Unlocking Common ED Procedures – Bougie Nights: The Surgical Airway Revisited

Author: Nima Rejali, DO (EM Resident Physician, Hackensack University Medical Center) // Reviewed by: Anthony DeVivo, DO (@anthony_devivo, EM-Critical Care Fellow, Icahn School of Medicine- Mount Sinai Hospital), Alex Koyfman, MD (@EMHighAK), Brit Long, MD (@long_brit) and Manpreet Singh, MD (@MprizzleER)

Welcome back to Unlocking Common ED Procedures! Today, we look at the cricothyrotomy.

Check out our new downloadable procedure card with QR code link to the article. Print them out and be ready to go over it with your learners!


A 56-year-old male with a history of oropharyngeal cancer presents to the Emergency Department (ED) with difficulty breathing.  He is in respiratory distress when EMS finds him and transports him to the ED on non-rebreather mask. Upon arrival to the ED, the patient is brought to the resuscitation bay where vitals are obtained, and you begin your assessment of the patient. His pulse ox is 80% on non-rebreather mask, and he has significant respiratory distress with notable stridor. You optimize the patient’s position for intubation and push your RSI medications of choice.  You attempt to intubate with direct laryngoscopy using a MAC 3 laryngoscope and are unable to visual the cords.  Subsequent attempt with MAC 4 and bougie is also unsuccessful. You then attempt intubation with a video laryngoscope but are unable to pass the ET tube due to the angle of the laryngoscope as well as a large obstructing mass in the hypopharynx. What are your next steps? What if there is no airway backup in your hospital? Do you have additional tools at your disposal to establish an airway?

Cricothyrotomy Indications

  1. Cannot intubate
  2. Cannot oxygenate/ventilate

Cricothyrotomy should only be attempted after other intubation methods have been exhausted or are not possible.  Ideally you should have already have had previous intubation attempts with both direct and video laryngoscopy. Whenever an intubation attempt fails, there should be some change to the next approach such as changing the size/type of laryngoscope, attempt with a bougie, attempt nasal intubation, etc.  Common reasons that may lead to failure to intubate or failure to oxygenate that would necessitate a cricothyrotomy include angioedema, massive hemoptysis, large volume emesis, and obstructing lesions (i.e. cancer) or anatomical changes (congenital and acquired such as post operative, post radiation, and post trauma). Indication for cricothyrotomy also includes need for an emergent airway intervention, but you are unable to obtain oral access either due to anatomy, trismus/spasm, or external factors such as a jaw that is wired shut.

Preparation is the key to any procedure we do in the ED.  If you have the luxury of knowing/suspecting it will be a difficult airway, then you can appropriately be set up to help ensure the procedure goes as smoothly as possible.  Should it be suspected it will be difficult prior to patient arrival or once you take that first look at the patient, vocalize concerns to the team so they can rally to your help.  While you assess the patient, have someone bring over the video laryngoscope, and have another member bring over the percutaneous cricothyrotomy kit or start procuring the tools necessary for an open cricothyrotomy. Consider the surgical airway as part of your airway algorithm, not as an outlier.  If you exhaust your options with direct or video laryngoscopy, be prepared to move on to a surgical approach. If a surgical airway may be needed immediately, then do not waste time with other approaches which you feel strongly will fail.  Do not consider the surgical airway as a last ditch effort if other methods fail, but rather an integral part in your arsenal during the appropriate time and place.


For adult patients, there are two main techniques utilized in the ED-the standard surgical technique as well as the Seldinger technique, also known as a percutaneous cricothyrotomy. Fortunately, cricothyrotomy is a rare procedure.  Unfortunately, due to how uncommon it is, we do not have large trials or literature comparing the two approaches. What studies do exist tend to be either cadaver studies or small case/observational studies.   A study conducted using 200 human cadavers and 20 different ED physicians showed that time from incision to first ventilation was faster using the Seldinger technique as opposed to the standard open technique1.  Additional studies have also shown that the Seldinger technique was associated with fewer complications than the open technique2,3 A study done using flight anesthesiologists showed that the bougie assisted open cricothyrotomy had less tracheal damage than the Seldinger technique4. Again in this study, Seldinger technique was faster than open technique4. This study was done using porcine cadavers, so it has been criticized in that it does not accurately reflect en vivo technical difficulties such as spontaneous breathing and bleeding.  It should be noted that overall the sample sizes for these studies are small, and it is difficult to control for variables such as clinician experience, patient condition, and body habitus, as well as indication for an emergent airway.

