Disclosures: Manoj K Mittal, MD, MRCP (UK), FAAP Nothing to disclose. Anne M Stack, MD Nothing to disclose. James F Wiley, II, MD, MPH Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.
INTRODUCTION — Needle cricothyroidotomy involves passing an over-the-needle catheter through the cricothyroid membrane (figure 1). This procedure provides a temporary secure airway to oxygenate and ventilate a patient in severe respiratory distress in whom less invasive techniques (eg, bag-valve-mask ventilation, laryngeal mask ventilation, endotracheal intubation) have failed or are not likely to be successful (ie, "can't intubate, can't ventilate") [1-4]. The delivery of oxygen to the lungs through an over-the-needle catheter inserted through the skin into the trachea using a high pressure gas source is considered a form of conventional ventilation called percutaneous transtracheal ventilation (PTV).
Although sometimes a point of confusion, PTV should not be mistaken for transtracheal jet ventilation, which is not considered conventional ventilation and refers to high frequency, low tidal volume ventilation and needs specialized ventilators usually only available in the operating room or intensive care unit. Although a technically different treatment, the term "jet ventilation" has also been used to describe conventional ventilation using a high pressure oxygen source via a percutaneous catheter [5-7].
Needle cricothyroidotomy differs from surgical cricothyroidotomy in that surgical cricothyroidotomy involves making an incision in the cricothyroid membrane and passing a tracheostomy or endotracheal tube through it into the trachea . Needle cricothyroidotomy may be performed on patients of any age but is considered to be preferable to surgical cricothyroidotomy in infants and children up to 10 to 12 years of age because it is anatomically easier to perform with less potential damage to the larynx and surrounding structures [8-11]. However, surgical cricothyroidotomy provides more effective ventilation than needle cricothyroidotomy because of the larger diameter tube used and is typically chosen instead of needle cricothyroidotomy in adults and children over 10 to 12 years of age.
Needle cricothyroidotomy and percutaneous transtracheal ventilation will be discussed here. Surgical cricothyroidotomy is discussed separately. (See "Emergent surgical cricothyrotomy (cricothyroidotomy)".)
DEFINITIONS — It is important to distinguish between the different methods of emergency airway access and specialized ventilation. For the purposes of this review, definitions are as follows:
Needle cricothyroidotomy — Needle cricothyroidotomy involves passing an over-the-needle catheter through the cricothyroid membrane (figure 1).
Surgical cricothyroidotomy — Surgical cricothyroidotomy is an emergent airway approach in which the clinician makes an incision in the cricothyroid membrane and passes a tracheostomy or endotracheal tube into the trachea. The standard, four step, and Seldinger techniques are common methods of surgical cricothyroidotomy. (See "Emergent surgical cricothyrotomy (cricothyroidotomy)".)
Percutaneous transtracheal ventilation — Percutaneous transtracheal ventilation (PTV) involves oxygenation and ventilation via a needle or surgical cricothyroidotomy using an improvised ventilation device. Confusingly, although this is a form of conventional ventilation, it is sometimes referring to as "jet ventilation" when a high pressure source is used to deliver oxygen. (See 'Bag-valve-mask connector options' below and 'Oxygen tubing connector options' below.)
Transtracheal jet ventilation — Transtracheal jet ventilation refers to high frequency, low tidal volume ventilation provided via a laryngeal catheter by specialized ventilators that are usually only available in the operating room or intensive care unit [5,6]. This procedure is occasionally employed in the operating room when a difficult airway is anticipated (eg, Treacher Collins syndrome, Robin sequence, head and neck surgery with supraglottic or glottic obstruction) [12-15].
INDICATIONS — The primary indication is inability to maintain the airway with noninvasive standard airway procedures (eg, bag-valve-mask ventilation, endotracheal intubation) or rescue procedures (eg, laryngeal mask airway). The typical setting involves patients with pathologic processes that cause distortion of the upper airway anatomy, for example [3,16-18]:
- Airway obstruction by uncontrolled bleeding into the oral cavity and/or vomiting
- Severe maxillofacial trauma - blunt, penetrating, or associated with mandibular fracture
- Laryngeal foreign body that cannot be removed expeditiously
- Swelling of upper airway structures
- Infection, like epiglottitis or Ludwig's angina
- Allergic or immunologic reaction, as from food allergy or hereditary angioedema
- Chemical or thermal burns to the epiglottis and upper airway
- Post-extubation glottic edema
Absolute — Needle cricothyroidotomy with percutaneous transtracheal ventilation (PTV) is absolutely contraindicated when the airway is maintainable through noninvasive means.
