Anesthesiologists are responsible for ensuring that patients receive enough oxygenation during surgical procedures. During general anesthesia, they typically do so through endotracheal intubation, which involves access to the upper respiratory system through the mouth and throat. However, it is not always an option for some patients, such as those undergoing surgery in or around the upper airway, and intubation can sometimes fail (1). Therefore, it is crucial that anesthesiologists maintain mastery of placing surgical airways, which serve to create an additional airway for patients to receive oxygen while use of their trachea is unavailable (2).
There are two primary types of surgical airways: cricothyrotomy and tracheostomy. Each technique has distinct indications, benefits, and risks that are useful for anesthesiologists and surgeons to know.
Believed to have been first performed by ancient Egyptians or earlier, cricothyrotomy is not a technique new to modern medicine. The modern technique is performed by making an incision through the cricothyroid membrane, located near the Adam’s apple, and inserting a tube to provide oxygen (3). It can also be achieved by placing a needle into the trachea, otherwise called ‘needle cricothyrotomy’ (2).
Cricothyrotomy became a mainstream practice in the 1970’s after two physicians, Brantigan and Grow, published a paper detailing a low complication rate on a series of patients undergoing elective cricothyrotomy (4). The technique is chosen when other methods of intubation have failed and there is a pressing need for an airway, such as in “Cannot Intubate, Cannot Oxygenate” (CICO) scenarios, though these occur infrequently (5).
Cricothyrotomies are advantageous as the cricothyroid membrane is easy to locate, making them useful for anesthesiologists needing to rapidly create surgical airways. Additionally, the technique is associated with less bleeding and can be quickly performed (6). Although cricothyrotomy is designed to save the patient’s life, and therefore has strong benefits, there are some risks in performing the technique. Laceration of the tracheal cartilage, perforation of the trachea, and infection could occur. Additionally, long term risks such as voice changes are possible (3).
Unlike cricothyrotomy, tracheostomies are much more complicated to perform and therefore are not typically performed in CICO or other emergent scenarios. Instead, this technique is more often used in premeditated situations where patients require long term intubation for indications such as the inability to extubate, maxillofacial trauma, laryngeal or neck trauma, obstructive sleep apnea, secondary effects of radiation therapy, reconstruction of the maxilla or mandible, and more.
The technique involves making an incision just below the cricoid cartilage and inserting a tracheostomy tube through which an oxygen mixture flows (2). Tracheostomies are advantageous as they provide patients with a long-term airway that is more comfortable for extended ventilation. Risks include hemorrhaging, infection, tube dislodging, and a late complication of pressure necrosis (7).
Surgical airways are indispensable for anesthesiologists, offering a direct, life-saving option when other airway methods fail. Proficiency in cricothyrotomy and tracheostomy techniques is essential for anesthesiologists, ensuring they can secure a patient’s airway quickly and effectively in challenging scenarios. Through careful assessment, training, and quick action, anesthesiologists can utilize surgical airways to ensure patients are able to properly breathe in both CICO and non-emergent situations
References
1. Thierbach, Andreas R., and Michael F. Murphy. “Prehospital Airway Management.” In Elsevier eBooks, 731–55, 2007. https://doi.org/10.1016/b978-032302233-0.50039-1.
2. Patel, Sapna A, and Tanya K Meyer. “Surgical Airway.” International Journal of Critical Illness and Injury Science 4, no. 1. January 1, 2014.: 71. https://doi.org/10.4103/2229-5151.128016.
3. McKenna, Peter, Ninad M. Desai, Amina Tariq, and Eric J. Morley. “Cricothyrotomy.” StatPearls – NCBI Bookshelf, February 4, 2023. https://www.ncbi.nlm.nih.gov/books/NBK537350/.
4. Brantigan, C. O., J B Grow Sr. “Cricothyroidotomy: Elective Use in Respiratory Problems Requiring Tracheotomy,” January 1, 1976. https://pubmed.ncbi.nlm.nih.gov/1249960/.
5. Shackles, John. “Emergency cricothyrotomy (cricothyroidotomy) in adults,” April 1, 2024. https://www.uptodate.com/contents/emergency-cricothyrotomy-cricothyroidotomy-in-adults.
6. Katos, M. Gregory, David Goldenberg. “Emergency cricothyrotomy” Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 18, Issue 2, 110 – 114. June 2007. https://www.optecoto.com/article/S1043-1810(07)00036-X/fulltext.
7. Raimonde, Anthony J., Natalie Westhoven, and Ryan Winters. “Tracheostomy.” StatPearls – NCBI Bookshelf. July 24, 2023. https://www.ncbi.nlm.nih.gov/books/NBK559124/.
