Airway Obstruction and Tracheotomy

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CPR classes are important for everyone to take, but standard chest compressions and breaths are most helpful in normal times, when there are ICUs and respirators readily available. One thing  CPR class teaches you that does have relevance to off-grid survival is how to deal with an airway obstruction.

An airway obstruction may happen for several reasons, but most commonly occurs as a result of food lodging in the back of the throat. This blockage, if complete, cuts off respiration and is life-threatening, but  can be treated successfully with knowledge and limited supplies. Early diagnosis and quick action is the key.

Some signs of an airway obstruction are:
• Difficulty breathing
• Noisy breathing, sometimes called “stridor“.
• Inability to talk; you need air to speak.
• Inability to cough for the same reason.
• The patient’s skin turning blue (called “cyanosis,” which is due to lack of oxygen circulating in the blood)
• Decreasing level of consciousness as oxygen levels drop.

cyanosis around the mouth

Photo by Jim Bryson

If you see a conscious adult in sudden respiratory distress, ask quickly: Are you choking? If they can answer you, there is still air passing into their lungs. If it’s a complete blockage, they will be unable to speak. They’ll be clearly agitated and holding their throat, but they’ll hear you and (frantically) nod their head “yes”. This is your signal to act.

Heimlich Maneuver

So what should you do for an adult in this situation? Quickly tell the victim that you’re there to help them and immediately get into position for the Heimlich maneuver, otherwise known as an “abdominal thrust”. Get behind the victim and make a fist with your right hand. Place your fist above the belly button and below the breastbone (also called the sternum); then, wrap your left arm around the patient and grasp the fist. Make sure your arms are positioned just below the rib cage. With a forceful upward motion, thrust your fist abruptly into the abdomen. You might have to do this multiple times before you dislodge the foreign body.

In old movies, you might see someone slap the victim hard on the back; this is not as likely to dislodge a foreign object as the abdominal thrust and might waste precious time. If you have to use a blow to the back. do it right in the center of the upper back with the victim bent over so that the torso is parallel to the ground. In this way, gravity might help the foreign object drop out of the mouth. Back blows are considered more effective in an infant: place the baby over your forearm (facing down) as if holding a football and apply several blows with the heel of your hand to the upper back.


If your patient loses consciousness and you are unable to dislodge the obstructive item, place the victim flat on their back and straddle them across the hips. Open their mouth and make sure that the object can’t be removed manually. If not, give several, say five, upward abdominal thrusts with the heels of your palms (one above the other) and check the oral cavity again; you might have partially dislodged the foreign object.

If abdominal thrusts fail in a person that is unconscious, you may have to resort to more extreme measures to save that person’s life. It’s important to realize that the person is unconscious due to oxygen deprivation, and further delay may lead to brain damage or death.


An extreme method that can be used to open an airway is the “tracheotomy”. This procedure, also called a cricothyroidotomy, involves cutting an opening in the windpipe below the level of an obstruction. Tracheotomy should be performed only when an airway obstruction completely prevents the ability to breathe and all other methods have proved unsuccessful.

To perform a tracheotomy, you will need a sharp blade and some sort of tube, such as a firm plastic straw. Of course, a good first aid kit is always good to have, but there might not be time for antiseptics; you are performing this procedure because someone becoming cyanotic and will die in the next few minutes.

(Aside: It should be noted that there are syringe sets manufactured for this purpose available by prescription and a number of improvisations that also exist.)

In austere settings, the procedure goes as follows:

Place a towel under the shoulders. This will tilt the head into a position that makes it easier to define structures.

Start at the Adam’s apple, also known as the laryngeal prominence, on the front of the neck. It’s seen easily in men, less so in women. Move about 1 inch down the windpipe until you feel a second bulge. This is the cricoid cartilage.

Make a vertical incision through the skin with your knife or a razor blade in the crease between the laryngeal prominence and the cricoid cartilage. This incision can be about an inch or so long, and is superior (in my opinion) to a horizontal incision in that it can be extended upwards or downwards in case you entered the skin at the wrong location. A vertical incision will also avoid cutting nerves on either side that help control speaking and swallowing.

A curved Kelly clamp or a finger could be used to stretch the skin incision for better visualization of the structures beneath. Separate the tissue underneath and you’ll find the greyish cricothyroid membrane. Make a horizontal incision through it no more than half an inch deep. Once opened, there may be a audible rush of air or a “pop” as the incision is made.

It should be noted that some make a vertical or cross-shaped incision below this level to make a larger opening through more of the windpipe. It’s harder, however, to cut through cartilage than membrane. In any case, the incision should allow passage of air into the lungs.

tracheotomy from zuidelma 1985
tracheotomy incision illustration from Zuidema et al 1985

Be careful not to cut too deeply or widely into the membrane. Much more than 1/2 inch deep and you may penetrate the back of the airway, cutting the esophagus underneath the windpipe and trapping air in the soft tissues of the neck. The base of the scalpel can be used to make the slit opening larger. Don’t remove your scalpel from the incision until you’ve placed an open tube in the trachea. There normally isn’t a great deal of blood with this procedure and should be controllable with direct pressure.

To maintain a clear airway, place something hollow in the opening. A “trach” tube would be great, but a plastic straw might do in a pinch. Thread it 1-2 inches down the windpipe; doing this makes it less likely to fall out (commercially-made tubes can be tied around the neck to secure it in place).
If the patient fails to breathe on their own despite a successful tracheotomy, you may need to perform CPR rescue breaths through the tube you inserted.

I don’t have to tell you that this is a difficult and dangerous procedure. A lot can go wrong and your equipment will likely be inferior to what is really needed. Remember, however, that the patient is dying and is already unconscious from lack of oxygen; it may be your last resort.

Only consider performing a tracheotomy when help is not forthcoming and you have tried every other option first. Even a successful emergency tracheotomy is only good for a short period of time before a more permanent solution is needed. You’ll need a system to keep the opening clear of mucus, etc. That’s only one of the hard realities that the medic must face in times of trouble.

Final Note: For those that aren’t acquainted with my work, I focus on what to do when there are no modern medical personnel or facilities available, as in a wilderness or survival setting. In normal times, seek modern and standard medical care whenever and wherever it exists.)

Joe Alton, MD


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