In addition, needle cricothyroidotomy with PTV should not be performed when damage to the larynx, cricoid cartilage, or trachea preclude successful oxygenation and ventilation via a transtracheal catheter, for example:
- Laryngeal injury with known damage to cricoid cartilage (laryngeal fracture)
- Tracheal rupture
- Tracheal transection with distal tracheal retraction into the mediastinum
Relative — Several relative contraindications arise in situations where anatomic distortion increases the risk of airway complications or where excessive bleeding may be encountered during needle cricothyroidotomy and PTV as follows:
- Anterior neck swelling (eg, angioedema, hematoma) that obscures anatomical landmarks
- Anatomic anomalies or distortion of the larynx and trachea (eg, repaired tracheal anomalies, Hurler syndrome) (see "Mucopolysaccharidoses: Clinical features and diagnosis", section on 'Hurler syndrome')
- Bleeding disorder
However, in most instances, the benefit of securing an airway will outweigh the risk of performing needle cricothyroidotomy in these circumstances.
Complete upper airway obstruction — In routine use of percutaneous transtracheal ventilation (PTV) through a catheter, much of the expired air comes out of the mouth and nose. Thus, with complete upper airway obstruction, egress of expired air is difficult. Initial studies in animals suggested that PTV in the setting of complete upper airway obstruction led to development of massive distension of lungs, severe barotrauma, and death . Subsequent studies have shown successful use of PTV in settings of complete upper airway obstruction using modified techniques that consist of prolonged expiratory time, larger internal diameter catheters, and lower oxygen flow rates [20-22].
PTV may be used successfully in partial laryngeal obstruction as the "ball-valve" effect, while constraining natural inspiration, adequately permits exhalation [14,23-25]. For infants and young children with complete upper airway obstruction and where other methods have been unsuccessful, it is reasonable to use PTV. Ventilatory methods should use a longer expiratory time (eg, I:E ratio of 1:8 to 1:10), lower oxygen delivery pressure and flow rate, and as large a catheter as possible. In addition, the clinician should carefully monitor for chest rise and fall with inspiration and expiration. Diminished chest fall with expiration should lead to further reduction in respiratory rate, longer expiratory time, and emergent chest radiography to look for signs of pulmonary barotrauma. (See 'Performing transtracheal ventilation' below.)
ANATOMY — The cricothyroid membrane, as the name implies, is bound by the cricoid cartilage inferiorly and the thyroid cartilage superiorly (figure 1). The key anatomic landmarks are (from cephalad to caudad): hyoid cartilage, thyroid cartilage, cricothyroid membrane, cricoid cartilage, and the tracheal rings.
In older children and adolescents, the laryngeal prominence at the upper border of the thyroid cartilage is easily felt. The thyroid cartilage can then be followed inferiorly to locate the cricothyroid membrane.
In infants and younger children, the laryngeal prominence is not developed, making it difficult to identify the thyroid cartilage. Instead, it is easier to follow the tracheal rings superiorly to locate the prominence of the cricoid cartilage. The cricothyroid membrane is located just superior to the cricoid cartilage. If the cricothyroid membrane cannot be located with certainty in an infant or a young child, percutaneous transtracheal ventilation can be safely performed by introducing the needle between the tracheal cartilages .
The cricothyroid arteries and veins usually overlie the apical portion of the membrane and come from the sides, anastomosing in the midline . Thus, needle cricothyroidotomy should be attempted in the central, lower portion of the membrane (figure 1).
In fresh adult cadavers, the size of the cricothyroid membrane was found to vary from 8 to 19 mm (mean 13.7 mm) in the vertical dimension, and from 9 to 19 mm (mean 12.4 mm) in the transverse dimension . These data suggest that catheters up to 13-gauge can be safely used in a patient with a fully developed airway. The cricothyroid membrane has a mean height of 2.6 mm (SD: 0.7) and width of 3 mm (SD: 0.6) in neonatal cadavers (mean height of 44.9 cm and a mean weight of 2 kg) . The clinician should place the largest catheter possible using this limited information and palpation of the cricothyroid membrane as a guide. The mean depth of tissue overlying cricothyroid membrane in adults is about 2.3 mm .
PHYSIOLOGY — Needle cricothyroidotomy was originally used for passive transtracheal oxygenation in the 1950s . Eventually, needle cricothyroidotomy with percutaneous transtracheal ventilation (PTV) emerged as the invasive rescue method of choice because it provided oxygenation as well as clearance of carbon dioxide. This approach could sustain life for a longer period of time than passive transtracheal oxygenation alone [1,12,31-33]. Smith and Ravussin were among the first to document successful use of needle cricothyroidotomy with PTV in infants and children in the 1970s [12,34].
