BRIEF REPORT

Cricothyrotomy Technique Using Gum Elastic

Bougie Is Faster Than Standard Technique: A
Study of Emergency Medicine Residents and
Medical Students in an Animal Lab
Chandler Hill, MD, Robert Reardon, MD, Scott Joing, MD, Dan Falvey, and James Miner, MD

Abstract
Objectives: The objective was to compare time to completion, failure rate, and subjective difficulty of a
new cricothyrotomy technique to the standard technique. The new bougie-assisted cricothyrotomy technique (BACT) is similar to the rapid four-step technique (RFST), but a bougie and endotracheal tube are
inserted rather than a Shiley tracheostomy tube.
Methods: This was a randomized controlled trail conducted on domestic sheep. During a 3-month period inexperienced residents or students were randomized to perform cricothyrotomy on anesthetized
sheep using either the standard technique or the BACT. Operators were trained with an educational
video before the procedure. Time to successful cricothyrotomy was recorded. The resident or student
was then asked to rate the difficulty of the procedure on a five-point scale from 1 (very easy) to 5 (very
difficult).
Results: Twenty-one residents and students were included in the study: 11 in the standard group and 10
in the BACT group. Compared to the standard technique, the BACT was significantly faster with a median time of 67 seconds (interquartile range [IQR] = 5582) versus 149 seconds (IQR = 111201) for the
standard technique (p = 0.002). The BACT was also rated easier to perform (median = 2, IQR = 13) than
the standard technique (median = 3, IQR = 24; p = 0.04). The failure rate was 1 10 for the BACT compared to 3 11 for the standard method (p = NS).
Conclusions: This study demonstrates that the BACT is faster than the standard technique and has a
similar failure rate when performed by inexperienced providers on anesthetized sheep.
ACADEMIC EMERGENCY MEDICINE 2010; 17:666669 2010 by the Society for Academic Emergency
Medicine
Keywords: cricothyrotomy, gum elastic bougie, difficult airway

ricothyrotomy is a critical procedure in emergency airway management. While the incidence

of emergency department cricothyrotomy is
decreasing, it remains one of the most important skills of
the emergency physician (EP).1,2 Many techniques of
cricothyrotomy have been described in the literature.39
The accepted standard is an open technique that involves
From the Department of Emergency Medicine, Hennepin
County Medical Center (CH, RR, JM, SJ), Minneapolis MN;
and the University of Minnesota Medical School (DF), Minneapolis, MN.
Received July 6, 2009; revisions received September 11, 2009,
October 31, 2009, and December 2, 2009; accepted December 3,
2009.
Presented at the Society for Academic Emergency Medicine
conference, New Orleans, LA, May 2009.
Address for correspondence and reprints: Chandler Hill, MD;
e-mail: hill.chandler@gmail.com.

666

ISSN 1069-6563
PII ISSN 1069-6563583

the use of a midline vertical incision, a dilator to open

this incision, and the insertion of a tracheostomy tube.6,7
A simplified technique known as the rapid four-step
technique (RFST) has been described and found to be
faster with a higher success rate than the standard technique.8
The RFST offers the advantages of eliminating both
the vertical midline incision and the use of a tracheal
dilator that are recommended in the standard open surgical method. This makes the procedure faster to perform while continuing to be highly successful in
cadaver models.8 In our clinical and laboratory experience with both the standard technique and the RFST,
we have noted that the limiting step in this procedure is
the insertion of a tracheostomy tube through the tracheal incision. This step can require significant force,
and inexperienced providers often are unable to pass
the tube into the trachea or create a false tract into the
subcutaneous tissue. We studied a new variation of the

2010 by the Society for Academic Emergency Medicine

doi: 10.1111/j.1553-2712.2010.00753.x

ACAD EMERG MED June 2010, Vol. 17, No. 6

www.aemj.org

RFST that employs a gum elastic bougie, a tool familiar

to EPs, to facilitate the insertion of an endotracheal
tube into the trachea. Specifically, we compared the
speed, efficacy, and ease of insertion of a novel cricothyrotomy technique using a gum elastic bougie (bougie-assisted cricothyrotomy technique [BACT]) to a
standard open technique.
METHODS
Study Design
This was a prospective, randomized comparison of two
cricothyrotomy techniques conducted on anesthetized
domestic sheep. The study protocol was approved by
the Human Subjects Research Committee and the Institutional Animal Use and Care Committee of Hennepin
County Medical Center.
Study Setting and Population
The study was conducted during the routine animal
procedure training lab for Hennepin County Medical
Center emergency medicine (EM) residents (PGY 13),
and medical students on their EM rotation, from September to November 2008.
Study Protocol
Operators were each chosen on 21 separate days over
a 3-month period on a volunteer basis from students
attending the training lab that day and were randomized to perform either standard cricothyrotomy
(Table 1) or BACT (Table 2). Randomization was
achieved by assigning each data collection sheet a computer generated random number (1 or 2), which corresponded to the procedure to be used. The data sheets
were kept in opaque folders in numbered order. At the
beginning of each lab session day, the next folder was
removed in consecutive order by the investigator to discover the procedure to be performed. The operators
were shown a short instructional video in the animal
lab describing the technique to be performed. No further instruction was given. The operator was allowed

