Protecting the airway is a fundamental aspect of medical care. In an emergency, it may be necessary to obtain access to the airway to support ventilation and oxygenation. In circumstances where it is not possible to restore alveolar oxygenation by non-surgical means (known as a CICO, or “Cannot Intubate, Cannot Oxygenate,” emergency), clinicians must rapidly establish access to the airway via surgical means.¹ Two major surgical techniques for emergency airway access are utilized in modern medicine: the tracheostomy and the cricothyrotomy.²

A tracheostomy is a surgical procedure which creates an opening in the upper trachea to reestablish ventilation. One of the oldest surgical procedures, tracheostomies were for some time the only available technique to address upper airway obstruction.³ Indications for emergent tracheostomies include acute upper respiratory obstruction (caused by a foreign body, angioedema, infection, anaphylaxis, etc.) which prevents successful endotracheal intubation, penetrating laryngeal trauma, panfacial fractures in which craniofacial dislocation contraindicates nasal intubation, and LeFort III fractures (a transverse fracture of the mid-face which essentially separates the maxilla from the skull base)⁴.³ Although tracheostomies are classically open procedures that occur in the operating room, they can also be performed percutaneously—as first described in 1985 by Ciaglia et al.—which makes the surgery more amenable as a bedside or ICU procedure.^3,5

In contrast, during a cricothyrotomy, a tube is inserted into an incision made in the cricothyroid membrane to form an airway. This technique was first detailed in 1909 by Dr. Chevalier Jackson, a laryngologist at Jefferson Medical School in Philadelphia. However, after reviewing cases of tracheal stenosis following cricothyrotomies, Dr. Jackson condemned the procedure, and it fell out of mainstream practice.² Cricothyrotomies would only return to mainstream practice in the 1970s after physicians Brantigan and Grow demonstrated a low complications rate for the procedure in a review of 655 patient cases.^6,2

Over the past century, several techniques were described by which one could obtain airway access in an emergency through the cricothyroid membrane, three of which are still in use today due to their endpoint of a controlled surgical airway. The first involves inserting a small caliber cannula, such as an IV angiocath, through the cricothyroid membrane percutaneously and then insufflating high-pressure oxygen into the trachea using jet ventilation. The second technique involves inserting a large caliber cannula percutaneously through the cricothyroid membrane, often using the Seldinger technique over a guide wire, allowing for low-pressure ventilation. Finally, there is the open surgical cricothyrotomy—the final pathway to the emergent airway. Many techniques are described for it, but the rapid “Scalpel-Finger-Bougie” technique is preferred across the field of emergency medicine. An emergent cricothyrotomy is indicated in any CICO emergency, which may be the result of oral or maxillofacial trauma, cervical spine trauma, profuse oral hemorrhage, copious emesis, and anatomic abnormalities that prevent endotracheal intubation.²

Although both tracheostomies and cricothyrotomies are used in modern medicine, the Difficult Airway Society’s 2015 guidelines recommend that cricothyrotomies performed by anesthesiologists be the preferred method of creating an emergency airway.⁷ Several factors influence this recommendation. One factor is that tracheostomies are a more complex procedure than cricothyrotomies, as the trachea rings are very close together, and result in part of at least one ring needing to be removed to allow the tube to be placed in a tracheostomy.⁸ Another significant reason for the Difficult Airway Society’s preference toward cricothyrotomies derives from data demonstrating a higher rate of complications associated with tracheostomies than with cricothyrotomies, with a systematic review in 2020 finding a greater incidence of late complications associated with emergency tracheostomies than with emergency cricothyrotomies.⁹ Thus, in an emergency (and particularly in prehospital settings)¹⁰, cricothyrotomies are the preferred mode of surgical airway access. However, as the 2020 review itself points out, there is not sufficient evidence to suggest that emergency cricothyrotomies can form long-term airways, meaning that current practice remains to convert emergency cricothyrotomies into tracheostomies efficiently once the initial CICO emergency is averted.⁹

References

(1) Pearce, W.; Barr, J.; Ziai, K.; Goyal, N. “Cannot Intubate, Cannot Oxygenate” (CICO) Rescue by Emergency Front of Neck Airway (eFONA). Oper. Tech. Otolaryngol.-Head Neck Surg. 2020, 31 (2), 96–104. https://doi.org/10.1016/j.otot.2020.04.005.

(2) McKenna, P.; Desai, N. M.; Tariq, A.; McMahon, K.; Morley, E. J. Cricothyrotomy. In StatPearls; StatPearls Publishing: Treasure Island (FL), 2025.

(3) Raimonde, A. J.; Westhoven, N.; Winters, R. Tracheostomy. In StatPearls; StatPearls Publishing: Treasure Island (FL), 2025.

(4) Stanley, R. B.; Nowak, G. M. Midfacial Fractures: Importance of Angle of Impact to Horizontal Craniofacial Buttresses. Otolaryngol. Neck Surg. 1985, 93 (2), 186–192. https://doi.org/10.1177/019459988509300211.

(5) Maheshwaran, S.; Thomas, S. V.; Raman, G. K.; Pookamala, S. Safety of Percutaneous vs Open Tracheostomy on Intubated Patients in ICU Setting: Which One Is Better? Indian J. Otolaryngol. Head Neck Surg. Off. Publ. Assoc. Otolaryngol. India 2022, 74 (Suppl 3), 4978–4981. https://doi.org/10.1007/s12070-021-02544-6.

(6) Brantigan, C. O.; Grow, J. B. Cricothyroidotomy: Elective Use in Respiratory Problems Requiring Tracheotomy. J. Thorac. Cardiovasc. Surg. 1976, 71 (1), 72–81.

(7) Frerk, C.; Mitchell, V. S.; McNarry, A. F.; Mendonca, C.; Bhagrath, R.; Patel, A.; O’Sullivan, E. P.; Woodall, N. M.; Ahmad, I. Difficult Airway Society 2015 Guidelines for Management of Unanticipated Difficult Intubation in Adults. Br. J. Anaesth. 2015, 115 (6), 827–848. https://doi.org/10.1093/bja/aev371.

(8) Surgical Airway – Critical Care Medicine – Merck Manual Professional Edition. https://www.merckmanuals.com/professional/critical-care-medicine/respiratory-arrest/surgical-airway (accessed 2025-05-05).

(9) Zasso, F. B.; You-Ten, K. E.; Ryu, M.; Losyeva, K.; Tanwani, J.; Siddiqui, N. Complications of Cricothyroidotomy versus Tracheostomy in Emergency Surgical Airway Management: A Systematic Review. BMC Anesthesiol. 2020, 20 (1), 216. https://doi.org/10.1186/s12871-020-01135-2.

(10)  Lacy, A. J.; Kim, M. J.; Li, J. L.; Croft, A.; Kane, E. E.; Wagner, J. C.; Walker, P. W.; Brent, C. M.; Brywczynski, J. J.; Mathews, A. C.; Long, B.; Koyfman, A.; Svancarek, B. Prehospital Cricothyrotomy: A Narrative Review of Technical, Educational, and Operational Considerations for Procedure Optimization. J. Emerg. Med. 2025, 70, 19–34. https://doi.org/10.1016/j.jemermed.2024.08.018.