Catheter-over-needle cricothyrotomy (CONC) and using percutaneous jet ventilation (PCJV), is a front-of-neck airway (FONA) technique that can be lifesaving when conventional airway methods fail. Airway emergencies are urgent, high-stakes events that require both technical skill and decisive leadership. Failure to secure oxygenation can quickly lead to hypoxia, brain injury, cardiac arrest, or death. The priority is not simply intubation; it is maintaining oxygenation, mobilizing the team, and escalating promptly when the initial plan fails.

This article uses the case to discuss a practical emergency workflow: define PCJV, decide when it is appropriate, recognize contraindications, place and confirm the catheter, ventilate safely, monitor for complications, and coordinate the team while definitive airway management continues. It will not discuss specific cricothyrotomy kit use.

Author’s Note: This post was originally published in October 2015 as “Don’t Be Afraid to Use Percutaneous Jet Ventilation” and has been completely revamped and updated for accuracy and comprehensiveness.

Case: Lost Airway With Front of Neck Airway (FONA)

Clinical Situation

Dr. E induced anesthesia for a 40-year-old male scheduled for knee arthroscopy. The patient was 6 feet tall with a BMI of 50. The initial plan was to maintain anesthesia with sevoflurane through an LMA, but the LMA would not seat properly. Dr. E attempted mask ventilation before trying another airway approach, but he was unable to ventilate. He then attempted intubation, but he could not visualize the larynx with either a MAC 4 or Miller 3 blade. The patient’s oxygen saturation fell rapidly from 98% to 50%, and the pulse decreased from 70 to 35.

Team Response

The room crew had been focused on case preparation and casual conversation, so they were unaware that the airway was becoming critical. Dr. E then loudly declared a Can’t Intubate Can’t Ventilate emergency. He directed the OR nurse to assist him and asked the OR tech to break scrub and bring the difficult airway cart. He proceeded with a front-of-neck airway using a catheter-over-needle device.

Front-of-Neck Airway Steps

1. Position the patient supine, extended the neck, and quickly prep the skin with an alcohol pad.
2. Identify the cricothyroid membrane between the thyroid cartilage and cricoid ring.
3. Select the largest appropriate catheter available that can attach securely to a syringe and allow air aspiration — in this case a 14 g.
4. Attach a 5–10 ml syringe containing 3-5 ml of saline to the catheter hub before insertion.
5. Insert the needle through the lower third of the cricothyroid membrane while aiming slightly caudad and aspirating continuously.
6. Confirm tracheal entry by observing air bubbles in the saline, then advanc the catheter off the needle while stabilizing the hub.
7. Reconfirm free air aspiration after placement before connecting the jet ventilator.
8. Keep the hub stable and confirm that the catheter is not kinked or obstructed. Monitored chest movement after administering a 4-second burst of oxygen. Stop if chest movement is absent or subcutaneous emphysema is noted.
9. Allow the patient to exhale fully between oxygen bursts.

Outcome

The patient’s oxygen saturation quickly improved from 40% to 98%, and his pulse rose into the 80s. As Dr. E woke the patient, he continued jet ventilation until the patient was breathing adequately on his own. He and the nurse watched for subcutaneous emphysema, which could have indicated catheter displacement. Once the patient was awake, Dr. E explained what had happened, and they postponed surgery to another day when fiberoptic intubation could be planned.

Learning Point

The crisis worsened because Dr. E had not planned for a difficult airway and assumed the LMA would prevent airway problems. Even after switching to intubation, he did not alert the team early. Because the team was not closely monitoring the airway management, they were caught off guard when he finally declared the emergency after the patient had already begun to decompensate.

Once the crisis was recognized, Dr. E led the team decisively. He sent the OR tech for the difficult airway cart and kept the OR nurse at his side, where she could provide the most useful support. Instead of continuing repeated ventilation or intubation attempts, he moved immediately to a FONA and rapidly rescued the patient from likely imminent cardiac arrest.

What Is Percutaneous Jet Ventilation?

Catheter-Over-Needle Cricothyrotomy (CONC): Refers to the anatomical placement of the small over-the-needle intravenous catheter through the cricothyroid membrane.

Percutaneous Jet Ventilation (PCJV) or Percutaneous Transtracheal Jet Ventilation (PTJV): Refers specifically to the high-pressure gas delivery method used to push oxygen through that catheter.

Percutaneous jet ventilation delivers rapid, high-pressure bursts of oxygen through a small airway catheter or cannula inserted through the skin, without the need for a traditional cuffed endotracheal tube. Percutaneous catheter-over-needle oxygenation may also be used electively during head and neck procedures. This article focuses only on emergency use.

