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✦ DNB DISTINCTION ANSWER

Cricothyrotomy and Percutaneous Tracheostomy

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🔑 KEY WORDS / HIGH-YIELD TAGS

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PART 1 — CRICOTHYROTOMY

1.1 Definition & Synonyms

Two forms:

• Surgical/Open cricothyrotomy — incision + tube insertion
• Needle cricothyrotomy → Percutaneous Translaryngeal Ventilation (PTLV) / Transtracheal Jet Ventilation

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1.2 Relevant Anatomy

Pitfall: Cricothyroid arteries branch from the superior thyroid artery and traverse the superior CTM — always incise in the caudad (lower) third of the membrane.

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1.3 Indications

• Primary: Cannot Intubate, Cannot Oxygenate (CICO) = Failed Airway
• Inability to maintain SpO₂ >90% between intubation attempts
• Failure after ≥3 attempts at endotracheal intubation
• Inability to bag-mask-valve ventilate
• Failure of rescue maneuvers (GEB, iLMA, video laryngoscopy)

1.4 Contraindications

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1.5 Techniques

A. Surgical (Open) Cricothyrotomy — Steps

1. Position: supine, neck extended (shoulder roll)
2. Identify CTM: "Laryngeal Handshake"
   - Dominant hand cephalad; thumb & middle finger stabilize
     thyroid cartilage; index finger palpates CTM
3. Stabilise larynx; vertical stab incision (1.5 cm) through skin
4. Horizontal incision through lower 1/3 of CTM
5. Hook caudal edge of CTM; dilate with tracheal hook or
   curved haemostat
6. Insert tracheostomy tube (Shiley 6.0) or ETT (6.0 cuffed)
   → direct caudally
7. Inflate cuff, confirm with ETCO₂ + bilateral auscultation
8. Secure tube; convert to formal tracheostomy within 72 hrs

Scalpel-Bougie technique (DAS/UK guideline preferred):

• Single vertical incision → horizontal CTM stab → bougie inserted caudally → 6.0 ETT railroaded over bougie

B. Needle Cricothyrotomy / PEAA (Percutaneous Emergency Airway Access)

1. 14-gauge over-needle catheter attached to syringe
2. Advance at 45° caudally through caudad 1/3 of CTM
3. Continuous negative aspiration → free air confirms placement
4. Advance catheter; remove needle
5. Attach to jet ventilator (15 psi) or BVM via adapter
6. I:E ratio 1:4 to allow CO₂ exhalation
   (ventilation is achieved but CO₂ clearance LIMITED)

Key limitation: Needle cricothyrotomy = oxygenation only (30–45 min maximum). CO₂ rises → MUST convert to definitive airway.

Devices: Cook Transtracheal Airway Catheter, Ravussin Catheter (pre-curved, kink-resistant)

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1.6 Step-by-Step Flowchart

        DIFFICULT AIRWAY
              │
    ┌─────────▼─────────┐
    │  Attempt ETI (x3) │
    │  ± Video laryngoscopy │
    │  ± GEB / LMA       │
    └─────────┬─────────┘
              │ FAIL
              ▼
    ┌────────────────────┐
    │  SpO₂ >90%?        │
    │  BVM maintainable? │
    └──────┬─────┬───────┘
         YES     NO
          │       │
     One more   ┌─▼──────────────────────┐
     attempt    │   FAILED AIRWAY = CICO  │
                │  CRICOTHYROTOMY NOW     │
                └─┬──────────────────────┘
                  │
          ┌───────▼────────────────┐
          │  Surgical Cricothyrotomy│◄── Preferred
          │  (Scalpel-Bougie or    │
          │   Standard Open)       │
          └───────┬────────────────┘
                  │ If surgical not possible
                  ▼
          ┌──────────────────────────┐
          │  Needle Cricothyrotomy   │
          │  + Jet Ventilation/BVM   │
          │  (Bridge, max 30–45 min) │
          └──────────────────────────┘
                  │
                  ▼
          Convert to formal tracheostomy
          within 24–72 hours

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1.7 Complications

Historical pearl: Chevalier Jackson (1921) reported subglottic stenosis as a major complication of cricothyrotomy; this led to its abandonment. Brantigan and Grow (1976) conclusively refuted this — complication rates were comparable to tracheostomy if proper technique was used.

