the anticipated extended stay on ICU a surgical tracheostomy is performed (considering she is a difficult airway). Tracheostomy dislodges a few days later and she develops severe subcutaneous emphysema and severe hypoxia. The tracheostomy track is no longer usable because the anatomy is distorted from the severe subcut emphysema. Bear in mind we now have lost our definitive airway and intubating her is impossible.
How do you secure an airway in this situation. Any ideas? You literally have seconds to get an airway???

Sucker wrote 11-20-2012 09:18:45 pm
Okay, I'll be the sucker.

I'd Bag-Valve-Mask as per usual. If I can bag her up to normal sats, no problem, take my time.

If I can't, would look. You didn't say she was impossible the first time, so would try to intubate her with a bougie. If I had a videolaryngoscope, would elect to go with that.

If that fails, I'd compress her neck to try to get rid of the air, which should be possible, and would go for a surgical cricothyroidotomy. Air shouldn't be a problem.

Klaus wrote 11-21-2012 12:01:48 am
You literally have seconds.
This patient is hypoxic, she has ARDS and already hypoxic. She was deemed a grade 3 intubation prior to all this and now she has more swelling of her palate and airway, her tracheostomy track is extremely difficult to access now.
Bag and mask tried but without any success, laryngoscopy was a total waste of time. Nothing was visible not even the tip of her epiglottis.
Compression of neck.. well I wish the surgical emphysema was that trivial. She was grossly swollen !!
Cricothyroidotomy....well this was late in the evening when there was no anesthetist or surgeon around.
Also how would you do a percutaneous one, without the benefit of any landmarks, if you chose that option?

And by the way, YOU ARE NOT A SUCKER, you are the brave one who took a punt. Fortune favours the brave.

There is no right or simple answer here. I just wanted to know what the experts or so called self styled authorities on airway management would have done.

It is the most frightening and humbling experience when you see a patient literally dying in front of you and you are helpless, not from want of trying but from not having any options.

Sucker wrote 11-21-2012 02:19:23 pm
Sounds like an awful experience (I'm assuming this is a true story).

A couple of points - I wouldn't be afraid of attempting a surgical cricothyroidotomy, I don't think this requires a surgeon / anaesthetist. Additionally, much like putting an ICC into a patient with subcutaneous emphysema, sometimes this makes it perversely easier - the tissue planes are separated, and its rarely under "tension", and as such, dissecting down to the trachea would likely be fairly easy. After initial skin incision, I'd expect to be able to define the anatomy fairly readily.

What did you do?

Sam George wrote 12-02-2012 09:39:25 pm
A blocked tracheostomy, doesn't mean the upper part is always blocked, I would always try to thread a epidural catheter and try if there is any scope for Retrograde intubation.

Esther wrote 12-04-2012 08:24:52 am
Are you saying you'd feed the epidural catheter up the tract? I think the initial question was what you would do if the trachy dislodged. If its a new trachy, the tract is likely difficult to follow, and the emphysema would make it worse.

How long would it take to do this? Its something I've never done...

Hella from Denmark wrote 02-23-2013 11:57:37 am
Best way by far is single cut with scalpel across membrane, insert dilator forcep, bougie and size 6 trach tube. NAP4 tells us needle jet insuff doesn't work in 60%, but surgical airway works 100%

Gemma from Canada wrote 02-25-2013 10:56:25 am
I don't know, I still think my preferred option would be a needle cricothyroidotomy - its more familiar (Seldinger perc trachy) so feels more comfortable in a crisis, and if you can jet ventilate someone, you might be able to tube them from the top with a bit more time, saves them potential complications.

Gemma from Canada wrote 02-25-2013 10:56:51 am
Not that I've ever had to do it for real, mind you...




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