As an ED provider, it is imperative to be familiar and competent with both techniques.  Although many ED physicians have a preferred method, should the initial method fail for any reason, we should be prepared to proceed with an alternative approach.

Open technique

  • Identify what equipment you have and what you still need. Ideally wait until all materials are at bedside prior to starting.

  • Palpate the larynx and identify the thyroid cartilage (A), cricothyroid membrane (B), and cricoid ring (C).

  • Incise the skin vertically. This incision should be as large as necessary to obtain adequate visualization of the structures. Pull the overlying skin taut to facilitate with dissection.  Anticipate making a3-5cm incision, however, the incision may need to be extended to obtain adequate visualization of structures. If necessary, you can extend your incision from thyroid cartilage to sternal notch but keep in mind that the larger the incision, the more the field will be contaminated with blood.

  • Make a horizontal incision through the cricothyroid membrane approximately 1cm in length.

  • Use either your finger or the back of the scalpel to bluntly dissect the space to create room for the endotrachealtube or Shiley. If you do not use your finger to dissect, make sure to place your finger within thetrachea after dissection and feel for the tracheal rings in order to make sure you are in the right space prior to placing the tracheostomy tube. This will help reduce the chance of creating a false passage into the subcutaneousspace.

  • While keeping a finger within thecricothyroid space, advance the ET tube or bougie over your finger to ensure correct placement into trachea and not creating a false track. If using a bougie, place the bougie into the trachea then introduce the ET tube over the bougie. You may be able to feel the tracheal rings with the tip of the bougie which will give you greater confidence you are in the trachea.

  • If using an ET tube, inflate the cuff now. If using a tracheostomy tube, remove the obturator, place the inner cannula, and inflate the cuff.  Use the pilot balloon to feel for how inflated the cuff is.

  • Attach tracheostomy tubing to either mechanical ventilator or bag-valve-mask and secure the tube to the patient.


Seldinger technique

  • Identify what equipment you have and what you still need. Ideally wait until all materials are at bedside prior to starting.

  • Palpate the larynx and identify the thyroid cartilage (A), cricothyroid membrane (B), and cricoid ring (C).

  • Place dilator into airway catheter so it is one unit.

  • Take a 10cc syringe (ideally filled with about 5cc of saline) and attach large bore introducer needle to syringe. If you are not using a pre-fabricated kit, obtain a 14-18 gauge needle and attach it to a 10cc syringe filled halfway with saline.

  • Penetrate the skin and cricothyroid membrane while aiming caudally to avoid trauma to the vocal cords.  Apply negative pressure on the syringe and aspirate as you advance. Once you enter the trachea, you should be able to pull back on the plunger with ease and also see bubbles flowing through the saline in the syringe.

  • Remove the syringe, maintain the position of the introducer needle, and thread through the guidewire.

  • Make a small incision where the skin meets the guidewire. This incision should be deep enough to also penetrate the cricothyroid membrane.

  • Thread the dilator/airway catheter combination over the guidewire and advance through the skin and underlying structures until the hub of the device is at the skin.

  • Remove the guidewire and dilator as one unit, leaving the airway catheter device in place.  Inflate the cuff and secure the device and attach to supplemental oxygen via ventilator or BVM.