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PART 2 — PERCUTANEOUS TRACHEOSTOMY (PDT)

2.1 Definition & History

Timeline:

• 1626 — Sanctorius: first percutaneous tracheal cannulation ("ripping needle")
• 1869 — Trendelenburg: first cuffed tracheostomy tube
• Late 1960s — Toye & Weinstein: Seldinger guidewire for tracheal access
• 1985 — Pasquale Ciaglia: described modern PDT → "Ciaglia technique" → now the gold standard

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2.2 Anatomy for PDT

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2.3 Indications

• Prolonged mechanical ventilation (most common; controversial timing)
• Upper airway obstruction (head/neck malignancy, angioedema, burns, trauma)
• Airway protection after neurological events (CVA, TBI, ICH)
• Chronic neuromuscular disease (MND, GBS, high cervical SCI)
• Obstructive sleep apnea (selected cases)
• Central airway obstruction (neoplasm, subglottic stenosis, radiation stricture)
• Emergency adjunct when ETI has failed

2.4 Timing

Current evidence: Multiple RCTs and meta-analyses (including the TracMan trial: 1,032 patients, 57 sites) show no mortality benefit of early vs. late tracheostomy. However, early tracheostomy may reduce ventilator-associated pneumonia (VAP). Decision must be individualised.

2.5 Contraindications

Uremia: PDT safe but pretreat with DDAVP (desmopressin) to improve platelet function.

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2.6 Ciaglia Blue Rhino PDT — Step-by-Step Procedure

PRE-PROCEDURE
─────────────
✓ Review CT neck (high-riding innominate artery, aberrant vessels)
✓ USS neck: identify vessels, thyroid isthmus, tracheal rings
✓ Labs: PT, PTT, platelets, BUN
✓ Increase FiO₂ to 1.0
✓ Shoulder roll → neck extended
✓ Sedation + analgesia + short-acting paralysis
✓ Sterile prep and drape

PROCEDURE (Ciaglia Blue Rhino)
──────────────────────────────
Step 1: Identify entry site — between rings 1–2 or 2–3
Step 2: Infiltrate 10 mL of 1% lidocaine + epinephrine
Step 3: 1.0–1.5 cm horizontal (or vertical) skin incision
        → blunt dissect to tracheal rings
Step 4: Bronchoscope positioned at distal ETT tip;
        Transillumination through anterior neck confirms level
Step 5: ETT cuff deflated; ETT pulled back to subglottis
        (bronchoscopist confirms position)
Step 6: 14-gauge introducer needle inserted MIDLINE
        under direct bronchoscopic vision
Step 7: Aspiration of air + direct bronchoscopic view = 
        confirmation of intratracheal position
Step 8: J-tipped guidewire advanced toward carina
Step 9: Short 14-Fr dilating catheter used for initial dilation
Step 10: Single tapered Blue Rhino dilator over guidewire
         (AVOID posterior tracheal membrane)
Step 11: Tracheostomy tube (loaded on obturator) passed
         over guidewire → cuff inflated
Step 12: Confirm position — bronchoscopy through ETT
         then through tracheostomy; tidal volume return

POST-PROCEDURE
──────────────
✓ Secure tube; CXR to exclude pneumothorax
✓ Tracheostomy collar/ties
✓ Suction setup

