Complications of cricothyroidotomy versus tracheostomy in emergency surgical airway management: a systematic review

Abstract

Background: Airway guidelines recommend an emergency surgical airway as a potential life-saving treatment in a "Can't Intubate, Can't Oxygenate" (CICO) situation. Surgical airways can be achieved either through a cricothyroidotomy or tracheostomy. The current literature has limited data regarding complications of cricothyroidotomy and tracheostomy in an emergency situation. The objective of this systematic review is to analyze complications following cricothyroidotomy and tracheostomy in airway emergencies. Methods: This synthesis of literature was exempt from ethics approval. Eight databases were searched from inception to October 2018, using a comprehensive search strategy. Studies were included if they were randomized controlled trials or observational studies reporting complications following emergency surgical airway. Complications were classified as minor (evolving to spontaneous remission or not requiring intervention or not persisting chronically), major (requiring intervention or persisting chronically), early (from the start of the procedure up to 7 days) and late (beyond 7 days of the procedure). Results: We retrieved 2659 references from our search criteria. Following the removal of duplicates, title and abstract review, 33 articles were selected for full-text reading. Twenty-one articles were finally included in the systematic review. We found no differences in minor, major or early complications between the two techniques. However, late complications were significantly more frequent in the tracheostomy group [OR (95% CI) 0.21 (0.20-0.22), p < 0.0001]. Conclusions: Our results demonstrate that cricothyroidotomies performed in emergent situations resulted in fewer late complications than tracheostomies. This finding supports the recommendations from the latest Difficult Airway Society (DAS) guidelines regarding using cricothyroidotomy as the technique of choice for emergency surgical airway. However, emergency cricothyroidotomies should be converted to tracheostomies in a timely fashion as there is insufficient evidence to suggest that emergency cricothyrotomies are long term airways.

Acute upper airway obstruction due to tonsillitis necessitating emergency cricothyroidotomy

“…Cricothyroidotomy can have serious complications like endotracheal tube misplacement, tracheal and vocal cord injury, vocal cord granuloma and paralysis, pneumonia, retropharyngeal abscess and late complications like tracheal and subglottic stenosis. 18 This incident was complicated by a posterior tracheal tear and minor injury to the vocal cords, which is a known complication in emergency cricothyroidotomy by conventional palpation method, even in experienced hands. The tracheal tear could perhaps have been avoided by prior use of airway ultrasound and also by directing the scalpel perpendicular to the skin.…”

Notfallkoniotomie – Schritt für Schritt

“…Heute wird bei elektiven Eingriffen die Tracheotomie bevorzugt, um Kehlkopfverletzungen zu vermeiden. Aufgrund der vergleichsweise einfachen Identifizierung des Ligamentum conicum und eines wahrscheinlich geringeren Blutungsrisikos gilt die Koniotomie jedoch weiterhin als Standardzugang in der Notfallsituation, obwohl eine geringere Rate an Akutkomplikationen gegenüber der Tracheotomie in klinischen Studien bislang nicht belegt werden konnte 4 .…”

Characteristics and outcomes of prehospital and emergency department surgical airways

“…Additional studies have found cricothyrotomy complication rates ranging from 41.9% to 57% and post‐procedural mortality ranging from 44.4% to 87% 7‐10 . A systematic review of surgical airways evaluated early and late complications regardless of location of procedure or provider experience and found that tracheostomy had more long‐term complications compared to cricothyrotomy 11 . Information regarding immediate and late complications, factors including provider experience, and associated morbidity and mortality is needed.…”