Delivered tidal volume during PTV is affected by multiple factors, including inspiratory pressure, duration of inspiration, airway resistance, size of catheter, and lung compliance [33,35]. PTV is less efficient than ventilation through endotracheal intubation because up to one-third of oxygen flow delivered to the catheter tip passes up through the glottic opening and out the nose and mouth [32,35]. High pressure oxygen delivery systems are optimal to provide effective ventilation through the relatively narrow catheters used for PTV. However, low pressure systems (eg, self-inflating bag connected to the cricothyroidotomy catheter via a 3.0 mm internal diameter endotracheal tube adapter, 7.0 mm ID ETT adapter connected through a 3 cc syringe, (figure 2)) are sufficient in most patients if a high flow oxygen system is not available [2,6,36,37]. (See 'Equipment' below.)
In adults, PTV is typically accomplished using a 50 pounds per square inch (psi) (350 kPa) oxygen source and a 13- to 16-gauge over-the-needle catheter [3,25,32]. Marr and Yamamoto showed that catheter size (13- to 16-gauge) does not appear to substantially affect gas flow rates when using wall outlet oxygen because gas flows in a turbulent fashion under high pressure through these narrow catheters . Large cannula (>4 mm), inserted via the Seldinger technique, enable ventilation with lower pressures in adults but require either a cuff or upper airway obstruction to prevent gas from escaping through the upper airway .
Lower driving pressures (25 to 35 psi [172 to 241 kPa]) are used in infants and younger children (under 12 years of age) in order to prevent barotrauma . Smaller catheters (16- to 18-gauge) are typically placed due to the anatomic limitation posed by the cricothyroid membrane in the pediatric population. (See 'Anatomy' above.)
Once ventilation is established, exhalation through the transtracheal catheter is insufficient to prevent hyperinflation of the lungs. However, in most instances where PTV is used, the patient's airway remains sufficiently patent to permit exhalation through the nose and mouth [3,24]. In situations where complete airway obstruction exists, the clinician should use longer expiratory time and lower oxygen delivery pressure. In addition, chest rise and fall with inspiration and expiration should be carefully monitored. Diminished chest fall with expiration should lead to further reduction in respiratory rate, prolongation of expiratory time, and emergent chest radiography to look for signs for pulmonary barotrauma. (See 'Performing transtracheal ventilation' below.)
PTV provides less efficient ventilation than endotracheal intubation. Because of the concern for carbon dioxide retention with PTV, the traditional approach has been to use it as a short term (eg, less than 45 minutes) temporizing airway measure . However, when oxygenation is well maintained, even relatively high levels of hypercarbia may be well tolerated, thus permitting its use for many hours at a time [2,7,38]. Regardless, the clinician should still rapidly seek to definitively secure the airway in most patients who require PTV, especially in settings complicated by increased intracranial pressure (because hypercarbia worsens intracranial pressure) or complete upper airway obstruction (increased risk of barotrauma).
There is no risk of gastric dilatation with needle cricothyroidotomy and PTV. The flow of gas up the airway aids in the expulsion of secretions, minimizing the need for suction and preventing pulmonary aspiration [32,39].
Using a canine model, researchers showed that it is not necessary to induce paralysis when using PTV for emergency ventilation of a sedated patient .
Evaluation — Needle cricothyroidotomy with percutaneous transtracheal ventilation (PTV) is an invasive emergent airway procedure that is life saving, albeit with significant potential morbidity. Thus, proper patient selection is essential. The key indication consists of inability to maintain a patient's airway utilizing noninvasive means (eg, bag-valve-mask ventilation, endotracheal intubation, laryngeal mask airway). These patients cannot be intubated and cannot be ventilated. Proposed criteria include :
- Inability to maintain adequate oxygenation with bag-valve-mask ventilation using 100 percent oxygen
- Inability to place or utilize a laryngeal mask airway
- Inability to endotracheally intubate (eg, three or more failed attempts or failure to intubate after 10 minutes in a patient who cannot be maintained with bag-valve-mask ventilation or other noninvasive device)
Pathologic processes that cause distortion of the upper airway anatomy comprise the typical scenarios. (See 'Indications' above.)
The presence of subcutaneous emphysema in the neck may indicate tracheal or cricoid injury and is typically a contraindication to the use of this procedure as is transection of the trachea with retraction of the distal end into the mediastinum. (See 'Contraindications' above.)
Special precautions are needed for infants and young children with complete upper airway obstruction, as in the case of a tight foreign body obstructing the larynx. (See 'Complete upper airway obstruction' above.)
Patient counseling/informed consent — Needle cricothyroidotomy with percutaneous transtracheal ventilation is usually an emergent procedure that does not allow for patient counseling/informed consent prior to the procedure. However, the procedure's necessity, benefits, and risks should be explained to the patient and/or caretaker at the earliest possible time after completion. If feasible, it is ideal for a member of the team not directly involved with the resuscitation to explain the procedure to the family as it is being done.
