Emergency Front-of-Neck Airway Rescue Via the Cricothyroid Membrane: A High-Resolution Computed Tomography Study of Airway Anatomy in Adults

Anesth Analg. 2021 Jul 1;133(1):187-195. doi: 10.1213/ANE.0000000000005583.


Background: Emergency front-of-neck airway rescue is recommended in a can't intubate, can't oxygenate clinical scenario. Cannula cricothyroidotomy has been reported as having a high failure rate. Our primary aim was to estimate the angle of the trachea in relation to the horizontal axis in a simulated emergency front-of-neck airway rescue position. Our secondary aims were to estimate the optimal cannula angle of approach and evaluate the anatomical relationship of the cricothyroid membrane (CTM) to adjacent structures. We also assessed whether the CTM lies above or below the neck midpoint, a point equidistant from the suprasternal notch (SSN), and the chin surface landmarks. All measurements were compared between the male and female subjects.

Methods: Subjects having elective computed tomography of their thorax were consented to have extension of the computed tomography to include their neck. A preliminary radiation dose and risk assessment deemed the additional radiation to be of very low risk (level IIa). Subjects were positioned supinely on the computed tomography table. Standard neck extension was achieved by placing a pillow under the scapulae and a rolled towel under the neck to simulate emergency front-of-neck airway rescue positioning.

Results: Fifty-two subjects were included in this study: 31 men and 21 women. The mean angle of the trachea in relation to the horizontal axis was 25.5° (95% confidence interval [CI], 21.8-29.1) in men and 14.0° (95% CI, 11.5-16.5) in women. The mean minimum angles required for hypothetical cannula cricothyroidotomy for men and women were 55.2° (95% CI, 51.8-58.7) and 50.5° (95% CI, 45.4-55.6), respectively. The CTM was located lower in the neck in men compared to women. The CTM was located below the neck midpoint in 30 of 30 (100%) male subjects and 11 of 20 (55%) female subjects (P < .001).

Conclusions: The trachea angulates posteriorly in a simulated emergency front-of-neck airway rescue position in supine subjects and to a greater degree in men compared to women (P < .001). The minimum angle required for hypothetical cannula cricothyroidotomy was >45° in the majority (75%) of subjects studied. A steeper cannula angle of approach may be more reliable and warrants further clinical study. If airway anatomy is indistinct and performing a vertical scalpel cricothyroidotomy, consideration should be given to performing this incision lower in the neck in men compared to women.

Publication types

  • Observational Study

MeSH terms

  • Aged
  • Aged, 80 and over
  • Airway Management / methods*
  • Cricoid Cartilage / anatomy & histology
  • Cricoid Cartilage / diagnostic imaging*
  • Cricoid Cartilage / surgery
  • Emergency Medical Services / methods*
  • Female
  • Humans
  • Male
  • Middle Aged
  • Neck / diagnostic imaging*
  • Neck / surgery
  • Prospective Studies
  • Thyroid Cartilage / anatomy & histology
  • Thyroid Cartilage / diagnostic imaging*
  • Thyroid Cartilage / surgery
  • Tomography, X-Ray Computed / methods*
  • Trachea / anatomy & histology
  • Trachea / diagnostic imaging
  • Trachea / surgery