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Surgical Airway


Vanessa Moll

, MD, DESA, Emory University School of Medicine, Department of Anesthesiology, Division of Critical Care Medicine

Reviewed/Revised Apr 2023
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If the upper airway is obstructed because of a foreign body or massive facial trauma or if ventilation cannot be accomplished by other means, surgical entry into the trachea is required. Historically, a surgical airway was also the response to failed intubation. However, surgical airways require on average about 100 seconds from initial incision to ventilation. Laryngeal mask airways Laryngeal Mask Airways (LMA) If no spontaneous respiration occurs after airway opening and no respiratory devices are available, rescue breathing (mouth-to-mask or mouth-to-barrier device) is started; mouth-to-mouth ventilation... read more (LMAs) and other supraglottic airways provide a faster means of rescue ventilation; because foreign body obstruction and (for an LMA) massive facial trauma are only rare contraindications to their use, very few patients require an emergency surgical airway.


Emergency cricothyrotomy

The patient lies supine with the neck extended. After sterile preparation, the larynx is grasped with one hand while a blade is used to incise the skin, subcutaneous tissue, and cricothyroid membrane precisely in the midline, accessing the trachea. A hollow tube is used to keep the airway open.

Emergency cricothyrotomy

Unlike positioning for laryngoscopy or ventilation, the correct position for cricothyrotomy involves extending the neck and arching the shoulders backward. After sterile preparation, the larynx is grasped with the nondominant hand while a blade held in the dominant hand is used to vertically incise the skin, subcutaneous tissue, and cricothyroid membrane. A tracheal hook helps keep the space open and prevent retraction of the trachea while a small endotracheal tube (6.0 mm internal diameter [ID]) or small tracheotomy tube (cuffed 4.0 Shiley preferred) is advanced through the surgical site into the trachea.

How To Do a Cricothyrotomy Using a Guidewire
How To Do a Cricothyrotomy

Complications include hemorrhage, subcutaneous emphysema, pneumomediastinum Pneumomediastinum Pneumomediastinum is air in mediastinal interstices. The main causes of pneumomediastinum are Alveolar rupture with dissection of air into the interstitium of the lung with translocation to... read more Pneumomediastinum , and pneumothorax Pneumothorax Pneumothorax is air in the pleural space causing partial or complete lung collapse. Pneumothorax can occur spontaneously or result from trauma or medical procedures. Diagnosis is based on clinical... read more Pneumothorax . Various commercial products allow rapid surgical access to the cricothyroid space and provide a tube that allows adequate oxygenation and ventilation. Needle cricothyrotomy with large-bore IV catheters cannot provide adequate ventilation unless a 50-psi driving source (jet insufflator or jet ventilator) is readily available.


Tracheostomy is a more complex procedure because the trachea rings are very close together and part of at least one ring usually must be removed to allow tube placement. Tracheostomy is preferably done in an operating room by a surgeon. In emergencies, the procedure has a higher rate of complications than cricothyrotomy and offers no advantage. However, it is the preferred procedure for patients requiring long-term ventilation.

Percutaneous tracheostomy is an attractive alternative for mechanically ventilated, critically ill patients. This bedside technique uses skin puncture and dilators to insert a tracheostomy tube. Fiberoptic assistance (within the trachea) is usually used to prevent puncture of the membranous (posterior) trachea and esophagus.

Erosion of the trachea is uncommon. It results more commonly from excessively high cuff pressure. Rarely, hemorrhage from major vessels (eg, innominate artery), fistulas (especially tracheoesophageal), and tracheal stenosis occur. Using high-volume, low-pressure cuffs with tubes of appropriate size and measuring cuff pressure frequently (every 8 hours) to maintain it at < 30 cm water decrease the risk of ischemic pressure necrosis, but patients in shock, with low cardiac output, or with sepsis remain especially vulnerable.

NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
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