Equipment — Needle cricothyroidotomy and percutaneous transtracheal ventilation can be performed using standard materials readily available in any hospital. Commercial setups are also attainable [3,7,41,42]. To ensure maximum effectiveness in a highly stressful emergent setting, the author recommends that equipment for PTV, including all the necessary components, be organized and readily available .
- Universal precautions (gown, cap, mask, eye protection, sterile gloves)
- Povidone iodine for site cleansing
- Sterile drape
- 1 percent lidocaine without epinephrine in syringe for injection of local anesthesia in the conscious or semi-conscious patient (see 'Analgesia and sedation' below)
- Three to 10 mL syringe filled with sterile saline
Catheter (large bore) — AVOID needleless safety catheters that cannot be connected to a syringe (eg, BD InSyte™ Autogard™) [12,44].
- Infants and young children - 16- to 18-gauge IV catheters
- Adults and adolescents - 12- (ID 2.8 mm) to 16-gauge (ID 1.5 mm) IV catheters (angiocath) or 6 French transtracheal catheter (2 mm ID, Cook Critical Care) 
- Alternative catheters include vessel dilators from central line kits (7 to 9 French for adults and 5 to 7 French for younger children), a catheter introducer (Arrow Emergency Infusion Device), or a commercially available cricothyroidotomy catheter (eg, Acutronic™) [15,22,45].
Bag-valve-mask connector options — If a bag-valve-mask will be used for patient ventilation, then it should connect to the catheter using one of the following improvised adapters:
- Three mL Luer lock syringe with plunger removed with 7.5 mm ID endotracheal tube connector (bag-valve-mask connector) (figure 2)
- 3.0 mm ID endotracheal tube connector attached directly to the catheter (figure 2) (bag-valve-mask connector)
- 2.5 mm ID endotracheal tube connector attached to cut off IV tubing with Luer lock end connected directly to the catheter (figure 3)
Oxygen tubing connector options — If oxygen tubing will be used to connect to the oxygen source, then the clinician may use one of the following options:
- Direct connection of oxygen tubing to catheter (figure 4)
- Y connector (oxygen tubing) (figure 4)
- Three-way stopcock (oxygen tubing) (figure 5)
High pressure oxygen source — One of the following oxygen sources is recommended:
- Hospital wall outlet without a regulator or set at the maximum flow rate of 15 L/min which provides oxygen at 58 psi (400 kPa, 4 atmospheres) for adolescents and adults; for younger children use a maximum flow rate of 10 to 12 L/min which provides oxygen at 25 to 35 psi (172 to 241 kPa, 1.7 to 2.4 atmospheres) [3,6]
- Oxygen tank without interposing a flow valve with flow rates as per a hospital wall outlet 
- Flush valve of a mechanical ventilator
DO NOT USE the common gas outlet of the anesthesia machine, as most machines have a pressure limiting valve on the back bar which opens at 5 psi (35 kPa) .
Oxygen tubing or equivalent — The tubing must be capable of withstanding high pressure.
Manual in-line valve — The setup must control intermittent flow of oxygen and ventilate the patient, examples include:
- A permanent, commercially available system (figure 6) (eg, by Instrumentation Industries, Inc.)
- A temporary system using Y-connector, side port cut into oxygen tubing, three-way stopcock, or catheter adapter with bag-valve-mask (figure 4 and figure 5 and figure 2 and figure 3) [33,36,37,47]
General considerations — Place the patient in the supine position on the stretcher. Unless there is a cervical spine injury (known or suspected), extend the patient's neck to help identify the procedural landmarks and to obtain the widest exposure of the cricothyroid membrane. While assembling the equipment for the procedure, ask an assistant (preferably the respiratory therapist) to preoxygenate the patient by administering high-flow oxygen via face mask if the patient is breathing spontaneously or via bag-valve-mask if not.
Site verification — The clinician should locate the cricothyroid membrane by palpating the prominence of the thyroid cartilage in older children, adolescents, and adults and moving the finger inferiorly into the depression between the thyroid and cricoid cartilages.
In infants and young children, the clinician should palpate the trachea just 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. If the cricothyroid membrane cannot be located with certainty in an infant or a young child, percutaneous transtracheal ventilation (PTV) can be safely performed by introducing the needle between the tracheal cartilages . (See 'Anatomy' above.)
Although not studied in children, investigators have demonstrated the ability to accurately and rapidly identify the cricothyroid membrane in adult cadavers and live patients using bedside ultrasonography .
