PLACES for Breathing

May 12 / Cody Winniford
We recently did some cadaveric airway training with Pulse Check Education, and of course the piese de resistance was the surgical cricothyroidotomy practice. People love that stuff and they clamor for opportunities to practice because it may the only time they do it on human anatomy for years… or ever. The literature around surgical airways places the occurrence at 1% or less of all airways performed… and that is really consistent across all care settings.  

Another way to look at it, and the way I see it is: 1% of the airways you will encounter will be the most cognitively, psycologically, physiologically, and skill challenging situations you will face. You statistically will get one chance in your career to do it… and it needs to be done exquisitely well. After all, a life depends on it.

Beyond the Mechanics: The Psychology of eFONA Most training focuses solely on the "how"—the "Stab-Twist-Bougie" or the "Scalpel-Finger-Bougie-Tube" technique. While mechanical proficiency is vital, it leaves much to be desired regarding individual skill comfort. Real mastery requires expanding past the procedure into cognitive offloading and early decision-making. Seeing it coming and having the fortitude to make the call and commit to the procedure. That can only come through training and practice.

The danger in airway management isn't always failing an intubation; sometimes, it’s perseverating on a failed attempt until the therapeutic window expires. We get hung up hoping the next attempt with a different blade will work just so we "don't have to cric this guy."

The Most Dangerous Minutes
The span of time between when the operator realizes that they have to perform a surgical airway and when they actually secure the airway are the most crucial and most dangerous for the patient. Sometimes we take so much time to make the decision to access the trachea that we lose the initiative and the intervention has no chance to improve things for the patient.
This indecision leads to anoxic brain injury. We must accept that if a patient needs the procedure, they need it. It is a life-saving intervention that should be prioritized in specific clinical contexts, not avoided as a "last-ditch" failure.

Evidence vs. Tradition
Get there early… or youre too late. What I see is that operators are suffering from the words of an instructor: "last resort" "QA/QI" "Dangerous" "Massive Bleeding." These words have created a mental model that the procedure is better off not attempted until you have literally tired everything else.

The punchline of this is that it likely comes from someone who has never done it, who was taught by someone who has never done it, who was taught by someone who watched it one time.
The evidence, and my personal experience, tell a different story.
 - Sometimes it is the first, most right thing to do. But I wasted time "trying" an intubation and SGA knowing that I needed to cut instead because "QA/QI…"
 - Bleeding can be an issue, but it you are in the right location and have good blade technique, you will not lacerate a major vessel and trigger catastrophic bleeding.
 - Yes, my report went to the clinical manager for a review. Not because the procedure did not go well, but because these events are so rare that we have to tease out all of the lessons we can; pass them on to our teammates; and make things better for the next patient. I never received criticism per se, but I did get this feedback: "You knew that was a cric from the get-go didn't you.." "Yep." "So, next time you know to just go for it."

Assessment: The SMART Approach
Your ability to address difficulties is directly related to the depth to which you go looking for them. A real hole in our training game as it pertains to this procedure is that we generally talk about it with 2 assumptions:
1.) Everyone can identify the anatomical landmarks… (but we only teach and practice on male anatomy models)
2.) That the anatomy can be identified/palpated externally.
3.) Bonus: This is a fail-safe procedure, a guaranteed life boat for airways when all else fails.
But there are patient related issues that can complicate things, either in placing the tube after incisions or identifying the anatomical landmarks.

S — Surgery — > recent surgeries on the neck can distort anatomy
M — Mass — > neck mass. A fat neck makes life difficult in finding the CTM and accessing the trachea.
A — Anatomy--> trauma to the trachea, congenital issues that restrict neck mobility, etc.
R — Radiation — > inflammation and swelling 2/2 radiation treatments.
T — Tumors-->  that are growing on the trachea can make it difficult to locate the CTM even after you have attempted to expose it following the first vertical incision.
These are all anatomical issues that will make it difficult to either find the CTM or place the tube (or both).

PLACES
Position the patient - as with everything in airway management… positioning is paramount. To the greatest and safest extent, ensure the head/chin are not flexed. Extend it and give yourself room to work. It also can bring the anatomy closer to the skin, spread the CTM and tracheal rings, and make it easier to palpate landmarks.

