As the Pendulum Swings from the Needle to the Scalpel, the Evolution of Emergency Airway Management Will Continue

The recent editorial by Asai¹  addressing the challenges of cricothyrotomy for the management of “cannot intubate, cannot oxygenate” situations appropriately identifies the need for additional research as to how to optimally manage this airway emergency. Although the study by Heymans et al.²  to which it refers addresses the advantages of an open scalpel–driven cricothyrotomy over a percutaneous approach, a fundamental aspect of cricothyrotomy, irrespective of the technique chosen, is the actual identification of the cricothyroid membrane itself.³  Recently, this was highlighted by a study that showed that neither anesthesiologists nor surgeons themselves are particularly good at finding this important airway landmark.⁴  So, whichever technique is chosen, it is important that adequate training in identification of the cricothyroid membrane has been first mastered.

It is also clear, both in this editorial and some of the other recent work that has published, that there is an ongoing evolution in the understanding of how to best manage the “cannot intubate, cannot oxygenate” emergency airway. An example of this evolution is seen in the swing in opinion away from needle cricothyrotomy (a long taught foundation in emergency airway management) back to an open scalpel–driven technique. However, before the percutaneous approach is abandoned, one must fully consider the evolution in research regarding its use. Indeed, abandoning the percutaneous route ignores the newer (and percutaneous compatible) devices that are now entering the marketplace that allow for effective and safer jet ventilation. Indeed, this would suggest that open or percutaneous do not necessarily need to be mutually exclusive. A hybrid model of sorts has been made possible by the recent regulatory approval of the Ventrain^® (Ventinova, The Netherlands) device,⁵  which has recently been demonstrated to allow the use of ventilation through small-bore tubes, in part, due to its ability to allow active expiration, thus reducing the potential for hyperinflation from jet ventilation in situations of poor air egress. One could easily see this type of device being used not only for percutaneous cricothyrotomy, but also in a situation where one is beginning with a surgical cricothyrotomy but is only able to place a small-bore tube into the trachea.

Thus, as the pendulum swings away from percutaneous to open cricothyrotomy, one should keep an open mind and look to other hybrid techniques. The scalpel may be better, but perhaps it is too early to dismiss the needle just yet.

The author declares no competing interests.