Cricothyroid Catheter Insertion, Cricothyroidotomy, and Tracheostomy

CHAPTER 199 Cricothyroid Catheter Insertion, Cricothyroidotomy, and Tracheostomy



David Roden


Establishing an airway is crucial to a patient’s survival and is of paramount importance in an emergency. If endotracheal or nasotracheal intubation is impossible, several techniques can be used to establish a surgical airway. Cricothyroid catheter insertion (also known as percutaneous transtracheal jet ventilation) and cricothyroidotomy are usually performed in emergencies, whereas tracheostomy is usually performed under controlled conditions.


Cricothyroid catheter insertion is the least invasive procedure, requires the least surgical skill, does not require an assistant, and is the quickest technique. It also has the lowest risk of complications, such as bleeding, glottic stenosis, subglottic stenosis, or tracheal ulceration. This technique provides a temporary airway to preserve oxygenation until a larger airway can be established. (If used with intermittent jet of pressurized 100% oxygen at 50 pounds per square inch [psi], adequate ventilation is also provided; exhalation occurs passively due to secondary recoil of the lungs and chest wall.) Emergency personnel also use cricothyroidotomy as a lifesaving maneuver. One advantage of cricothyroid catheter insertion and cricothyroidotomy is the speed with which they can be performed. They also do not require a lot of equipment and result in less scarring than tracheosotomy. Because the airway is most superficial at the level of the cricothyroid membrane and anatomic landmarks are easily identifiable, this location is ideal for the clinician to create an airway. Serious bleeding and perforation of other structures can also usually be avoided at this site.


Tracheostomy is the most complicated surgical airway procedure and requires the most equipment. It is performed at a level two tracheal rings below the cricothyroid membrane. This site is farther away from the larynx, so the incidence of laryngeal injury is much lower, especially if the opening is maintained for a prolonged time. Dissection is more complicated because the trachea is located deeper than the cricothyroid membrane, so the clinician must be familiar with local anatomy to minimize risk. Tracheostomy is associated with two to five times the complication rate when performed as an emergency procedure; therefore, it is rarely performed except under controlled circumstances in the operating room. In addition, the complete procedure usually takes too long to be useful for emergency airway management and can be difficult for the untrained clinician to perform. The only situation in which emergency tracheostomy is preferred is when the specific location of the injury or disease (e.g., subglottic tumor, thyroid cartilage fracture) precludes alternatives.



Cricothyroid Catheter Insertion



Indications



• Temporary need for an airway

• Upper airway obstruction, usually resulting from foreign body, infection, neoplasm, edema, or trauma

• Preferred technique for establishing emergency airway in pediatric age group if endotracheal intubation fails


Contraindications



• There is an intact nonsurgical airway.

• Subglottic obstruction exists.

• Thyroid cartilage fracture or damage to larynx or cricoid cartilage: anterior neck trauma may be a contraindication if these structures are possibly damaged. In these situations, tracheostomy is preferred.

• Complete airway obstruction is a contraindication for jet ventilation (results in barotrauma or auto–positive end-expiratory pressure [auto-PEEP]; a patent airway is needed for outflow of gas with expiration).


Equipment



• Goggles or eye protection

• Mask, cap, gown, and sterile gloves

• 12-, 14- or 16-gauge, 2- to 3-inch over-the-needle catheter (angiocatheter)

• 5- or 10-mL syringe

• Lidocaine 1% with epinephrine in 10-mL syringe with 22-gauge, image-inch needle

• Skin-sterilizing supplies such as povidine–iodine (if time allows)

• Adhesive tape

• Umbilical tape, 2-0 monofilament nylon suture and needle holder or commercially available endotracheal tube connecter

• High-pressure oxygen supply (30 to 60 psi) with a pressure gauge and a pressure-regulating valve (if high-pressure oxygen is not available, a 3-mL syringe barrel [without a plunger] can be attached to the catheter; a standard endotracheal tube connector can then be used to attach the catheter to a bag-mask-valve [Ambu bag] device)

• Hand-operated valve connected inline to tubing and catheter

• Alternate: an oxygen regulator and manual trigger


Preprocedure Patient Preparation


No patient education is needed in the emergency setting. Documentation should be made in the patient’s chart that informed consent was obtained if time allows. If time does not allow, an explanation of the emergent need for this procedure should be documented.



Procedure



1 Position the patient in the supine position with the chin directly midline and maximally extended (if no cervical spine trauma). If a cervical fracture is suspected, the neck should remain immobilized in a neutral position.

2 Clean the neck with povidone–iodine or other antiseptic solution.

3 Observe universal blood and body fluid precautions. Observe sterile technique (cap, gloves, mask, gown, and drapes).

4 Use the nondominant hand to identify the cricothyroid membrane, which is located immediately caudal to the prominent thyroid cartilage (Adam’s apple). It is the first small depression or indentation inferior to the hard thyroid cartilage, between the cricoid and thyroid cartilages. It should be easily palpable, even in obese individuals.

