**6.1 Scalpel cricothyroidotomy**

Scalpel cricothyroidotomy is the rapid and most suitable method of securing the airway in the emergency situation. A cuffed endotracheal tube in the trachea prevents the airway from aspiration, provides a secure route for expiration, permits low-pressure ventilation using traditional breathing systems and allows end-tidal CO2 monitoring. A number of surgical techniques have been described, but there is a lack of evidence of the superiority of one over another. The techniques all have common steps in general: neck extension, identification of the cricothyroid membrane, cutting through the skin and

#### **Figure 6.**

*Fiberoptic guided tracheal intubation through supra-glottic airway device (SAD) using Aintree intubation catheter (DAS guideline with written permission).*

cricothyroid membrane and insertion of a cuffed endotracheal tube. In some instances, the skin and cricothyroid membrane are cut sequentially; in others, a single incision is recommended. Many include a placeholder to keep the wound open until the endotracheal tube is in place. Some use special equipment like cricoid hook, tracheal dilators, etc. A single stab incision through the cricothyroid membrane is appealing in terms of its simplicity, but this approach may fail in the thick neck patient or if the anatomy is difficult, and a vertical skin incision is recommended in this situation [43].

#### **6.2 Narrow cannula technique**

Narrow-bore cannula techniques are effective in the elective setting; however, their limitations have been well known. Ventilation can be achieved only by using a high-pressure machine, and this is associated with a high risk of barotrauma. Failure because of kinking, obstruction, malposition, or displacement of the cannula can occur even with predesigned cannulae, such as the Ravussin™ (VBM, Sulz, Germany). High-pressure ventilation equipment may not be available in all facilities, and most anaesthesiologists do not use them on a regular basis. Their use in these situations should be restricted to experienced clinicians who use them in routine clinical practice [43].

**63**

reliable.

**Figure 7.**

**7.1 Extubation**

**6.3 Wide-bore cannula**

*Oesophageal/tracheal Combitube.*

Wide-bore cannula over the guidewire: some wide-bore cannula kits, such as the Cook Melker® emergency cricothyrotomy set, use a wire-guided (Seldinger) technique. This approach is less invasive than a surgical cricothyroidotomy and decrease the need for special machine for ventilation. The skills required are familiar to anaesthesiologists and intensivists because they are common to central line insertion and per-cutaneous tracheostomy method; however, these techniques require fine and smooth motor control, making them less suited to stressful situations. However, a wire-guided technique may be a reasonable alternative for anaesthetists who are experienced with this method, the evidence suggests that a surgical cricothyroidotomy is both faster and more

Non-Seldinger wide-bore cannula: A number of non-Seldinger wide-bore cannula-over-trochar devices are available for airway rescue. Although successful use has been reported in Cannot intubate, cannot oxygenate (CICO), there have

Extubating patients at the end of surgery should be discussed between anaesthesia and surgery teams. Patients with severe trauma to the airway, those with

been no large studies of these devices in clinical practice [43].

**7. Postoperative management**

*Airway Trauma: Assessment and Management DOI: http://dx.doi.org/10.5772/intechopen.96894* *Airway Trauma: Assessment and Management DOI: http://dx.doi.org/10.5772/intechopen.96894*

*Special Considerations in Human Airway Management*

cricothyroid membrane and insertion of a cuffed endotracheal tube. In some instances, the skin and cricothyroid membrane are cut sequentially; in others, a single incision is recommended. Many include a placeholder to keep the wound open until the endotracheal tube is in place. Some use special equipment like cricoid hook, tracheal dilators, etc. A single stab incision through the cricothyroid membrane is appealing in terms of its simplicity, but this approach may fail in the thick neck patient or if the anatomy is

*Fiberoptic guided tracheal intubation through supra-glottic airway device (SAD) using Aintree intubation* 

Narrow-bore cannula techniques are effective in the elective setting; however, their limitations have been well known. Ventilation can be achieved only by using a high-pressure machine, and this is associated with a high risk of barotrauma. Failure because of kinking, obstruction, malposition, or displacement of the cannula can occur even with predesigned cannulae, such as the Ravussin™ (VBM, Sulz, Germany). High-pressure ventilation equipment may not be available in all facilities, and most anaesthesiologists do not use them on a regular basis. Their use in these situations should be restricted to

difficult, and a vertical skin incision is recommended in this situation [43].

experienced clinicians who use them in routine clinical practice [43].

**6.2 Narrow cannula technique**

*catheter (DAS guideline with written permission).*

**62**

**Figure 6.**

**Figure 7.** *Oesophageal/tracheal Combitube.*
