My approach would be to just Keep It Simple:

scalpel to cricothyroid membrane, maintain control of the newly-created cricothyrotomy, pass gum-elastic bougie and rail-road a 6.5 ETT over the top.

Most evidence I have looked at suggests that a needle cricothyrotomy and gas insufflation will at best buy you 10 minutes of oxygenation - while this might be very useful 'breathing space' my preference would be to establish a more definitive airway early.

Bougie-cricothyroidotomy has even been done in complete darkness: Three-step emergency cricothyroidotomy (Mil Med 2007).

Flint, Russell and Thompson (BJA 2009) showed that for needle/cannula cricothyroidotomy, anything less than a purpose-built jet ventilation system (in their case the 'Manujet') does not deliver adequate minute ventilation.

They investigated 20, 16, 14 & 13 guage cannula coupled with a "... ENK oxygen flow modulator, a Manujet, a self-inflating resuscitation bag, the oxygen flush of an anaesthetic machine, and oxygen from a wall-mounted flow meter attached via a three-way tap to the cannula."

"Extrapolated to the clinical situation, these data suggest that low-pressure devices will not deliver adequate MVs via a cannula cricothroidotomy and should no longer be advocated. Purpose-made devices should be available in all areas where anaesthesia is administered or airway interventions are performed."

Flint NJ, Russell WC, Thompson JP. Comparison of different methods of ventilation via cannula cricothyroidotomy in a trachea-lung model. Br J Anaesth. 2009 Dec;103(6):891-5.

Mariappa and colleagues recently compared three common cricothyroidotomy kits on porcine airways: the standard scalpel technique (as Naomi describes), the Cook Melker Cricothyrotomy Kit and the Portex Cricothyroidotomy Kit.

The Cook Melker kit stood out as the clear winner, achieving a successful airway in 100% cases (versus 55% & 30% for scalpel & Portex kit respectively), and causing no airway injury (versus 20% & 55% respectively). Time to achieve successful airway was similar for all three techniques.

• Mariappa V, et al. Cricothyroidotomy: comparison of three different techniques on a porcine airway. Anaesth Int Care. 37(6) 2009.

Scrase and Woollard performed a review (2006) comparing cannula circothyroidotomy using a low pressure system, with cannula and jet ventilator, or surgical airway with self-inflating bag.

Their review shows that cannula ventilation methods, even with a jet ventilator, are often inadequate due to limitation of expiration if there is significant upper airway obstruction. At one extreme cannula ventilation becomes "...totally inadequate within 60 s if a low pressure (15 L/min) self-assembled ventilation system is used."

"Needle cricothyroidotomy can only be used as an effective ventilation strategy if combined with a jet ventilator. Even then, the risk of barotrauma associated with air trapping must be considered in the presence of a high degree of upper airway obstruction, ruling out the universal appli- cation of needle cricothyroidotomy as an airway rescue method of last resort. In contrast, the surgical airway provides effective ventilation at lower (safer) pressures regardless of the degree of restriction of the upper airway."

Scrase I, Woollard M. Needle vs surgical cricothyroidotomy: a short cut to effective ventilation. Anaesthesia. 2006 Oct;61(10):962-74.

One of my colleague's, an army reservist anesthetist, has had the (mis)fortune of having performed four emergency cricothyroidotomies in his consultant career. This has given him quite the reputation as the go-to-guy for emergency airway problems!

In his practice he moves straight away to a definitive airway rather than a needle cricothyroidotomy. His technique is simple:

1. Scalpel cut horizontally across the membrane.
2. Single stab down into airway.
3. Reverse scalpel, place handle into incision and rotate 90^o to hold lumen open.
4. Pass a small ETT (6.0-6.5).

Personally I would feel more comfortable oxygenating with a needle cric' first, and then using a formal kit - however his confidence and decisiveness highlight the advantage of experience when managing critical scenarios that most of us will see infrequently in our careers.

Having practised all of these methods recently (at a simulation day, I'm not that unlucky), I have to say this what I would do first (It is a modification of the technique Naomi has described above):

1. Scalpel stab horizontally into the airway (if you can find the cricothyroid membrane, that's great)
2. Keeping the scalpel in place, rotate it 90 degrees to oopen up a little triangular flap/hole.
3. Pass a bougie past the blade
4. Railroad your tube over the bougie.

http://www.youtube.com/watch?v=TveIsbjmakU

If you are lucky enough to have a frova at hand, I would jet ventilate down it as shown in the video. In my limited experience, a CICV situation only ever arises when you can't get hold of a roomful of helpers immediately.

The key points are :use a fat-bladed scalpel (a 10 or 20 is ideal) :leave the scalpel in place so that you don't 'lose' your hole in all that blood :rotate, rotate, rotate the tube (it will be a tight fit.).

It is simple and efficient. I have seen surgeons performing an emergency cric the way it is taught in EMST, and it was a bloody mess (not a "jolly mess" but a real, sanguine mess).

The jet ventilation even using a properly designed manujet is slow: you can probably give only a few breaths a minute, as the exhalation period is so slow via the cannula. It is probably even worse through the Frova bougie because of its length.

I hope I won't ever have to use it in real life, but I think going to a difficult airway simulation session is gold.