The one area of greatest concern, amongst delegates when I’m giving an airway workshop, is when and how, to do a surgical airway. Why do we fear this so much?

It’s very simple. There are three main reasons:

1. We keep asking ourselves, “When should I really do the surgical airway?” So we aren’t sure of the indications.

2. We keep asking ourselves, “What if I screw it up?”

3. We don’t do this procedure often, in fact very rarely, so we are not as skilled as we would like to be.

Let me go over some of the main points associated with surgical airway, that will clarify all of these issues.

The surgical airway is a last avenue, it is usually the final pathway in the management of the emergency airway.

The indication for the surgical airway is simply cannot ventilate and cannot oxygenate. It is not cannot intubate.

Although our initial aim is to secure the airway, by putting a cuff in the trachea and inflating it, our plans must change, once we cannot obtain access to the trachea, via the cords.

You say, but I can’t intubate and I don’t have a secure airway. I must do the surgical airway.


Stop for a moment and think. The third reason that we are so afraid of the surgical airway is that we don’t do many. This in itself presents issues when you are trying to do it. You need to be exceptionally confident with your landmarks for finding the cricothyroid membrane. That’s why I spend so much time talking about this at the workshops, because at that time, this is the only learning you may have. That’s why I use ‘pig’s tracheas’, so you get used to knowing what it feels like to touch real tissues.

This is a life saving procedure to be used when there are no alternatives, however, the consequences from it being done incorrectly can be significant and incude lacerated tracheas, penetration of the oesophagus and more.

So I say, can you really not intubate? Have you tried the tube with an introducer and have you tried a bougie, have you tried changing the position of the patient, or a new blade, or even a new operator? OK.

Now can you really not ventilate and oxygenate?

Have you tried a jaw thrust and an oropharyngeal airway?

You have? How about a laryngeal mask? But it doesn’t secure the airway you say. True, but with controlled bagging i.e. pressing on the bag over a period of 1-2 seconds, rather than blowing an aggressive blast of oxygen in, and the use of cricoid, you may be able to ventilate and oxygenate the patient until assistance arrives.

I’m not saying wake the patient, inless you are performing a semi-elective procedure. In most cases in the emergency department, that’s impossible. I’m saying ventilate and oxygenate until someone with more experience or a ‘gadget’ of some sort comes along.

I honestly believe that we don’t use enough laryngeal masks in the ED. I know all about “but they don’t protect the airway”, but this is a choice between cutting the neck, which you may never have done before and will probably never do again after this episode and ventilating and oxygenating until some other avenue is found.

Think about this, it may save you a lot of stress.

So to summarise:

The indication for surgical airway is cannot ventilate and cannot oxygenate. It isn’t cannot intubate. Have you tried everything to open the airway? Have you tried an oropharyngeal airway? Have you tried a laryngeal mask? Have you tried relaxing the pressure on the cricoid a little, as this in itself can collapse the airway?

Once you have done these things and realise that you can oxygenate and ventilate, you can try intubating again, with the confidence that comes from knowing that if you cannot pass the tube, you can still keep the patient alive. Keep the surgical airway for those patient where you have tried everything but cannot push any oxygen in.

Peter Kas