Tips, Tricks, and Considerations

  1. Check your own pulse.  This is said over and over again in EM.  The stress level is always high in emergent airway scenarios.  As the physician in the room doing the procedure, we have to take control and redirect the room.  If you’re not calm, the rest of the teamwon’t be either.
  2. Become familiar with the anatomy of the larynx.  It is important to know what the structures should look like but more importantly what they FEEL like.  Cricothyrotomies are bloody, and it will be difficult to visualizethe structures. It is important to know what these structures feel like-particularly the cricoid cartilage, the thyroid cartilage, and the cricothyroid membrane.
  3. Before performing a cricothyrotomy, stand at the side of the bed where you would do the procedure and place your non-dominant hand over the larynx to palpate the above mentioned structures. This is commonly referred to “the laryngeal handshake” and is key in helping you identify your landmarks prior to starting the procedure. Place the thumb and middle finger on the sides of the laryngeal cartilage and then use the index finger to palpate the cricothyroid membrane.
  4. If you are unsure whether you have cut into the trachea during an open procedure, use the bougie to feel for the tracheal rings and then place your Shiley or ET tube over the bougie.
  5. There has been discussion as to using ultrasound to identify the laryngealstructures to help guide access through the cricothyroid membrane. While there are benefits to using this modality, particularly if there is lots of neck edema or subcutaneous fat, it does add time and an extra step toward completing the procedure. In an already stressful environment, getting an ultrasound machine in place and adequately identifying the structures while the patient may be having heavy retractions from respiratory distress and/or be de-saturating may not make this the ideal situation for an ultrasound assisted procedure.  If you plan to use the ultrasound, make sure the situation is appropriate and you are familiar with both the machine and the way these structures look on ultrasonography.  A video is linked HERE that covers how to use ultrasound to identify these structures for your education. A 2015 RCT study of traditional percutaneous cricothyrotomy vs an ultrasound assisted percutaneous approach using human cadavers with difficult to identify neck anatomy showed a reduction of tracheal/laryngeal injury of 74% vs 25% using ultrasound and increased probability of correct insertion by 5.6 times in study population with more difficult to palpate neck anatomy5.
  6. Take care to dissectadequately in order toproperly identify the cricothyroid membrane.  This procedure is often bloody, and in patientswith a large amount ofsubcutaneous fat, it can be particularly difficult to access the trachea-especially if there are alarms going off, people all around you freaking out, and a decompensated actively dying patient. Use your tools to help maintain the patency of the tract you create either through your finger, back of the scalpel, or bougie. Also keep in mind that when in a real bind and you are having difficulty orienting within the anatomy, aim for the air bubbling out the neck below the overlying blood.
  7. Once you place the tube, your work is not finished! Properly securing the tube is the next major objective.  Once the tube is secured, continue to bag the patient until you can place the patient on a ventilator. Obtain a post procedure chest x-ray and keep a close eye on the patient for signs of tube dislodgement such as desaturation and subcutaneous air in the neck. Also ensure appropriate analgesia and sedation.
  8. As we can see, there are a variety of approaches. There is no definitive superior approach identified thus far in the literature. Given the low frequency of need for this procedure and difficulty in obtaining consent ,such a study will be hard to accomplish.  However, literature suggests practitioner success increased after training/practice, and their success rates were much higher during formal data collection vs pre-data training3,4,6,7.  Do what is comfortable for you, do what you have available at your bedside, and practice practice practice! Be prepared to use other approaches if necessary, but your highest success will lie with the method you have trained and practiced the most.
  9. Be prepared for post-procedure complications.  Most commonly you will have to deal with bleeding around the site.  Apply direct pressure and/or whichever absorbable hemostatic agent your hospital supplies. The most dreaded immediate complication is tube dislodgement or initial placement into a subcutaneous tract.  Signs and symptoms of such a complication are mentioned above under number (7). Other complications to be aware of include thyroid/cricoid cartilage fractures.  It is difficult to assess for such injuries in the ED unless you directly know you cut through one of these during your procedure or heard/felt it crack as you placed your tube.  If you have suspicion for such an injury, consult ENT if you have not already called them. If the scalpel or needle is advanced too deep, there is also possibility for esophageal injury. This can also occur during placement of the tube into the trachea. Most commonly these are not transmural tears, but a transmural esophageal tear can pose a larger problem for the patient. First, ensure the tube is not in the esophagus – this can be accomplished with CO2 color change capnography as well as direct visualization of the tube in the trachea from above if possible with direct or video laryngoscopy. Clinically you should watch for desaturations, distension of the stomach, and lack of breath sounds bilaterally. Patients with a full thickness esophageal injury will likely have or develop pneumomediastinum on chest xray and begin a similar disease progression as a patient with Boerhaave’s syndrome. If this is suspected or confirmed, you should consult thoracic surgery, as the patient will likely need to go to the OR for primary esophageal closure and washout.

