- Locate the cricothyroid membrane, bound by cricoid cartilage inferiorly and thyroid cartilage superiorly.
- Use universal precautions and sterile technique. Cleanse the puncture site with povidone-iodine solution.
- Attach a 3- to 10-mL syringe with a few mL of saline to a 13 to 18 gauge IV catheter. (AVOID needleless catheters that will not attach to a syringe.)
- Hold the trachea in place and provide skin tension with the thumb and middle finger of the non-dominant hand on either side of the trachea while palpating the cricothyroid membrane with the index finger.
- Enter the cricothyroid membrane in its inferior-central part, directing the needle caudally (toward the feet) at an angle of 30 to 45 degrees.
- Puncture the skin and subcutaneous tissue. Advance the needle while continuously applying negative pressure on the syringe, until air bubbles are seen, confirming intratracheal placement.
- Advance the catheter forward off the needle until its hub rests at the skin surface. Remove the syringe and the needle.
- Reattach the syringe to the catheter and again aspirate for air to confirm that the catheter remains in the trachea.
- Hold the catheter firmly in place at all times or delegate an assistant to do so.
- Connect to a self-inflation ventilation bag and inflate with 100 percent oxygen (options include a 3-0 endotracheal tube adapter attached directly to a 14 Ga catheter hub or a 7-0 endotracheal tube adaptor attached to the barrel of a 3 cc syringe that is attached to the catheter [any size]). Alternatively, connect directly to high pressure oxygen tubing (connected to a valve and a source of 100 percent oxygen) to the catheter.*
- Give a few ventilations by delivering short bursts of gas to reconfirm placement and ensure that the equipment is functioning properly.
- Secure the transtracheal catheter with suture or a tracheostomy tie while ventilation continues.
- Begin regular ventilation with I:E ratio 1:4 and respiratory rate 10 to 12 breaths/min in the patient without complete upper airway obstruction; adjust in patients with complete airway obstruction: I:E ratio 1:8 to 1:10 respiratory rate 5 to 6 breaths/min).
- Monitor the patient carefully. If full lung deflation is not occurring between breaths, gently press on the chest to express retained gas during exhalation.
- Initiate establishment of a more definitive airway (endotracheal tube or tracheostomy), which may require consultation with anesthesiology and/or otolaryngology.
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- In older children, feel the laryngeal cartilage and then palpate inferiorly to identify cricothyroid membrane.
- In infants and young children, start at the sternal notch and palpate the tracheal rings superiorly to locate the prominence of the cricoid cartilage. The cricothyroid membrane, even if not felt clearly, is just superior to the cricoid cartilage.
- If the cricothyroid membrane cannot be located with certainty in an infant or a young child, the catheter can be introduced between tracheal cartilages.
- The cricothyroid membrane should be punctured below its central part to avoid blood vessels.
- One person should be assigned to hold the hub of the IV catheter in place over the neck at all times.
- A pre-assembled system including all the necessary components for needle cricothyrotomy and PTV should be readily available in all resuscitation areas.
- The system should be used in regular mock codes to improve familiarity of the medical, nursing, and respiratory therapy staff.
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