Role of PCJV in a CICV Crisis

During a CICV crisis, percutaneous catheter jet ventilation (PCJV) can rapidly oxygenate a patient with an obstructed airway, often faster than establishing a surgical airway. This can buy critical time to secure definitive airway access, such as intubation or a surgical airway. For this reason, all providers should understand when and how to use PCJV.

Oxygenation Is the Priority!

The most important factor in preventing anoxic brain injury is how quickly effective oxygenation is restored—not how quickly a definitive airway is placed.

Why Rapid Action Matters

Airway loss is one of the leading causes of injury and death in the ASA Closed Claims database. Half of perioperative airway-related claims—and all claims from other settings—involved death or brain injury. Although CICV events are uncommon, occurring in about 1 in 10,000 to 1 in 50,000 general anesthetics, they are immediately life-threatening.

With an estimated 20 million intubations performed each year in the United States, this incidence represents roughly 500 to 2,500 potential CICV events annually. Emergency surgical airway occurs in about 1 in 50,000 cases but accounts for up to 25% of anesthesia-related deaths—approximately 500 cases and 125 deaths each year.

Barriers to Timely Use

Closed claims analyses and published reports show that front-of-neck access is often delayed. PCJV is commonly positioned late in failed-airway algorithms, likely because of its rare but serious risks. If the catheter is not correctly placed in the trachea, PCJV can worsen airway obstruction or contribute to cardiovascular collapse. Fear, limited experience, and unfamiliar equipment may also cause clinicians to hesitate or overlook PCJV during an emergency.

Indications For Percutaneous Jet Ventilation

PCJV is an emergency oxygenation technique to consider when conventional approaches have failed or are not possible, and when delaying oxygenation would place the patient at greater risk than proceeding. Because percutaneous transtracheal jet ventilation carries rare but potentially life-threatening risks, it should be reserved for situations in which oxygenation cannot be maintained by safer conventional methods.

• Can’t intubate, can’t ventilate
• Severe maxillo facial trauma
• Bleeding in the upper airway that obscures your ability to see anatomy
• Severe swelling/edema
• Chemical or thermal burns
• Surgical airway of choice for children younger than 12 years of age (due to the small airway and increased risk of laryngeal injury with cricothyrotomy)
• Diagnostic or surgical laryngoscopy requiring good exposure of the larynx, continuous control of airway patency, and immobility of the vocal cords where elective tracheostomy is not a good option. In this case usually high frequency jet ventilation is used rather than manual jet ventilation.(1)

Contraindications For Percutaneous Jet Ventilation

Because of the risk of pneumothorax and subcutaneous or mediastinal emphysema, jet ventilation should not be used when you are able to secure the airway using more conventional and non-invasive means. In addition, it should not be used if there is:

• Damage to the trachea or tracheal rupture: pressurized air would escape into the soft tissues
• Severe obstruction of the airway above the cricothyroid membrane: patient would be unable to exhale and risk of pneumothorax would increase

Relative Contraindications For Percutaneous Jet Ventilation

• Bleeding diathesis
• Inability to identify cricothyroid landmarks: increased possibility of misplacing the catheter

Percutaneous Catheter-Over-Needle Insertion Technique

In an emergency, think of the procedure in five steps: prepare, insert, confirm, secure, and ventilate. The details below follow that order so the reader can move quickly from decision to action.

If you have time, and if the patient is conscious, provide analgesia by injecting lidocaine at the insertion site. At the same time, you can easily inject a little lidocaine into the lumen of the trachea to blunt the cough reflex. However, if severe hypoxia is present don’t wait to numb the skin. Act quickly.

Step 1: Prepare and Identify the Cricothyroid Membrane

The cricothyroid membrane is located between the thyroid cartilage above and the cricoid ring below.

The patient should be supine. If there is no risk of cervical spine injury, extend the head to expose the neck. Prep the skin.

Identify the cricothyroid membrane by finding the cricoid ring. The membrane lies in the gap between the ring and the thyroid cartilage above it. The membrane is about 1 cm high and 2 cm wide in the average adult. The vocal cords lie about 1 cm above the membrane in the adult. The blood vessels tend to overlie the upper third of the cricothyroid membrane. Make your puncture in the lower third to minimize the risk of hitting them.

Step 2: Choose the Largest Appropriate IV Catheter

Use the largest IV catheter appropriate for the patient, such as a 10 or 14-gauge catheter in adults and a smaller 16- or 18-gauge catheter in children. Any catheter-over-needle IV set can be used to puncture the cricothyroid membrane, provided the catheter hub can attach securely to a syringe for aspiration.

You must be able to freely aspirate air to ensure tracheal placement. Many standard IV catheters now include safety shields to prevent needlestick injuries and are not designed for syringe aspiration. Keep appropriate large-bore emergency catheters available separately from routine IV supplies. CVP trays contain all of the things needed for both PCJV, as well as cricothyrotomy. Commercial cricothyrotomy catheters are another option.

