Best Practices for Emergency Surgical Airway

by Amy E. Hamaker •

Is tracheotomy safer and more effective than cricothyrotomy in an emergency surgical airway?

Bottom line: Complications associated with emergency cricothyrotomy may not occur as frequently as presumed. Tracheotomy is an effective means of securing the airway in an emergent setting, with similar risk for intraoperative and postoperative complications compared to cricothyrotomy. Ultimately, management should depend on clinician experience and patient characteristics.

Background: Early establishment of a safe airway is a basic tenet of trauma care. The most recent Advanced Trauma Life Support manual specifies that “a surgical cricothyrotomy is preferable to a tracheotomy for most patients requiring an emergency surgical airway,” based on the perception that the cricothyrotomy is easier and safer to perform, associated with less bleeding, and requires less surgical time. Traditional surgical teaching has also dictated that a cricothyrotomy should be converted to a tracheotomy within 72 hours, based on presumed association with subglottic stenosis. However, emerging data on the outcome and morbidity of cricothyrotomy compared with tracheotomy do not always support these assumptions. The most common complications of cricothyrotomy include incorrect execution resulting in injury of cartilaginous structures with failure to obtain an airway, occurring at a rate of 0–31.6%. Serious complications after tracheotomy occur at a rate of 0–5%, and include damage to nearby structures, hemorrhage, and pneumothorax. Furthermore, conversion from cricothyrotomy to tracheotomy tube may be associated with underappreciated risk, associated with increased length of hospital stay, neurologic impairment, and death.

Study design: Literature review.

Synopsis: PubMed, Embase, MEDLINE, and the Cochrane Library were searched from inception through January 2019 for English-language studies reporting emergency cricothyrotomy and tracheotomy outcomes. The investigators identified 783 articles, and 20 met inclusion criteria. Thirteen evaluated emergency cricothyrotomy and included 1,219 patients (mean age = 39.8 years); four evaluated emergency tracheotomy and included 342 patients (mean age = 46.0 years); two evaluated both procedures. The rate of complications with both cricothyrotomy and tracheotomy was comparable. The most frequent early complications were failure to obtain an airway (1.6%) and hemorrhage (5.6%) for cricothyrotomy and tracheotomy, respectively. Airway stenosis was the most common long-term complication, occurring at low rates in both procedures (0.22%–7.0%).

Citation: DeVore EK, Redmann A, Howell R, Khosla S. Best practices for emergency surgical airway: a systematic review. Laryngoscope Investig Otolaryngol. Published online November 19, 2019. doi: 10.1002/lio2.314.