Analgesia and sedation — Under emergent circumstances there may not be time to administer sedative or analgesic medications. The most important goal is to secure the airway. In the case of respiratory depression or arrest, sedation may make matters worse and is not advised. However, if the patient is agitated and struggling and this behavior is impeding the progress of the procedure, a sedative and analgesic can be given to help control the patient.
Paralysis or subsequent continuation of paralysis may be considered based on the patient's response to the procedure and adequacy of ventilation achieved. In canine studies, PTV without paralysis has been achieved in sedated animals with unobstructed airways .
Skin preparation — Prepare the skin of the anterior neck with an antiseptic solution (eg, povidone-iodine). If time permits, anesthetize the skin, subcutaneous tissues, and the cricothyroid membrane with a local anesthetic such as 1 percent lidocaine administered through a 27- or 30-gauge needle.
Monitoring — Monitor heart rate and rhythm, blood pressure, respiratory rate, and oxygen saturation throughout the procedure. Lower the patient's gown and sheet to observe the rise and fall of the chest with respiration. Capnography should be used as feasible both during the procedure (to ensure intratracheal location of the needle or the catheter) and during patient ventilation [25,48].
Once the catheter is in place and percutaneous transtracheal ventilation is established, the site of needle cricothyroidotomy should be observed closely for any kinking or dislodgement of the catheter, subcutaneous emphysema (may indicate dislodgment of the cannula), or bleeding . Chest radiographs should be obtained to ensure that the lungs are not over-expanded. Adequacy of PTV should be assessed using clinical parameters as well as frequent blood gas analysis.
Method — (figure 7)
- Needle cricothyroidotomy should be performed with universal precautions and sterile technique. The puncture site is cleansed with povidone-iodine solution after sterile gloves have been donned.
- Hold the trachea in place and provide skin tension with the thumb and middle finger of the non-dominant hand placed on either side of the trachea. Use the index finger to palpate the cricothyroid membrane.
- Hold a 3 to 10 mL syringe half-filled with saline attached to the needle or the over-the-needle IV catheter in the dominant hand.
- Place the needle in the midline of the neck at the inferior margin of the cricothyroid membrane (to avoid the cricothyroid blood vessels located superiorly and laterally). Direct it caudally (toward the feet) at an angle of 30 to 45 degrees.
- Puncture the skin and subcutaneous tissue. Advance the needle while continuously applying negative pressure on the syringe, until air bubbles are seen, confirming intratracheal placement.
- Advance the catheter forward off the needle until its hub rests at the skin surface. Remove the syringe and the needle.
- Reattach the syringe to the catheter and again aspirate for air to confirm that the catheter remains in the trachea.
- Hold the catheter firmly in place at all times or delegate an assistant to do this to reduce the chance of kinking or dislodgement, even after it has been secured with suture material.
Performing transtracheal ventilation
- Connect the catheter to high pressure tubing (connected to a valve and a source of 100 percent oxygen) or to a bag-valve-mask (figure 2 and figure 3 and figure 4 and figure 5). (See 'Bag-valve-mask connector options' above and 'Oxygen tubing connector options' above.)
- Give a few ventilations to reconfirm placement and ensure that the equipment is functioning properly.
- Fix the catheter in place with a suture or a tracheostomy tie, as possible.
- Interpose a capnometer in the circuit to monitor end tidal CO2, if possible.
- Begin regular ventilation by intermittently opening and closing the in-line valve (figure 6); by intermittently occluding the side port, y-connector, or stopcock (figure 4 and figure 5); or by ventilations with the self-inflating resuscitation bag, depending on the system in use.
- Use I:E ratio of 1:4 to 1:5, with a breath rate of 10 to 12/min for most children. Change the ratio to 1:2 to 1:3 with a breath rate of 15 to 20/min in the setting of increased intracranial pressure to improve CO2 elimination. With partial or complete upper airway obstruction, use the ratio of 1:8 to 1:10 with a breath rate of 5 to 6/min to reduce the risk of pulmonary barotrauma. Adjust these ratios based on clinical monitoring, blood gas measurements, and chest radiography.
- Stand clear and observe universal precautions as oropharyngeal secretions may sometimes be expelled through the patient's mouth and nose with great force.
Cricothyroidotomy may also be performed rapidly and effectively using a modified Seldinger technique (wire-guided or catheter-over-needle technique). (See "Emergent surgical cricothyrotomy (cricothyroidotomy)", section on 'Seldinger technique'.)
