Today on the podcast, we discuss a little philosophy of crics, then go to an interview with Rich Levitan on a case of central airway obstruction that he saw.
Richard Levitan
Perhaps no other US Emergency Physician has done more to advance airway management than Rich Levitan. He is a constant innovator and relentless EM educator. As Conflict of Interest, Rich has numerous patents for which he receives royalties from companies listed below.
My Initial Discussion
Scalpel vs. Scalpel
Never Trust a Cric Dreamer or a Cric Ace
Never use the Chef Knife Scalpel Technique!
Rich's Airway Case
This is the email I received…
Airway enthusiast friends,0330…working solo at critical access hospital (ED crew is me, 2 nurses)…50 year old woman with stridor, drooling, pulse ox 60%, heart rate 165, BP 90….history of weight loss for months, trouble swallowing, now unable to take any liquids and trouble breathing for ~1-2 days. High flow helped oxygenate for a few minutes but she would cycle down to severe desaturations and become semi-conscious.The woman had had an outpatient CXR a week earlier showing a mass…but she was not immediately referred for CT. She had been having trouble getting a primary care appointment for months. Husband right up front tells me he's angry, and they don't trust doctors. Asked me why his wife didn't get the CT scan sooner, even though he told her provider she was having trouble swallowing with weight loss. A nurse practitioner had told her it was just GERD.I told the patient and her husband, “I am going to knock you out with medicine and cut a hole in your airway to keep you from choking”….she nodded “yes”, and her husband said “Please!”. He was in the room watching as I did it.I gave a dose of Ketamine and cut her neck as my primary approach…didn'tthink she could lay flat. There was way too much secretions, drool, and agitation to scope, and zero time. Any manipulations sent her into a coughing/choking episode with worse desaturations. It was one of those “walk the talk” moments…I'm an airway enthusiast [“expert”–is a term I avoid]. No one cares—just get it done, or she's dead. #10 blade, finger, 6-0 tube. Took under ten seconds.I couldn't get her scanned…her airway was too unstable to allow it. I spoke to a thoracic surgeon 90 minutes away who realized, as I did, that a lesion in the esophagus was probably compressing from behind…and it might be too far down to bypass with a tube….and that it's acting like a flutter valve. Basically she needed a stent or ECMO. Best ventilation achieved was with bagging a decent volume–2 hands–but only 6-7 breaths a minute–she needed a lot of time to exhale–still we had to disconnect and suction every ten or twenty minutes when pulse ox would drop to 70's and lower.Took four hours from arrival to finally get helicopter transfer out; she made it to the receiving center with continuing see-sawing episodes of hypoxia, but got a Y stent placed in the trachea at the carina. Esophageal tumor is at the level of the carina compromising distal trachea and the proximal segments of both bronchi. May have TE fistula. It's a wonder she lived. Pics attached.Definitely a case for discussion at my next airway course.
Central Airway Obstruction
Rich's Stuff
Additional New Information
Fantastic Comments from Aman Thind:
Great podcast, Scott. I’ve obsessed quite a bit about this subject so thought I’d share some thoughts. My background is IM-CCM but I’ve picked a lot of smart IP docs’ brains on this.
#Definitions, categories, and anatomy –
– CAO usually refers to narrowing of the trachea +/- mainstem bronchi. Narrowing of the subglottis (the space between the cords and the first tracheal rings) is sometimes included in the definition. However, any pathology at (glottis) or above the cords (supraglottis) is excluded.
– The obstruction can be fixed (i.e. tracheal/subglottic stenosis e.g. from post-intubation, luminal tumor) or dynamic (i.e. tracheomalacia e.g. from cartilage weakness, external compression).
– If the narrowing is purely from external compression, the rigidity of the ETT should be able to overcome that (perhaps one should railroad it over bougie for smoother delivery). In general, dynamic obstruction (which sounds like this case could have been) is less scary to manage. If segmental (e.g. from goiter), the tube can be advanced distally (ideally with bronch visualization). If diffuse, high PEEP can help stent open the airway. I will limit the rest of the discussion to fixed stenosis that can be much harder to manage.
#Initial approach to airway and the role of surgical airway –
Anatomical knowledge is key here and should be sought from history, imaging etc., if possible. If respiratory distress is confirmed to be from CAO, two things need to be considered:
(i) Laryngeal visualization and path-to-glottis should be no more difficult than average. The problem is, by definition, below the cords. This is in contrast to angioedema, epiglottitis, oral tumors etc. where the problem is above the cords.
(ii) Surgical airway may not bypass the narrowing. Cricothyroidotomy provides access to the subglottic space. For all practical purposes, this would not bypass the obstruction in CAO where the site of obstruction is at &/or distal to the subglottis. Emergent/awake surgical trach performed by a skilled surgeon would be an option in isolated subglottic stenosis. If the very proximal trachea is stenosed, a low trach may be an option but if the stenosis extends lower than that, a trach would not bypass it.
