Cricothyroidotomy for definitive airway management:

- 1) Many medics and other providers operating independently in far-forward environments are trained to use cricothyroidotomy as their primary definitive airway. While the use of a surgical airway first line is appropriate in patients presenting in-extremis or with the loss of an airway (e.g., severely injured trauma patients with facial or neck trauma), patients with COVID-19 generally present with gradually progressive symptoms and intact native airways.
- 2) Early intra-theater transfer to a facility with advanced capabilities is preferable to early cricothyroidotomy whenever possible.
- 3) Laryngeal mask airway or other supraglottic airway placement may be a sufficient bridge to definitive airway placement. Placement of a mask over the LMA (hole cut in the middle of the mask for the LMA) will minimize aerosol spread from any air leak. PEEP above 10 cm H2O via LMA may not be effective and may exacerbate any leak around the LMA. Sedation and analgesic requirements for an LMA may be slightly more than with a cricothyroidotomy.
- 4) Cricothyroidotomy without the ability to provide mechanical ventilation consumes significant resources (manpower required to bag-ventilate the patient with PEEP, inefficient delivery of oxygen via bag-ventilation, and significant aerosol risk to those providing care).