Table 1
Standard Technique
Instruments
Scalpel with No. 11 blade, curved hemostat, Trousseau
dilator, tracheal hook, and No. 5 Shiley tracheostomy tube
Steps
1. Standing on the right side of the patient, stabilize the
larynx with thumb and index finger of the left hand, and
identify the cricothyroid membrane.
2. Make a 2.5-cm midline incision over the cricothyroid
membrane using a No. 11 blade.
3. Use the curved hemostat to dissect through the
subcutaneous tissue to the cricothyroid membrane.
4. Use the scalpel to make an incision into the trachea.
5. Extend the incision laterally in both directions.
6. Insert a tracheal hook on the caudal aspect of the
larynx.
7. Insert a Trousseau dilator and open the membrane
vertically.
8. Insert a No. 5 tracheostomy tube.
9. Remove the inner cannula and insert the adaptor.

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Table 2
The Bougie-assisted Cricothyrotomy Technique
Instruments
Scalpel with No. 20 blade, tracheal hook, 70-cm gum
elastic bougie (Sun-Med Endotracheal Introducer,
Sun-Med, Largo, FL), and 6-0 endotracheal tube
Steps
1. Standing on the left side of the patient, stabilize the
larynx with the thumb and middle finger of your left
hand, and identify the cricothyroid membrane.
2. Using a No. 20 scalpel blade make a transverse stabbing
incision through the skin and cricothyroid membrane.
3. Place a tracheal hook at the inferior margin of the
incision and pull up on the trachea.
4. Insert the bougie through the incision.
5. Place 6-0 endotracheal tube over the bougie and into
the trachea.

time to become familiar with the equipment and ask

questions about anatomical landmarks. The instructional video for the BACT, using the Sun-Med Endotracheal Introducer (Sun-Med, Largo, FL), was developed
by the investigators (Video Clip S1, available as supporting information in the online version of this paper).
The instructional video for the standard method was a
New England Journal of Medicine (NEJM) video entitled
cricothyroidotomy obtained from the NEJM website
in the videos in clinical medicine series published
May 2008.4 The steps of the procedures for a right
handed operator are described in Figures 1 and 2. Each
procedure was supervised by one of two investigators
who collected the data. An investigator and a lab
instructor who was either a PGY 3 EM resident or an
EM faculty member supervised the training lab. Neither
supervisor intervened during the study procedure
unless the attempt was a failure.
Measurements
The level of training of the operator, the number of
attempts, the total length of the procedure, and any
complications were recorded. The operator was then
asked to rate the difficulty of the technique on a fivepoint scale from 1 = very easy to 5 = very hard.
The start of the procedure was marked when the operator began to palpate for the cricothyroid membrane.
The end of the attempt was marked at the inflation of
the cuff of either the endotracheal tube or the tracheostomy tube. Correct placement was assessed by end tidal
CO2. The procedure was considered a failure if the first
placement of the endotracheal tube or tracheostomy
tube was not confirmed to be in the trachea. Based on
previously defined standards for optimal cricothyrotomy procedure times, an attempt longer than 3 minutes
was also considered a failure.10
Data Analysis
Data were collected by the investigators. Data analysis
was performed using STATA 10.0 (StataCorp, College
Station, TX). Descriptive statistics were used as appropriate. The times to complete the procedure and the
operators perceived difficulty of the technique score

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Hill et al.