5 If the patient is awake, and time allows, infiltrate lidocaine as a wheal and then down to the membrane in the desired location using a 10-mL syringe with a 22-gauge needle.

6 With the nondominant hand, immobilize the thyroid cartilage and hold the skin taut over the cricothyroid membrane.

7 Direct the catheter-over-needle attached to the syringe downward in the midline and caudally at an angle of 45 degrees (Fig. 199-1). Inserting the catheter-over-needle in the inferior aspect of the cricothyroid membrane minimizes risk of injury to the cricothyroid arteries. Aspirate with the syringe during insertion. When air is obtained with aspiration, the needle has entered the trachea.

8 Advance the catheter over the needle, withdraw the needle and syringe, and attach the distal end of the high-pressure oxygen tubing to the catheter.

9 Open the hand-operated release valve to deliver pressurized oxygen to the trachea. As soon as the chest rises, assume that the patient has been oxygenated; the valve should then be closed. Open the valve, watch the chest rise, and close the valve—in a rhythmic pattern—to approximate actual breathing. Adjust the overall pressure level to allow adequate lung expansion.

10 Most upper airway obstructions are incomplete and allow some ventilation to occur with forced exhalations. (If the chest remains inflated during the exhalation phase, a complete proximal airway obstruction may be present. In this case, a second large-bore over-the-needle catheter can be inserted next to the original catheter. If the chest still remains distended, cricothyroidotomy should be performed.)

11 The oxygen line should be taped to the catheter. Next, secure the catheter and oxygen tubing by placing a stitch through the skin near the catheter (after infiltration of lidocaine in the conscious patient), wrapping one end of the suture around the catheter several times and tying it to the base of the other end of the suture near the skin. The other end of the suture can then be wrapped several times around the oxygen tubing and tied to the original end of the suture near the skin. Alternatively, a piece of umbilical tape or adhesive tape can be wrapped around the patient’s neck, the catheter hub, and the oxygen tubing. Or a commercially available endotracheal tube holder can be wrapped around the patient’s neck and connected to the oxygen tubing; the catheter will still have to be secured with suture or by being taped to the tubing and skin.

12 Obtain an arterial blood gas. Pulse oximetry, blood pressure, and telemetry should be monitored.

image

Figure 199-1 Over-the-needle catheter is inserted through cricothyroid membrane with syringe attached. The clinician should aspirate while inserting the needle.



Complications



• Inadequate ventilation or hypoxia (often due to catheter kinking as it travels through the tissue; use of commercially available kink-resistant catheters minimizes this risk)

• Barotrauma (can cause pneumothorax, pneumomediastinum, or pneumopericardium; auto-PEEP can result in decreased mean arterial pressure)

• Subcutaneous emphysema

• Aspiration (pressurized airflow may minimize risk of aspiration; however, make sure to suction upper airway before discontinuing cricothyroid catheter)

NOTE: Cricothyroid catheter insertion through the cricothyroid membrane may maintain spontaneous respirations for a few minutes. This is the procedure of choice for children under 12 years old because the cricothyroid membrane is small. If this maneuver is inadequate, formal tracheostomy is indicated.



Cricothyroidotomy



Indications



• Upper airway obstruction, usually resulting from foreign body, infection, neoplasm, edema, or trauma

• When endotracheal or nasotracheal intubation has failed, is contraindicated, or is unavailable

• Patient with a cervical spine fracture who cannot extend neck for intubation

• Prior cricothyroidotomy catheter insertion complicated by carbon dioxide retention or air entrapment


Contraindications



• Intact nonsurgical airway

• Subglottic obstruction

• Thyroid cartilage fracture or damage to larynx or cricoid cartilage (anterior neck trauma may be contraindication if these structures are possibly damaged); in these situations, trachestomy preferred

• Patient younger than 8 years old (cricothyroid catheter insertion or needle cricothyroidotomy is the preferred procedure for this age group)

• Relative contraindications: a coagulopathy, massive neck swelling or hematoma, or previously prolonged endotracheal intubation (tracheostomy or conversion to tracheostomy may be preferred)


Equipment



• Goggles or eye protection

• No. 15 scalpel blade with handle

• Size 4 to 6 endotracheal tubes or size 4 to 6 Shiley cuffed tracheostomy tubes

• Adhesive tape

• Umbilical tape and 2-0 monofilament nylon suture and needle holder (if a tracheostomy tube is used)

• Sterile 4 × 4–inch gauze sponges

• Self-refilling bag-valve-mask unit (Ambu bag) with tubing and oxygen source

• Suction and suction catheters

If time allows


• Povidone–iodine (Betadine) or other antiseptic skin preparation

• Mask, cap, gown, and sterile gloves

• Sterile fenestrated drape

• Lidocaine 1% with epinephrine in 10-mL syringe with 22-gauge, image-inch needle

If a tracheostomy tray is available:


• Hemostat clamps (2)

• Kelly clamps (2)

• Tracheal dilator (Trousseau)

• Curved scissors

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May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Cricothyroid Catheter Insertion, Cricothyroidotomy, and Tracheostomy

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