Can a tracheostomy (trach) tube be used in place of a cricothyrotomy (cric)?

Can You Use a Trach Tube in Place of a Cricothyrotomy?

No, a tracheostomy tube should not be used in place of a cricothyroidotomy during a "cannot intubate, cannot oxygenate" (CICO) emergency—scalpel cricothyroidotomy with a standard small cuffed tracheal tube (5.0-6.0 mm) is the recommended default technique. 1

Why Cricothyroidotomy is Preferred Over Tracheostomy in Emergencies

Speed and Reliability

• Scalpel cricothyroidotomy is faster and more reliable than attempting tracheostomy in emergency situations 1
• The cricothyroid membrane is more superficial and easier to identify than the trachea lower in the neck 1, 2
• Tracheostomy requires more time, deeper dissection, and greater technical expertise 1

Anatomical Advantages

• The cricothyroid membrane location avoids major vascular structures and the thyroid gland 2
• Lower tracheal access (tracheostomy site) involves more complex anatomy with increased bleeding risk 1
• In children, the trachea is small, pliable, and difficult to palpate, making tracheostomy even more challenging 1

Equipment Considerations

• The recommended tube for emergency cricothyroidotomy is a standard 5.0-6.0 mm cuffed tracheal tube, not a tracheostomy tube 1, 2
• A 5.0 mm Melker™ cricothyroidotomy tube is also appropriate 1
• Standard tracheal tubes provide a cuffed airway that enables waveform capnography confirmation, PEEP application, and aspiration protection 1, 2

The Recommended Technique: Scalpel-Bougie-Tube Cricothyroidotomy

Four-Step Approach

1. Identify the cricothyroid membrane with maximum neck extension 1, 2
2. Make a horizontal incision with a wide scalpel blade (size 10 or 20) if the membrane is palpable, or a large vertical midline skin incision if impalpable 1
3. Apply caudal traction on the cricoid cartilage 2
4. Insert a bougie as a guide for the 5.0-6.0 mm tracheal tube 1, 2

Post-Procedure Verification

• Confirm placement with waveform capnography 1, 2
• Ventilate with low-pressure source initially 2
• Once stabilized, the airway will need conversion to a formal tracheal tube or tracheostomy 1

When Tracheostomy Might Be Considered

Failed Cricothyroidotomy Scenario

• If scalpel cricothyroidotomy via the cricothyroid membrane fails, front-of-neck airway access can be attempted lower in the trachea 1
• An experienced operator may attempt percutaneous or surgical tracheostomy as a rescue technique 1
• This is described as "a desperate situation" where cardiac arrest is usual 1

Special Anatomical Considerations

• Patients who have undergone cricothyroid approximation surgery may have complete loss of the cricothyroid membrane, making cricothyroidotomy impossible 1, 2
• In such cases, percutaneous access between the second and third tracheal rings may be an option, but this must be planned in advance 1

Recently Removed Tracheostomy

• If a patient's tracheostomy has been very recently removed, it may be possible to re-cannulate the stoma 1
• However, this should not delay front-of-neck airway access if re-cannulation is unsuccessful 1

Critical Pitfalls to Avoid

Timing Errors

• Delayed progression to cricothyroidotomy is a widely recognized problem resulting in avoidable harm 1
• Get the front-of-neck airway set to bedside after one failed intubation attempt 1, 2
• Open the set after one failed attempt at facemask or supraglottic airway oxygenation 1, 2
• Use the set immediately at CICO declaration 1, 2

Wrong Equipment Choices

• Do not attempt tracheostomy as the primary emergency surgical airway—it is too slow and complex 1
• Avoid narrow-bore cannulae and transtracheal jet ventilation, which have high failure rates and cannot provide PEEP 1
• Ensure the smaller tracheal tube size (5.0-6.0 mm) fits over the type of bougie used in your unit 1

Pediatric Considerations

• In infants and small children, the cricothyroid space is too small for cricothyroidotomy 3
• Emergency tracheostomy may be necessary in pediatric patients, but this requires specialized training and is technically challenging 1, 3
• Pediatric tracheostomy tubes are typically uncuffed and shorter in length than adult tubes 1

Bottom Line

Use a standard small cuffed tracheal tube (5.0-6.0 mm) via scalpel cricothyroidotomy, not a tracheostomy tube, for emergency front-of-neck airway access. 1, 2 Tracheostomy is reserved for failed cricothyroidotomy scenarios or when performed by experienced operators in specific anatomical situations. 1