COMPLICATIONS — Barotrauma and catheter issues that prevent transtracheal ventilation are the two most commonly described complications of percutaneous transtracheal ventilation (PTV) (table 2) [3,7,12,14,15,32]:
- Subcutaneous emphysema can develop during cricothyroidotomy, securing of the catheter, PTV, or after removing the catheter [3,14,49]. Kinking or dislodgement of the transtracheal catheter may result in rapid accumulation of subcutaneous gas in the tissues. In addition, multiple attempts at catheter placement may allow gas to escape into the tissues from previous puncture sites. Techniques to prevent the development of subcutaneous emphysema include:
- Using kink-resistant Teflon™ catheters
- Assigning an individual to hold the catheter hub
- Utilizing a commercially available cricothyroidotomy catheter with attached flanges for securing the catheter (avoids kinking and misplacement)
- Placing a fingertip firmly over the puncture site and applying pressure for a few minutes to prevent air leak after catheter removal
Subcutaneous emphysema after PTV typically resolves without intervention .
- Pulmonary barotrauma may arise from an overly high respiratory rate that leads to insufficient time for passive exhalation and can cause lung hyperinflation, pneumothorax, and pneumomediastinum. These complications may also cause diminished venous return to the heart resulting in reduced cardiac output and/or hypotension [2,3,13,32,50]. Pulmonary barotrauma is more likely in the setting of complete upper airway obstruction. Very slow breath rates (eg, 5 to 6 breaths/minute) and very long expiratory time (eg, I:E ratio of 1:8 to 1:10) are recommended to avoid barotrauma in this setting.
- In one series, PTV could not be accomplished in 6 of 29 (21 percent) emergency patients who required a rescue airway because of poor landmarks, catheter kinking, or inability to place the catheter in the trachea . Proper training and the use of Teflon™ or commercially available cricothyroidotomy catheters are potential ways to improve the success rate for PTV. Varaday et al. have described an easily made model for teaching cricothyroidotomy to medical personnel using readily available materials in any operating room like a plastic tray, standard plastic breathing tubing, tape, and gauze .
Other less common complications of needle cricothyroidotomy and PTV include damage to adjacent structures, bleeding, and infection (table 2) [7,49,50,52]. Although pulmonary aspiration may occur during PTV, in a canine model, it provided significant protection from aspiration relative to dogs with unprotected airways .
FOLLOW-UP CARE — Prolonged percutaneous transtracheal ventilation (PTV) is associated with excessive inspiratory workload, hypercapnia, barotrauma, and catheter dislodgement with subcutaneous emphysema [3,7,53]. Thus, a definitive airway (ie, endotracheal tube or tracheostomy) should be obtained as soon as possible after PTV is established. Emergent anesthesiology and otolaryngology consultation may be required, especially in patients with traumatic injury to the face and/or neck.
In non-traumatic cases, intubation, with direct laryngoscopy or guided by endoscope, is successful in the majority of cases. Subsequent intubation may be easier as the high tracheal pressure from expiratory gases tends to open the previously collapsed glottis, improving visualization of the glottic opening. In addition, there is reduced operator stress and more time to visualize, and if needed, suction the glottic opening [3,54].
- Needle cricothyroidotomy involves passing an over-the-needle catheter through the cricothyroid membrane (figure 2). (See 'Definitions' above.)
- Percutaneous transtracheal ventilation (PTV) is the delivery of oxygen to the lungs through an over-the-needle catheter using a high pressure gas source and is considered a form of conventional ventilation. (See 'Definitions' above.)
Indications and contraindications
- The primary indication for needle cricothyroidotomy with PTV is inability to maintain the airway with noninvasive standard airway procedures (eg, bag-valve-mask ventilation, endotracheal intubation) or rescue procedures (eg, laryngeal mask airway). (See 'Indications' above.)
- Needle cricothyroidotomy with PTV is absolutely contraindicated when the airway is maintainable through noninvasive means. (See 'Contraindications' above.)
- In addition, needle cricothyroidotomy with PTV should not be performed when damage to the larynx, cricoid cartilage, or trachea preclude successful oxygenation and ventilation via a transtracheal catheter. (See 'Contraindications' above.)
Preparation and procedure
- The cricothyroid membrane, as the name implies, is bound by the cricoid cartilage inferiorly and the thyroid cartilage superiorly (figure 1). The key anatomic landmarks are (from cephalad to caudad): hyoid cartilage, thyroid cartilage, cricothyroid membrane, cricoid cartilage, and the tracheal rings. (See 'Anatomy' above.)
- Needle cricothyroidotomy and percutaneous transtracheal ventilation (PTV) can be performed using standard materials readily available in any hospital (figure 2 and figure 3 and figure 4 and figure 5 and figure 6). Commercial setups are also attainable. To ensure maximum effectiveness in a highly stressful emergent setting, the equipment for PTV, including all the necessary components, should be organized and immediately available. (See 'Equipment' above.)
- The tables and figure summarize the procedure (table 1 and figure 7) and potential complications (table 2) for needle cricothyroidotomy with PTV. (See 'Preparation' above and 'Procedure' above and 'Complications' above.)
