Trans-tracheal catheter FONA

The technique for placing this type of trans-tracheal catheter is as follows:

1. Position the patient

Head and neck should be extended or even hyper-extended to reveal as much of the anterior neck as possible. In practice this means removing any support/ pillow from under the head.

2. Position yourself

If you are right-handed, stand at the patient's left schoulder. If you are left-handed, vice versa. The non-dominant hand palpates the anatomy and identifies the cricothyroid membrane, the dominant hand cannulates.

3. Open and prepare the kit

Fill a 5 ml syringe with 2 ml of saline. Connect the trans-tracheal cannula to the syringe.

4. Identify cricothyroid membrane

Palpate with your non-dominant hand. We suggest to start palpating at the sternal notch with your thumb and index finger, and move upwards along the tracheal rings until the cricoid cartilage is encountered. The 'ditch' above the cricoid cartical is the CTM. Keep your fingers spread slightly to 'fix' the larynx in the midline and keep the CTM between your fingers.  This maneuver has been described as the 'laryngeal handshake'. Don't move your hand for step 5.

5. Cannulate the trachea

With your dominant hand, start cannulating slightly angled towards the feet under constant gentle aspiration. The bevel opening of the needle should face caudad.

6. Advancing trans-tracheal catheter into trachea

Once you can aspirate air freely, release your palpating non-dominant hand and use it to advance the catheter off the needle into the trachea all the way to the hub. You should not encounter any significant resistance. Now pull out the needle.

6. Confirm correct position

Connect the syringe to the inserted trans-tracheal cannula and check for free air aspiration one more time.

8. Start oxygenation

Start delivering oxygen using one of the device options below. It is very important to fix the catheter with your hand. An unsecured catheter will 'fly' out of the patient if high-pressure oxygen is applied (especially with the Enk oxygen flow modulator or a jet ventilator).

• Enk oxygen flow modulator: Make the connection between Enk oxygen flow modulator and the Luer connector of the trans-tracheal cannula as described on the FONA (front-of-neck airway) equipment page. Select a high flow of >15 l/min at the O2 outlet (i.e. open it all the way). Create inspiratory flow through the device by (varying degrees of) thumb occlusion.
• (Manual) jet ventilator: Manual jet ventilation os decribed on a separate page.
• Self-inflating/ Ambu® bag: Make the connection between the self-inflating bag and the Luer connector of the trans-tracheal cannula using one of the methods described on the FONA (front-of-neck airway) equipment page. Bag-ventilate through the cannula. Note that resistance to airflow will be high, so a longer inspiratory time will be needed to deliver a meaningful tidal volume.

NOTE: With transtracheal catheters/ all small-bore FONA devices, expiration occurs through the upper airway, not the device!

We do not discuss 'home-built' equipment for oxygenation through a trans-tracheal cannula here for the reasons outlined on the FONA (front-of-neck airway) equipment page.