maintains its anatomical functions, and identication of the cricothyroid membrane indicates the site of the cutaneous incision. The incision is made in the vertical direc­tion, extending about 3–5 cm on the midline, thus avoiding vascular structures located laterally (Fig.6). The cricothyroid membrane is sectioned for 1cm horizon­tally because its extension is greater than its height, allowing adequate separation of the thyroid and cricoid cartilages, which should be done without excessive force to avoid risk of injury to the vocal cords, located 1–2cm above. The index ngertip of the nondominant hand should be kept within the cricothyroid membrane incision in order not to lose it. If it is difcult to maintain laryngeal immobilization due to obe­sity, trauma, edema, or other causes, the scalpel can be held in position until a hook or a claw is positioned to pull the thyroid cartilage so there is no loss of the mem­brane opening. Insert a dilator or Kelly tweezers into the opening of the membrane to facilitate the introduction of the tracheostomy cannula. Remove the dilator or Kelly tweezers and hook or claw carefully to avoid damaging the cuff of the trache­ostomy cannula. Inate the cuff of the tracheostomy cannula and x it with a lace. Make a dressing with gauzes below the cannula aps to protect the skin.

The rapid 4-step technique can be performed in a short time and requires only a scalpel with a number11 or 15 blade, a traction hook or claw, and a tracheostomy cannula. It begins with palpation and identication of the cricothyroid membrane, followed by a horizontal incision extending about 2cm, involving the skin, subcu­taneous cellular tissue, and cricothyroid membrane. Before removal of the scalpel, insert the hook or the claw to pull the thyroid cartilage, which will help immobilize the larynx, allowing introduction of the tracheostomy cannula (Fig.7). This can be assisted with an intubation cannula introducer (called a “bougie”), which will serve as a guide. This technique greatly reduces the surgical time, and its procedure is simpler than the standard technique [17] (Fig.8).

The time and success of a cricothyroidostomy procedure depend on the tech­nique used, the patient, and the experience of the physician. Studies on cricothy­roidostomy techniques are limited due to the absence of randomized clinical protocols, and the current literature is based on reports of cadaver or animal studies, with conicting ndings. Thus, the best technique and the best clinical circum­stances are still unknown. An observational study reported that experienced physi­cians needed an average of 73s (ranging from 53 to 255 s), while inexperienced ones required an average of 180s to complete cricothyroidostomy with the standard technique in unxed corpses. Studies using unxed corpses have demonstrated an 88% success rate in performing cricothyroidostomy with the standard technique and with the rapid 4-step technique, but the latter was faster, taking an average time of