- Jorden RC, Moore EE, Marx JA, Honigman B. A comparison of PTV and endotracheal ventilation in an acute trauma model. J Trauma 1985; 25:978.
- Coté CJ, Eavey RD, Todres ID, Jones DE. Cricothyroid membrane puncture: oxygenation and ventilation in a dog model using an intravenous catheter. Crit Care Med 1988; 16:615.
- Patel RG. Percutaneous transtracheal jet ventilation: a safe, quick, and temporary way to provide oxygenation and ventilation when conventional methods are unsuccessful. Chest 1999; 116:1689.
- Mutzbauer TS, Keul W, Bernhard M, et al. [Invasive techniques in emergency medicine. IV. Cricothyrotomy in emergency situations]. Anaesthesist 2005; 54:145.
- Ihra G, Gockner G, Kashanipour A, Aloy A. High-frequency jet ventilation in European and North American institutions: developments and clinical practice. Eur J Anaesthesiol 2000; 17:418.
- Cook TM, Nolan JP, Magee PT, Cranshaw JH. Needle cricothyroidotomy. Anaesthesia 2007; 62:289.
- Mace SE, Khan N. Needle cricothyrotomy. Emerg Med Clin North Am 2008; 26:1085.
- Mutzbauer TS, Munz R, Helm M, et al. [Emergency cricothyrotomy--puncture or anatomical preparation? Peculiarities of two methods for emergency airway access demonstrated in a cadaver model]. Anaesthesist 2003; 52:304.
- Sise MJ, Shackford SR, Cruickshank JC, et al. Cricothyroidotomy for long-term tracheal access. A prospective analysis of morbidity and mortality in 76 patients. Ann Surg 1984; 200:13.
- Craven RM, Vanner RG. Ventilation of a model lung using various cricothyrotomy devices. Anaesthesia 2004; 59:595.
- Chan TC, Vilke GM, Bramwell KJ, et al. Comparison of wire-guided cricothyrotomy versus standard surgical cricothyrotomy technique. J Emerg Med 1999; 17:957.
- Ravussin P, Bayer-Berger M, Monnier P, et al. Percutaneous transtracheal ventilation for laser endoscopic procedures in infants and small children with laryngeal obstruction: report of two cases. Can J Anaesth 1987; 34:83.
- Benumof JL, Scheller MS. The importance of transtracheal jet ventilation in the management of the difficult airway. Anesthesiology 1989; 71:769.
- Weymuller EA Jr, Pavlin EG, Paugh D, Cummings CW. Management of difficult airway problems with percutaneous transtracheal ventilation. Ann Otol Rhinol Laryngol 1987; 96:34.
- Boyce JR, Peters GE, Carroll WR, et al. Preemptive vessel dilator cricothyrotomy aids in the management of upper airway obstruction. Can J Anaesth 2005; 52:765.
- Ezri T, Szmuk P, Warters RD, et al. Difficult airway management practice patterns among anesthesiologists practicing in the United States: have we made any progress? J Clin Anesth 2003; 15:418.
- Bork K, Siedlecki K, Bosch S, et al. Asphyxiation by laryngeal edema in patients with hereditary angioedema. Mayo Clin Proc 2000; 75:349.
- Hinze JD, Barker JA, Jones TR, Winn RE. Life-threatening upper airway edema caused by a distal rattlesnake bite. Ann Emerg Med 2001; 38:79.
- Neff CC, Pfister RC, Van Sonnenberg E. Percutaneous transtracheal ventilation: experimental and practical aspects. J Trauma 1983; 23:84.
- Frame SB, Simon JM, Kerstein MD, McSwain NE Jr. Percutaneous transtracheal catheter ventilation (PTCV) in complete airway obstruction--a canine model. J Trauma 1989; 29:774.
- Stothert JC Jr, Stout MJ, Lewis LM, Keltner RM Jr. High pressure percutaneous transtracheal ventilation: the use of large gauge intravenous-type catheters in the totally obstructed airway. Am J Emerg Med 1990; 8:184.
- Campbell CT, Harris RC, Cook MH, Reines HD. A new device for emergency percutaneous transtracheal ventilation in partial and complete airway obstruction. Ann Emerg Med 1988; 17:927.
- deLisser EA, Muravchick S. Emergency transtracheal ventilation. Anesthesiology 1981; 55:606.
- Smith RB, Babinski M, Klain M, Pfaeffle H. Percutaneous transtracheal ventilation. JACEP 1976; 5:765.
- Ward KR, Menegazzi JJ, Yealy DM, et al. Translaryngeal jet ventilation and end-tidal PCO2 monitoring during varying degrees of upper airway obstruction. Ann Emerg Med 1991; 20:1193.