Rapid Procedure Review

Open Technique

  1. Prep the neck and ensure all necessary materials are within reach.
  2. Palpate the larynx and identify thyroid cartilage, cricoid cartilage, and cricothyroid membrane if possible.
  3. Make a vertical midline incision approximately 3cm over where you believe the cricothyroid membrane is.
  4. Make a horizontal incision through the cricothyroid membrane and place either your finger or a bougie into the trachea to maintain patency of your tract.
  5. Place the Endotracheal or tracheostomy tube into the trachea.
  6. Inflate the cuff and check that you are in the trachea by listening for breath sounds, noting color change on the capnography, etc.
  7. Secure the airway with trach tape or collar wrap and place patient on mechanical ventilation.

Seldinger Technique

  1. Prep the neck and ensure all necessary materials are within reach.
  2. Palpate the larynx and identify thyroid cartilage, cricoid cartilage, and cricothyroid membrane if possible.
  3. Place an 18 gauge or larger needle on a 10cc syringe filled halfway with saline.
  4. Make a puncture midline over the cricothyroid membrane and apply negative pressure on the plunger until air bubbles are seen flowing into the saline.
  5. Remove the syringe and keep the needle in place within the trachea.
  6. Thread a guidewire through the needle and then make a skin incision to allow for the dilator.
  7. Remove the needle and pass the dilator and airway catheter as one unit over the guidewire into the trachea.
  8. Remove the guidewire and dilator together, leaving the airway catheter in place.
  9. Inflate the cuff and check that you are in the trachea by listening for breath sounds, noting color change on the capnography, etc.
  10. Secure the airway with trach tape or collar wrap and place patient on mechanical ventilation.

Case Conclusion:

You use a #10 blade to sharply dissect down to the trachea. You cut through into the cricothyroid space and place a bougie first followed by an 8.0 ETT.  You are able to bag the patient without difficulty and place him on a ventilator where he is pulling appropriate tidal volumes and has no issues with peak pressures. There is some post-procedure bleeding which you control with gauze and direct pressure followed by packing with absorbable hemostat.  You call the ICU to admit the patient and also place a call to the on-call surgical team so they can monitor the airway should any complications arise.  You debrief your team on a job well done and make sure the difficult airway box is restocked appropriately for the next time a similar scenario presents itself in the ED.

Check out this amazing illustration from @HansonsAnatomy 

References/Further Reading:

  1. Schaumann N, Lorenz V, Schellongowski P, et al. Evaluation of Seldinger technique emergency cricothyroidotomy versus standard surgical cricothyroidotomy in 200 cadavers. Anesthesiology 2005; 102:7.
  2. Benkhadra M, Lenfant F, Nemetz W, et al. A comparison of two emergency cricothyroidotomy kits in human cadavers. Anesth Analg 2008; 106:182.
  3. Chan TC, Vilke GM, Bramwell KJ, et al. Comparison of wire-guided cricothyrotomy versus standard surgical cricothyrotomy technique. J Emerg Med 1999; 17:957.
  4. Nakstad AR, Bredmose PP, Sandberg M. Comparison of a percutaneous device and the bougie-assisted surgical technique for emergency cricothyrotomy: an experimental study on a porcine model performed by air ambulance anaesthesiologists. Scand J Trauma Resusc Emerg Med. 2013; 21:59.
  5. Siddiqui N, Arzola C, Friedman Z, Guerina L, You-Ten KE. Ultrasound improves Cricothyrotomy success in cadavers with poorly defined neck anatomy: a randomized control trial. Anesthesiology. 2015;123(5):1033–1041.
  6. Nikolaus Schaumann, Veit Lorenz, Peter Schellongowski, Thomas Staudinger, Gottfried J. Locker, Heinz Burgmann, Branko Pikula, Roland Hofbauer, Ernst Schuster, Michael Frass; Evaluation of Seldinger Technique Emergency Cricothyroidotomy versus Standard Surgical Cricothyroidotomy in 200 Cadavers. Anesthesiology 2005;102(1):7-11.
  7. Wong DT, Prabhu AJ, Coloma M, Imasogie N, Chung FF: What is the minimum training required for successful cricothyroidotomy? A study in mannequins. Anesthesiology 2003; 98:349–53.

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