LONG TERM CRICS ARE SAFE

cric safeCricothyroidotomy is the go-to option for emergency surgical airway at the end of a can’t intubate, can’t ventilate scenario. It feels like an extreme measure in a pressing situation, and we’ve also been loaded with the impressions that crics are only for relieving emergencies. They will harm our patients in the long run, and must be replaced by an endotracheal tube or a ‘proper’ trachie ASAP. But much of this seem based on a paper from 1921.

Of course, emergency crics have a lot of risk attached to them. Not mainly from the procedure, but from all the stress and urgency surrounding them. Elective crics are another matter. They can be used as an alternative to a trachie, but have mostly been considered a proper trachie’s bastard brother. Mainly due to fear of subglottic stenosis. This fear might be very exaggerated.

1921 urban legend
In this ‘landmark’ paper, Dr. Jackson found an alarming incidence of subglottic stenosis, but a large part of the patient population had larynx anomalities. Also, for the cric, the cricoid cartilage was usually dissected. So, lots of risks for subglottic stenosis. In addition to this, tube technology has evolved, and today’s tubes are much less traumatic to surrounding tissue than the olden ones.

So Dr. Jackson’s proclamation that high tracheostomy “should never be taught or done”; and when done, should be converted to a “low tracheostomy” as soon as possible, might be plain wrong.

Pros of crics
Mainly, the cricothyroid membrane is much closer to the skin – it’s a more superficial procedure than a tracheostomy. Also, it’s not so close to any important structures. It is easier to do in a non-hyperextended neck, and in obese patients with a short, fat neck. It’s shielded by bone structures posteriorly, so not as easy to cut through as the trachea. The opening has a natural boundary. Since it’s more superficial, it’s easier and faster to do with few and simple tools.

fat cric
Image showing challenging anatomy, making cric preferable over trachie. Image from this article

A review of elective crics
Several centres have enclaves that use cricothyroidotomy as the preferred access to the trachea when a surgical airway is needed. So the review linked below looked at papers from these centres, and found crics to be as safe as trachies in these settings. Same complications incidence – including subglottic stenosis, that was very uncommon in crics as well as in conventional tracheas.

Emergency crics have their own problems, like mostly being done in far from sterile setting. And the procedure itself will usually be less, well, elegant. But it seems crics usually won’t harm your patient longterm.

Conclusion
Crics seem safe, also for more ‘permanent’ airways. The barrier to do crics are high. Very high. Too high, as concluded by DAS and NAPP4. There are a lot of stress factors to doing a cric, but at least know that by placing a tube through the cricothyroid membrane, as long as you’re doing it right, you’re not doing harm to your patient. And the cric you make can in theory be used for as long as the patient needs an artificial airway.

Cricothyroidotomy for elective airway management in critically ill trauma patients with technically challenging neck anatomy, Crit Care, 2002.

Elective surgical cricothyroidotomy in oral and maxillofacial surgery, Br J Oral Maxillofac Surg. 2013.

Cricothyroidotomy: When, why, and why not? American Journal of Otolaryngology, 2000.

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