Locate the CTM - Dr. Levitan make sit simple - "I will find the CTM after the first vertical incision." Quit goofing around trying to externally locate the CTM. Instead focus on finding the midline of the neck:
 • Find the midline.
 • Then expose the CTM with the first vertical cut.

Access the trachea — poke it, stab it, extend the horizontal incision, etc. Get into the airway. Ensure you make enough room for the tube to fit. My personal experience with this revealed that when the site is too small, you have some trouble differentiating between your tracheal access and the spaces lateral to the trachea, leading to placement into a “false lumen.” Make a bigger hole… and once you make a hole, keep something in it!

(NOTE: Dr. Levitan talks in depth about how the anatomy around the CTM actually protects the patient from accidents. The mantra is “the cartilagenous cage will protect.” The caveat being… as long as you are in the right place and using good technique. Check out his talk from Big Sick ‘23, it is practice changing.)



Control the tube — movement to the stretcher/vehicle, loading into the vehicle, and transfer of care at the destination are the most dangerous times for the tube. HOLD ON TO IT. During these times it is ill advised to rely solely on commercial ties or devices. In my experience, the transfer of care poses the most danger as there are a few hands on the patient, and sometimes not enough EARS listening to you. With your hand in the way, holding the tube, it draws attention to it and can slow things down a bit.

ETCo2 Confirmation — sustained WFC remains the gold standard for airway placement confirmation, regardless of how you access it. Check out the recent @alertmedic1 post on ETCo2 for confirmation and knowing when to pull the tube and do it again.

Secure the Tube - Do not rely solely on commercial ties or devices during loading or transfer. Hold the tube with your hand. It is intentional that this is mentioned twice. During a chaotic hand-off at a trauma center, having your hand physically on the airway draws attention to it and ensures that "too many hands" don't accidentally dislodge your hard-won access.

Conclusion
Surgical airway management is only as scary as you make it. It is only as risky as you let it be. What I mean is that you can buy down the risk through training and practice. This can either be thr If we continue to teach it as a procedure to be "avoided at all costs," we create a mental model of fear that leads to hesitation when seconds count.
My challenge to you is this: increase your training frequency and fidelity. Use models that don't have perfect landmarks. Practice the "SMART" assessment on every respiratory patient you see, even if you don't think they'll need a tube. By the time you’re standing over a patient who can’t be oxygenated, you shouldn't be "wringing your hands." You should be executing a well-rehearsed plan.
Secure the airway.
Save the brain.
Don't let indecision be the reason your patient doesn't make it home.
Bibliography:
 1. Bick E, Barnes J, Roberts J. Can’t intubate can’t oxygenate: It takes more than a patent airway to oxygenate a patient. Eur J Anaesthesiol. 2020;37(6):503-504. doi:10.1097/EJA.0000000000001143..
 2. Schober P, Biesheuvel T, de Leeuw MA, Loer SA, Schwarte LA. Prehospital cricothyrotomies in a helicopter emergency medical service: analysis of 19,382 dispatches. BMC Emerg Med. 2019 Jan 23;19(1):12. doi: 10.1186/s12873-019-0230-9. PMID: 30674276; PMCID: PMC6343329.
 3. Schauer SG, April MD, Fairley R, et al. A Comparison of the iGel Versus Cricothyrotomy by Combat Medics Using a Synthetic Cadaver Model: A Randomized, Controlled Pilot study. J Spec Oper Med. 2020;20(4):68-72. doi:10.55460/A3RU-HNS9..
 4. Barnard EBG, Ervin AT, Mabry RL, Bebarta VS. Prehospital and en route cricothyrotomy performed in the combat setting: a prospective, multicenter, observational study. J Spec Oper Med. 2014;14(4):35-39. doi:10.55460/62V1-UIZC..
 5. Morton S, Avery P, Kua J, O’Meara M. Success rate of prehospital emergency front-of-neck access (FONA): a systematic review and meta-analysis. Br J Anaesth. 2023;130(5)..
 6. Walls RS. Manual of Emergency Airway Management 6E. Wolters Klewer; 2023.
 7. Law JA, Kóvacs G. Airway management in emergencies 2E. People’s Medical Publishing Hose; 2017.
 8. Berkow LC, Sakles JC. Cases in emergency airway management. Cambridge University Press; 2015.