The Difficult Airway in Adult Critical Care

Gavin G. Lavery, MD, FCARSCI, MB, BCh, BAO; Brian V. McCloskey, MB, BCh, FRCA, FFARCSI, MRCP


Crit Care Med. 2008;36(7):2163-2173. 

In This Article

Surgical Airway

The indication for a surgical airway is inability to intubate the trachea in a patient who requires it and the techniques available are cricothyroidotomy or tracheostomy.[24] Conventional wisdom states that tracheostomy is the more complex and time-consuming procedure, which should only be performed by a (experienced) surgeon.[144] Studies in the critical care environment suggest that, in the elective situation, cricothyroidotomy is simpler and (at worst) has a similar complication rate.[145,146] Cricothyroidotomy may be performed using three techniques: needle, wire-guided percutaneous, or surgical. Although needle cricothyroidotomy has long been advocated,[147] recent work suggests surgical cricothyroidotomy is superior.[148] When compared with a wire-guided technique, the surgical technique was both quicker (even when performed by nonsurgeons) and produced more effective ventilation[149] in a mannequin. Previously, surgical cricothyroidotomy has been viewed as a temporary airway that should be converted to tracheostomy within a few days. However, a surgical cricothyroidotomy can be used successfully as a definitive (medium-term) airway without any additional risk of complications,[150,151] whereas it would appear that the conversion from cricothyroidotomy to tracheostomy may be an unnecessary and high-risk procedure.[152,153]


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