CRICOTHYROTOMY TECHNIQUE USING BOUGIE IS FASTER THAN STANDARD TECHNIQUE

were compared using Wilcoxon rank sum tests. The

level of training of the operators and the number of
attempts made during the procedure were compared
using chi-square tests. To detect a 50% difference in
the length of the procedure, with a power of 90% and
an alpha of 0.05, 10 subjects were required in each
group.
RESULTS
Twenty-one individuals were included in the study: 11
in the standard group and 10 in the BACT group. The
level of experience of the operators was similar in both
groups. In the BACT group the operators were six
medical students, three first-year residents, and one
second-year resident. The standard group consisted of
six medical students, three first-year residents, one second-year resident, and one third-year resident. Only
one cricothyrotomy was performed by each of the 21
participants.
Compared to the standard technique, the insertion
time for the BACT technique was faster (median
time = 67 seconds
[IQR = 5582]
vs.
149 seconds
[IQR = 111201]; p value = 0.002). The BACT was also
rated easier to perform than the standard technique
(median rating = 2, [IQR = 13] vs. median rating = 3
[IQR = 24], respectively; p = 0.04).
Failure to correctly place the tube occurred in 3 11
(27.3%, 95% confidence interval [CI] = 6.02% to 61%) in
the standard group versus 1 10 (10.0%, 95% CI = 0.25%
to 44.5%) in the BACT group (p = 0.31). In the standard
method group, one operator placed the tracheostomy
into the subcutaneous tissue. Two operators were
unable to pass the tracheostomy tube, and a repeat
incision was made and the tube was placed correctly by
the lab instructor. In the BACT group, one operator
was unable to pass the bougie through the incision,
and a new incision was made and the procedure completed by the lab instructor.
DISCUSSION
Emergent cricothyrotomy is a procedure where time
matters. Patients are critically ill and the procedure is
often begun with life-threatening hypoxia already present. Many techniques for cricothyrotomy exist.58 The
RFST was developed to eliminate the unfamiliar Trousseau dilator that is used in the standard open technique
and the time-consuming midline incision.8 In previous
research, the RFST has been shown to be faster than
both the open surgical technique and the Seldinger
technique.3,8 In our experience, the limiting step of both
the RFST and the open surgical technique is the insertion of the tracheostomy tube through the incision. We
developed the BACT as a combination between the
RFST and the use of the bougie to overcome this limiting step. The BACT has the added benefit of eliminating
the tracheostomy tube, a piece of equipment not as
familiar to EPs as the endotracheal tube. In this study,
the BACT took half the time to complete compared to
the open surgical technique. It was subjectively easier
to perform than the standard technique and had a similar failure rate. This method has been used successfully

in our clinical practice and is now taught routinely in

our animal lab.
The bougie is a valuable piece of equipment for EPs
as a rescue device for the difficult airway. In typical
use, the bougie is inserted into the trachea during difficult orotracheal intubation. The endotracheal tube is
then placed over the bougie, allowing it to serve as a
guide into the trachea. The addition of the bougie to
cricothyrotomy offers several advantages over other
techniques. The thinner bougie is easier to place
through the incision made during cricothyrotomy than
either the tracheostomy tube or endotracheal tube. As
the bougie enters the trachea, tactile confirmation of
correct placement is possible, as the curved edge of the
bougie is designed to create vibrations as it passes over
the tracheal rings. The bougie then serves as a guide
for the endotracheal tube through the ostomy during
placement. In this study, the three failures of the standard open technique involved either false passage into
the soft tissue of the neck or the inability to push the
tracheostomy tube through the incision. These complications are addressed by the addition of the bougie in
the BACT, likely improving the speed of the procedure
and trend toward fewer failures.
The technique described here does not use a midline
incision. However, it is important to note that some
patients, especially those with large necks, will require
a midline incision to appropriately palpate the cricothyroid anatomy. While not studied here, in these select
cases we recommend the use of a vertical midline incision followed by the steps of the BACT.
LIMITATIONS
We have used anesthetized sheep as a model for the
human airway. While sheep have similar anatomy to
humans, clearly differences exist. These differences may
have made it easier to perform the BACT compared to
the standard method. Other studies of cricothyrotomy
have used cadaver models, preserved pig larynxes, or
plastic models.3,8 In comparison to these models, using
live animals does more accurately simulate the complications that arise from bleeding at the incision site, one
of the major sources of complication in retrospective
reviews of cricothyrotomy.1,10 Using a live animal
model also better simulates the sense of urgency for
providing a rapid airway.
Additionally, our operators were very inexperienced.
Over half in each group were medical students who
may have had increased difficulty in performing the
more complex standard technique. A study of more
experienced physicians with significant cricothyrotomy
experience may not have found such a difference in
speed or success rate between the procedures. However, given the declining incidence of cricothyrotomy, it
is important that any cricothyrotomy technique have
high success rates by inexperienced operators.
CONCLUSIONS
We have studied a new technique of cricothyrotomy
that uses the addition of a bougie to facilitate tracheal
cannulation. This technique is faster and subjectively

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easier to perform than the standard method when performed by inexperienced operators undergoing procedure training on an animal simulation model. Failure
rates between the two techniques were similar.
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Supporting Information
The following supporting information is available in the
online version of this paper:
Video Clip S1. 5-step cricothyrotomy.
The video clip is in QuickTime.
Please note: Wiley Periodicals Inc. is not responsible
for the content or functionality of any supporting
information supplied by the authors. Any queries
(other than missing material) should be directed to the
corresponding author for the article.