#How can a resuscitationist handle these cases –
– If there’s time and resources, these cases should ideally be handled in the bronch suite/OR by someone skilled in rigid bronchoscopy (IP, Thoracics). They can balloon dilate a stenosis in seconds and do other cowboy stuff like coring through the tumor with the rigid scope to “create” an airway. Perhaps NIPPV and some precedex/ketamine can be considered as a bridge to that.
– If that’s not an option, or if you’re walking into a case where someone has already induced them, the best thing to do is to park the ETT as deep as it goes and ventilate them with high pressures. This is the single most important insight I’ve gained having seen a few of these cases. You would basically treat this patient on the vent as you would a status asthmaticus (tolerate high pressures, decent TV, low RR). I would personally set the PEEP to zero as they would have a decent amount of autoPEEP and they won’t have the “PEEP absorber” effect an asthmatic would. Attaching an example from Twitter (I would have personally chosen a higher TV and lower RR)
– This would work especially well in tracheal stenosis where the ETT cuff can occupy the subglottis/proximal trachea (I might cut the end of the tube distal to the cuff to make it seat better). However, in subglottic stenosis, the cuff would be sitting at/above the cords so you might have to hyperinflate it to avoid massive leak. One option in this situation would be to pack the mouth/pharynx with wet kerlix to improve the seal. Will Rosenblatt actually has a video of a subglottic stenosis case they induced while parking a 7.5 tube right above the stenosis – https://www.youtube.com/watch?v=QC6pQNs5AnQ. Although they did a flexible scope intubation, this could easily have been a regular VL intubation as there was nothing wrong with the airway above the cords and the path-to-glottis was unaffected.
Cheers,
Aman Thind.
More on EMCrit
- EMCrit 248 – How to Teach Surgical Airways–you knows, Crics: The One-Hour Cricothyrotomy Course
- https://emcrit.org/cric
- EMCrit 231 – How to Practice Cricothyroidotomy (Cric)
Additional Resources
You Need an EMCrit Membership to see this content. Login here if you already have one.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
- EMCrit 1:1 Nursing 001 – An Easy Case of Sepsis - May 15, 2025
- EMCrit Ghali Grills 003 – Further Disambiguating “PEA” - May 10, 2025
- EMCrit Wee – Neuroleptic Malignant Syndrome (NMS) Explosion - May 1, 2025
Great podcast, Scott. I’ve obsessed quite a bit about this subject so thought I’d share some thoughts. My background is IM-CCM but I’ve picked a lot of smart IP docs’ brains on this. #Definitions, categories, and anatomy – – CAO usually refers to narrowing of the trachea +/- mainstem bronchi. Narrowing of the subglottis (the space between the cords and the first tracheal rings) is sometimes included in the definition. However, any pathology at (glottis) or above the cords (supraglottis) is excluded. – The obstruction can be fixed (i.e. tracheal/subglottic stenosis e.g. from post-intubation, luminal tumor) or dynamic (i.e. tracheomalacia… Read more »
that was what I was wondering – why cut if the obstruction is so low – Why not intubate ? she was drooling from her esophageal obstruction ? why rush to cut?. Absolutely commend the physician for doing what he did. Still waiting for my dreaded day where I have to do this.
We discussed this in the podcast–did you just get a chance to look at the shownotes so far?
amazing comments!!! I moved them up to the main post screen
Thanks for the great podcast. I just have a follow-up question. I am a community intensivist in Canada. I was in a situation where myself and the Emergency physician were preparing a double setup for an emergent difficult airway.
The RT on the team mention to me that she has had significant difficulty securing 6ETT post cric (specifically in a situation for transport) and suggested directly placing a 6 trach through the cric technique to allow for more stability and to be able to secure the tube. I was wondering on your thoughts or experience in doing this.
Thanks,
Emily
hi Emily…
I should prob let Scott answer this… but one method is to cut the ETT 6-0 down at just above the cuff insufflation port, (reattaching he connector of course), making it shorter and less unstable/awkward.
(IMHO)
tom fiero
jeez… thank you both Rich and Scott. love his. truly an excellent deeper dive into difficult airway, but with the fortunately uncommon central airway pathology/obstruction complicating matters. as you might recall, back about 2018, I had a terrible case in our ER. I was so terribly distraught by it that I contacted you both at the time. briefly, a 50 y old female comes in by ambulance shocky, in severe respiratory distress. has a history of “throat tumor when she was 9. had lots of radiation to her neck at that time. they told us never to let anyone intubate… Read more »
More just for fun than on topic. Being an ace is not for surviving dog fights, but rather for shooting down an enemy aircraft. David Grossman talks about this in On Combat. It is more than just experience, it also involves certain psychological traits and a lack of some normal inhibition. Plus, the right kind of experience, success tends to breed success, while failure can lead to fear and more failure. Ground combat has shown that training can overcome the psychological inhibition and drastically improve the lethality of ground forces. With few exceptions, we don’t rise to the occasion, we… Read more »