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Thyroid
prominence
Cricothyroid
membrane
Cricoid
A cricothyroidotomy enters the larynx in The tube then passes through the cricoid
the midline just below the vocal cords. The ring, which is the narrowest part of the
incision passes through skin, subcutanous upper airway (Figure 3, 4).
fat, middle cricothyroid ligament of
cricothyroid membrane, and mucosa of
subglottic larynx (Figure 2).
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The thyroid isthmus typically crosses the is to select a tube which is 1mm smaller
2nd and 3rd tracheal rings, and is out of than would normally be used for oro-
harms way, unless a pyramidal thyroid tracheal intubation 2. If a Shiley tracheos-
lobe is present (Figure 2). The only blood tomy tube is to be used, it should not
vessels that may be encountered are the exceed Size 4 (9.4mm OD)
anterior jugular veins (off the midline), and
the cricothyroid arteries.
Needle cricothyrotomy
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3. Prepare a sterile field
4. Inject 1% lidocaine with 1:100 000 epi-
nephrine into the skin and through the
cricothyroid membrane into the airway
to anaesthetise the airway and suppress
the cough reflex (if time to do so)
5. Fix the thyroid cartilage with the 1st &
3rd fingers of the non-dominant hand
leaving the 2nd finger free to locate the
cricothyroid membrane
6. With the dominant hand, pass a 14-
gauge intravenous cannula attached to Figure 13: Air bubbles appear in the fluid-
a syringe filled with normal saline, filled syringe as the needle traverses
through the cricothyroid membrane, cricothyroid membrane 4
directing it caudally at 450 (Figure 11).
Bending the distal part of the needle 8. Advance the cannula and then retract
can assist with directing the catheter the needle
along the tracheal lumen (Figure 12). 9. Attach jet ventilation and ventilate at
15 L/min
10. Judge the adequacy of ventilation by
movement of the chest wall and aus-
cultation for breath sounds, and by
pulse oximetry
Preoperative evaluation
Preoperative preparation
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trachea (Figure 4); alternatively insert Percutaneous cricothyroidotomy: Surgi-
a bougie through the tract into the cal steps
airway
9. Insert a tracheostomy or endotracheal 1. Position the patient supine with neck
tube (<7mm ID), either directly or by exposed and extended (if possible)
railroading it over the bougie 2. Identify surface landmarks i.e. thyroid
10. If using a cuffed tube, inflate the cuff cartilage, cricoid cartilage and crico-
with air thyroid membrane
11. Commence ventilation 3. Prepare a sterile field
12. Confirm correct placement of the tube 4. Inject 1% lidocaine with 1:100 000 epi-
by observation of movement of the nephrine into the skin and through the
chest, auscultation, and end-tidal CO2 cricothyroid membrane into the airway
if available to anaesthetise the airway and suppress
13. Secure the tracheostomy tube by the cough reflex (if time to do so)
suturing it to skin and/or tracheal tape 5. Fix the thyroid cartilage with the 1st &
secured around the neck (Figure 17) 3rd fingers of the non-dominant hand
leaving the 2nd finger free to locate the
cricothyroid membrane
6. With the dominant hand, make a small
stab incision in the skin with a scalpel
over the cricothyroid membrane
(Figure 19)
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Figure 23: Jointly advance dilator and
tracheostomy tube over guide wire 4
Figure 20: Pass needle through
cricothyroid membrane 4 13. Remove both dilator and guide wire
leaving the tracheostomy tube in situ
(Figure 24)
10. Retract and remove the needle once the 14. Secure the tracheostomy tube with
guide wire has been advanced into the tracheostomy tape
airway (Figure 22)
Early Complications
Bleeding
Paratracheal false tract: Inadvertent ex-
tratracheal placement of the tracheos-
tomy tube can be fatal. It is recognised
by the absence of breath sounds on
auscultation of the lungs, high venti-
latory pressures, failure to ventilate the
Figure 22: Remove the needle leaving lungs, hypoxia, absence of expired
guide wire in place 4 CO2, surgical emphysema, and an in-
ability to pass a suction catheter down
11. Pass the dilator and tracheostomy tube the bronchial tree, and on chest X-ray
over the guide wire Posterior tracheal wall perforation into
12. Jointly advance the dilator and tracheo- oesophagus
stomy tube over the guide wire into the Pneumothorax, surgical emphysema
airway (Figure 23) Hypercarbia and barotrauma
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Late Complications tions need to be suctioned in an aseptic and
atraumatic manner.
Glottic or subglottic stenosis due to
perichondritis and fibrosis of cricoid Cleaning tube: Airway resistance is
Dysphonia related to the 4th power of the radius with
Persistent stoma laminar flow, and the 5th power of the
Tracheoesophageal fistula radius with turbulent flow. Therefore even
a small reduction of airway diameter
and/or conversion to turbulent airflow as a
Postoperative care result of secretions in the tube can
significantly affect airway resistance.
Pulmonary oedema: This may occur Therefore regular cleaning of the inner
following sudden relief of airway cannula is required using a pipe cleaner or
obstruction and reduction of high intra- brush.
luminal airway pressures. It may be
corrected by CPAP or positive pressure Securing tube: Accidental decannulation
ventilation. and failure to quickly reinsert the tube may
be fatal. This is especially problematic
Respiratory arrest: This may occur during the 1st 48hrs when the tract has not
immediately following insertion of the matured and attempted reinsertion of the
tracheostomy tube, and is attributed to the tube may be complicated by the tube
rapid reduction in arterial pCO2 following entering a false tract. Therefore the tight-
restoration of normal ventilation, and ness of the tracheostomy tapes should be
hence loss of respiratory drive. regularly checked.
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