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2.7 PDT Flowchart

    PATIENT REQUIRING TRACHEOSTOMY
                 │
    ┌────────────▼────────────────┐
    │  Assess anatomy (USS ± CT)  │
    │  Labs: PT, PTT, Plt, BUN    │
    └────────────┬────────────────┘
                 │
    ┌────────────▼──────────────────────────┐
    │  Is anatomy favourable?               │
    │  - Palpable cartilages?               │
    │  - No overlying vessels?              │
    │  - Coagulation acceptable?            │
    │  - PEEP <12 cmH₂O?                   │
    └────┬──────────────────────┬───────────┘
        YES                     NO
         │                       │
         ▼                       ▼
    PDT (Bedside ICU)     Surgical Tracheostomy
    Bronchoscopy-guided   (OR, open dissection)
         │
         ▼
    Seldinger technique:
    Needle → Guidewire → Dilator → Tube
         │
         ▼
    Confirm: Bronchoscopy + ETCO₂ + CXR
         │
         ▼
    Ongoing tracheostomy care &
    early decannulation assessment

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2.8 PDT vs. Surgical Tracheostomy — Comparison

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2.9 Complications

Acute

Late

TIF Management Mnemonic: "DCOR" Do NOT deflate cuff → Call surgeon immediately → OR for immediate repair → Resuscitate

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PART 3 — SIDE-BY-SIDE QUICK COMPARISON TABLE

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PART 4 — CLINICAL SCENARIOS (DNB APPLICATION)

Scenario 1: CICO in a trauma patient with massive orofacial injuries

• Action: Immediate surgical cricothyrotomy (scalpel-bougie technique)
• Do NOT attempt repeated laryngoscopy or needle cricothyrotomy (inadequate CO₂ clearance)
• Convert to formal tracheostomy within 24–72 hours

Scenario 2: ICU patient, intubated 14 days, failed multiple weaning trials, TBI

• Action: PDT — USS-guided, bronchoscopy-assisted, Ciaglia Blue Rhino
• Check coagulation, palpate anatomy, PEEP assessment

Scenario 3: Post-PDT patient, day 9 — massive haemorrhage from tracheostomy

• Think TIF immediately
• DO NOT deflate cuff; apply digital pressure; call vascular/cardiothoracic surgery; OR for innominate artery ligation

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PART 5 — DNB EXAM BULLET SUMMARY

Cricothyrotomy — High-Yield Points

• CTM = emergency airway of choice in CICO
• Dimensions: 9 mm × 30 mm; access in LOWER 1/3
• Relatively avascular — cricothyroid arteries at superior margin
• Contraindicated in age <5–12 years (use needle only)
• Success: 90–100% surgical; ~50% needle (by non-surgeon)
• Needle cricothyrotomy = temporising measure only — max 30–45 min
• Convert surgical cricothyrotomy to tracheostomy within 72 h
• Subglottic stenosis risk: historical overconcern; equivalent to tracheostomy with good technique
• Jackson (1921) overestimated risk → refuted by Brantigan & Grow (1976)

Percutaneous Tracheostomy — High-Yield Points

• PDT first described by Ciaglia (1985) — Ciaglia Blue Rhino = gold standard
• Ideal site: between rings 1–2 or 2–3
• Requires bronchoscopic guidance (reduces complications)
• USS neck pre-procedure to identify overlying vessels
• Timing: no proven mortality benefit early vs. late (TracMan trial)
• Most feared late complication: TIF (<1%; mortality ~86%)
• Tracheal stenosis: clinically significant only when >75% luminal reduction; stridor when <5 mm
• DDAVP pre-procedure in uraemic patients
• NOT for emergency airway access
• PDT complication rates equivalent to surgical tracheostomy when bronchoscope-guided

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REFERENCES

• Roberts and Hedges' Clinical Procedures in Emergency Medicine, Chapters on Cricothyrotomy & Percutaneous Translaryngeal Ventilation
• Current Surgical Therapy, 14e — Thiboutot & Feller-Kopman, Percutaneous Dilatational Tracheostomy
• Miller's Anesthesia, 10e — Cricothyrotomy and PEAA
• Barash's Clinical Anesthesia, 9e — Emergency Airway Management
• Current Surgical Therapy 14e — Comparison: PDT vs. Surgical Tracheostomy