“Underneath this little stone
Lies Robert Earl of Huntington;
No other archer was so good -
And people called him Robin Hood.
Such outlaws as he and his men
Will England never see again.”



Surgical and Percutaneous Cricothyroidotomy

  • incision made through the cricothyroid membrane to establish a patent airway during certain life-threatening situations

  • performed as a last resort in cases where orotracheal and nasotracheal intubation are impossible or contraindicated

  • quicker to perform than tracheotomy

  • does not require manipulation of the cervical spine

  • associated with fewer complications

  • performed by making a vertical incision on the skin of the neck just below the "Adam's apple", or thyroid cartilage, then making another transverse incision in the cricothyroid membrane which lies deep to this point


  • Inability to obtain an oral or nasopharyngeal airway in a patient who requires emergent intubation

  • Severe facial or head and neck trauma

  • Acute loss of the airway due to supralaryngeal obstruction secondary to tumor, anaphylaxis, foreign body, trauma, or burn injury



  • tracheotomy is a surgical procedure which consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea (windpipe)

  • tracheostomy, is the resulting stoma (hole) can serve independently as an airway or as a site for a tracheostomy tube to be inserted; this tube allows a person to breathe without the use of the nose or mouth

  • Indications:

    • long term mechanical ventilation​

    • severe facial trauma

    • obstructive sleep apnea
    • tumors of the head and neck (e.g., cancers, branchial cleft cysts)

    • acute angioedema

    • inflammation of the head and neck

    • failed orotracheal or nasotracheal intubation (either tracheotomy or cricothyrotomy may be performed)

  • in 2003 American cadaveric study identified multiple tracheal ring fractures with the Ciaglia Blue Rhino technique as a complication occurring in 100% of their small series of cases. The comparative study above also identified ring fractures in 9 of 30 live patients while another small series identified ring fractures in 5 of their 20 patients. The long term significance of tracheal ring fractures is unknown​

  • References:

    • Hotchkiss KS, McCaffrey JC (January 2003). "Laryngotracheal injury after percutaneous dilational tracheostomy in cadaver specimens". The Laryngoscope. 113 (1): 16–20. doi:10.1097/00005537-200301000-00003. PMID 12514375

    • Ambesh SP, Pandey CK, Srivastava S, Agarwal A, Singh DK (December 2002). "Percutaneous tracheostomy with single dilatation technique: a prospective, randomized comparison of Ciaglia blue rhino versus Griggs' guidewire dilating forceps". Anesthesia and Analgesia. 95 (6): 1739–45, table of contents. doi:10.1097/00000539-200212000-00050. PMID 12456450

    • Byhahn C, Lischke V, Halbig S, Scheifler G, Westphal K (March 2000). "Ciaglia Blue Rhino: Ein weiterentwickeltes Verfahren der perkutanen Dilatationstracheotomie" [Ciaglia blue rhino: a modified technique for percutaneous dilatation tracheostomy. Technique and early clinical results]. Der Anaesthesist (in German). 49 (3): 202–6. doi:10.1007/s001010050815. PMID 10788989

High-Flow Nasal Cannula

  • flow meter (up to 60L/min)

  • can place a blender to select FiO2 (without blender = 100% oxygen)

... but I would more especially commend the clinician who, in acute diseases, by which the bulk of mankind are cutoff, conducts the treatment better than others.
Hippocrates, 400 BC