- Little CM, Parker MG, Tarnopolsky R. The incidence of vasculature at risk during cricothyroidostomy. Ann Emerg Med 1986; 15:805.
- Bennett JD, Guha SC, Sankar AB. Cricothyrotomy: the anatomical basis. J R Coll Surg Edinb 1996; 41:57.
- Navsa N, Tossel G, Boon JM. Dimensions of the neonatal cricothyroid membrane - how feasible is a surgical cricothyroidotomy? Paediatr Anaesth 2005; 15:402.
- Nicholls SE, Sweeney TW, Ferre RM, Strout TD. Bedside sonography by emergency physicians for the rapid identification of landmarks relevant to cricothyrotomy. Am J Emerg Med 2008; 26:852.
- Jacoby, JJ, Hamelberg, W, Reed, JP, Gillespie, B. A simple technique for artificial respiration. Am J Physiol 1951; 167:798.
- REED JP, KEMPH JP, HAMELBERG W, et al. Studies with transtracheal artificial respiration. Anesthesiology 1954; 15:28.
- Jacobs HB, Smyth NP, Witorsch P. Transtracheal catheter ventilation: clinical experience in 36 patients. Chest 1974; 65:36.
- Attia RR, Battit GE, Murphy JD. Transtracheal ventilation. JAMA 1975; 234:1152.
- Smith RB, Myers EN, Sherman H. Transtracheal ventilation in paediatric patients; case reports. Br J Anaesth 1974; 46:313.
- Yealy DM, Plewa MC, Stewart RD. An evaluation of cannulae and oxygen sources for pediatric jet ventilation. Am J Emerg Med 1991; 9:20.
- Marr JK, Yamamoto LG. Gas flow rates through transtracheal ventilation catheters. Am J Emerg Med 2004; 22:264.
- Chong CF, Wang TL, Chang H. Percutaneous transtracheal ventilation without a jet ventilator. Am J Emerg Med 2003; 21:507.
- Goldstein B, Shannon DC, Todres ID. Supercarbia in children: clinical course and outcome. Crit Care Med 1990; 18:166.
- Yealy DM, Plewa MC, Reed JJ, et al. Manual translaryngeal jet ventilation and the risk of aspiration in a canine model. Ann Emerg Med 1990; 19:1238.
- Tran TP, Rhee KJ, Schultz HD, Carl ML. Gas exchange and lung mechanics during percutaneous transtracheal ventilation in an unparalyzed canine model. Acad Emerg Med 1998; 5:320.
- Delaney WA, Kaiser RE Jr. Percutaneous transtracheal jet ventilation made easy. Anesthesiology 1991; 74:952.
- Scuderi PE, McLeskey CH, Comer PB. Emergency percutaneous transtracheal ventilation during anesthesia using readily available equipment. Anesth Analg 1982; 61:867.
- American College of Emergency Physicians, American Academy of Pediatrics. Care of children in the emergency department: guidelines for preparedness. Ann Emerg Med 2001; 37:423.
- Soto R, Mesa A. New intravenous catheter not suitable for trans-tracheal jet ventilation. Anesth Analg 2001; 92:1074.
- Boyce JR, Peters G. Vessel dilator cricothyrotomy for transtracheal jet ventilation. Can J Anaesth 1989; 36:350.
- Thompson C, Halder S, Wimbush S. Effective ventilation following emergency needle cricothyroidotomy. Resuscitation 2007; 72:164.
- Gaufberg SV, Workman TP. New needle cricothyroidotomy setup. Am J Emerg Med 2004; 22:37.
- Tobias JD, Higgins M. Capnography during transtracheal needle cricothyrotomy. Anesth Analg 1995; 81:1077.
- Carden E, Calcaterra TC, Lechtman A. Pneumatocele of the larynx: a complication of percutaneous transtracheal ventilation. Anesth Analg 1976; 55:600.
- Newlands SD, Makielski KH. Cervical osteomyelitis after percutaneous transtracheal ventilation and tracheotomy. Head Neck 1996; 18:295.
- Varaday SS, Yentis SM, Clarke S. A homemade model for training in cricothyrotomy. Anaesthesia 2004; 59:1012.
- Fikkers BG, van Vugt S, van der Hoeven JG, et al. Emergency cricothyrotomy: a randomised crossover trial comparing the wire-guided and catheter-over-needle techniques. Anaesthesia 2004; 59:1008.
- Ooi R, Fawcett WJ, Soni N, Riley B. Extra inspiratory work of breathing imposed by cricothyrotomy devices. Br J Anaesth 1993; 70:17.
- McLeod AD, Turner MW, Torlot KJ, et al. Safety of transtracheal jet ventilation in upper airway obstruction. Br J Anaesth 2005; 95:560.