The Bougie-Aided Cricothyrotomy

Surgical cricothyroidotomy is considered a critical skill in emergency airway management, though it is rarely used and fraught with complications. A variety of approaches are taught, including both the standard and rapid four-step techniques. We report a case in which an air medical crew used a gum-elastic bougie (endotracheal tube introducer), a common device in many airway kits, to facilitate surgical cricothyroidotomy in a 58-year-old patient with a pharyngeal mass, respiratory failure, and failed rapid sequence induction. We believe this technique may decrease the time until ventilation, minimize complications compared with other cricothyroidotomy techniques, and allow insertion of a larger-diameter endotracheal tube compared with other techniques. Case A fixed-wing flight crew was called to transport a 58-yearold male patient from a small rural hospital secondary to a pharyngeal mass complicated by alcohol withdrawal. The radiologist interpreted the image seen on a computed tomography scan as a 6 cm by 6 cm by 6 cm mass at the base of tongue and left tonsillar area with pharyngeal displacement and distortion of normal neck anatomy. On arrival, the crew found an emaciated patient in respiratory failure with supraclavicular and intercostal retractions and with altered mental status; he opened his eyes only to deep painful stimuli. His vital signs revealed a temperature of 101.4°F rectally, saturation of 95% with an oxygen-powered albuterol nebulizer at 15 L/min, a regular heart rate of 144 beats/min, a respiratory rate of 26 to 40 breaths/min, and a blood pressure of 120/70 mmHg. The patient had received SoluMedrol, Ativan, and Romazicon before arrival. Although a difficult airway was anticipated, it was determined that the patient would require definitive airway control before the 2-hour transport. This small facility has no otolaryngologist availability, and the certified registered nurse anesthetist on call had yet to arrive, with no known estimated time of arrival. While simultaneously preparing for a surgical airway, the patient was positioned optimally and rapid sequence intubation initiated with etomidate and rocuronium. The flight nurse attempted direct laryngoscopy with a #4 Macintosh blade, without success. Frank blood was suctioned from the oropharynx, and the best view was Lehane and Cormack Class IV. It was then decided to perform a surgical cricothyroidotomy. Bag-valve mask ventilation was required to maintain the oxygen saturation above 90% while preparing for and during this procedure. The flight nurse made a vertical incision over the cricothyroid membrane, followed by a horizontal incision into the membrane. They placed a 6.0 cuffed endotracheal tube into the incision directed distally; however, during positive-pressure ventilation, gurgling sounds were heard from the patient’s mouth, and there were no audible breath sounds. A gum-elastic bougie was then introduced into the incision. Tracheal position was confirmed with “hold-up,” and a 6.0 endotracheal tube was introduced into the opening over the bougie. Breath sounds were equal bilaterally, and tube placement then was re-verified with capnography. The tube was secured and the patient placed on the transport ventilator. The remainder of the transport was uneventful. The cricothyrotomy was eventually converted to a tracheostomy without any noted complication from the initial procedure. The patient was diagnosed with a squamous cell carcinoma of the tongue and ultimately transferred to hospice.