Mini-tracheotomy

The technique of placing a small diameter, uncuffed plastic tube through the cricothyroid membrane under local anaesthetic.

Indications

• Removal of retained secretions, usually if patient’s cough is weak.

• Emergency access to lower airway if upper airway obstructed.

Contraindications/cautions

• Coagulopathy.

• Non-compliant, agitated patient (unless sedated).

Technique

Some commercial kits rely on blind insertion of a blunt introducer; others use a Seldinger technique where a guidewire is inserted via the cricothyroid membrane into the trachea. An introducer passed over the wire dilates the track, allowing easy passage of the tube.

1 Use an aseptic technique. Cleanse site with antiseptic. Locate cricothyroid membrane (midline, ‘spongy’ area between cricoid and thyroid cartilages).

2 Infiltrate local skin and subcutaneous tissues with 1% lidocaine 9 epinephrine (adrenaline). Advance needle into deeper tissues,

aspirating to confirm absence of blood, then infiltrate with lidocaine until cricothyroid membrane is pierced and air is easily aspirated.

3 If using Seldinger technique, insert the guidewire through the membrane into the trachea. Tether thyroid cartilage with one hand, incise skin and tissues vertically in midline (alongside wire) using a short-bladed guarded scalpel provided with pack. Insert scalpel to blade guard level to make adequate hole through cricothyroid membrane. Remove scalpel.

4 Insert introducer through incision site into trachea (or over guidewire). Angle caudally. Relatively light resistance is felt during correct passage; do not force introducer if resistance is excessive.

5 Lubricate plastic tube and slide it over introducer into trachea.

6 Remove introducer (+ wire), leaving plastic tube in situ.

7 Confirm correct position by placing own hand over tube and feeling airflow during breathing. Suction down tube to aspirate intratracheal

contents (check pH if in doubt). Cap opening of tube. Suture to skin.

8 Perform CXR (unless very smooth insertion and no change in cardiorespiratory variables).

9 O2 can be entrained through the tube, or a catheter mount placed to allow bagging, the use of intermittent positive pressure breathing and/

or short-term assisted ventilation.

Complications

• Puncture of blood vessel at cricothyroid membrane may cause significant intratracheal or external bleeding. Apply local pressure if this occurs after blade incision. If bleeding continues, insert mini-tracheotomy tube for a tamponading effect. If bleeding persists, insert deep sutures either side of mini-tracheotomy; if this fails, contact surgeon for assistance.

• Perforation of oesophagus.

• Mediastinitis (rare).

• Pneumothorax.