Step 3: Attach the Syringe and Confirm Air Aspiration

Attach a 5-10 ml syringe to the hub of the needle. A 5-ml syringe is easier to manage with one hand. The syringe should contain 3-5 ml of saline so that you can see air bubbles once you enter the trachea.

Step 4: Advance the Needle/Catheter Into the Trachea

Stand at the head of the bed and aim the needle slightly caudad at an angle of about 30-40 degrees. Aspirate continuously as you advance. Your insertion should be slow and deliberate to avoid puncture of the posterior tracheal wall. The diameter of the adult trachea averages 18 mm. As soon as you enter the tracheal lumen you will see bubbles in the saline as you aspirate air, verifying intratracheal placement.

After entering the trachea, advance the catheter off the needle. It should slide in easily. Hold the catheter by the hub to keep it stable. Keep your holding hand in contact with the neck so you do not accidentally pull it out of position.

Step 5: Verify, Secure, and Maintain Tracheal Placement

Once the catheter is placed, reattach the syringe to the catheter hub. Aspirate air again without resistance to confirm placement. Never skip confirmation that the catheter is in the tracheal lumen. Be sure the catheter is never kinked or obstructed by the tracheal wall. Jet ventilation against or into the wall can cause massive subcutaneous emphysema with severe airway distortion and obstruction.

Steady the catheter by the hub to ensure that it doesn’t move. Keep your fingers in contact with the neck while holding the hub to avoid accidentally pulling the catheter out of position.

If the catheter will remain in place beyond immediate rescue ventilation, tape the hub securely to the skin. Dedicated cricothyroidotomy catheters may include a flange that allows the catheter to be secured more reliably.

Critical Safety Checks Before Ventilation

• Confirm intratracheal placement by freely aspirating air before connecting any ventilation source.
• Keep the catheter hub stable and ensure the catheter is not kinked, obstructed, or pressed against the tracheal wall.
• Watch chest movement continuously and allow complete exhalation between jet bursts.
• Stop ventilating and reconfirm catheter placement if subcutaneous emphysema develops or placement becomes uncertain.

Ventilate Safely with a Percutaneous Jet Ventilator

To ventilate the patient, connect the catheter to a ventilation system. Because the catheter is narrow, a jet ventilator is usually the most effective way to deliver oxygen. A typical jet ventilator connects to a 50-psi oxygen source and lets you manually trigger controlled bursts of oxygen flow.

A regulator reduces the source pressure and lets you adjust the delivered pressure, which is displayed on a manometer. The device connects through a long pressure hose with a Luer-lock adaptor that attaches to the tracheal catheter. The example shown is from my operating room and illustrates components common to these devices. Become familiar with the jet ventilator used in your institution.

Jets can come with a variety of triggers. In this example the trigger is a squeeze lever. Other jets might have a button you can depress or a port that you can occlude with your thumb

You should set the highest amount of pressure to be delivered using the pressure regulator before starting to avoid barotrauma. You can always increase this if necessary.

What Pressures Should I Use To Ventilate?

Connect jet ventilator to oxygen source (via quick connect) and luer lock on the catheter. With the device connected, watch the patient’s chest as you trigger the oxygen flow by pressing the button. As you keep the trigger pressed for several seconds — and only several seconds — the chest wall will rise as the lungs inflate. A 4 second burst typically delivers 1 liter of air. Start at lower pressures and limit initial air bursts to 1-2 seconds to gauge chest expansion, then adjust.

Like a balloon filling from a helium tank, the lungs can inflate rapidly when gas enters under pressure. Stop oxygen flow once the chest rises adequately and monitor the pressure gauge. Let the patient exhale between air bursts!

• Adults: jet pressure starting at 20 psi, increased gradually until adequate chest rise and fall is noted, < 50 psi
• Children: jet pressure starting at 5-10 psi which is increased until adequate chest rise and fall is noted, <30 psi
• Rate: 20 bursts per minute.
• Insufflation should last approximately 1 second, and exhalation should be given 3-4 seconds.
• An adequate expiratory phase is important to minimize the risk of barotrauma.

Careful eye-hand coordination is essential: watch the chest deflate fully before delivering the next insufflation.

Allow The Patient To Exhale!

Allow the lungs to deflate fully before delivering the next jet burst.

Because the catheter is too small for exhalation, the airway above the cricothyroid membrane must always remain at least partially open. Airway obstruction may occur simply if the airway is not held open.

If the patient cannot exhale, or is not given enough time to exhale, tension pneumothorax can occur. Do not press the trigger unless you are watching the patient’s chest!

Securing the Catheter

Securing the catheter while in use is important. If the catheter migrates out of the trachea, then misplacement of the catheter can lead to subcutaneous emphysema and loss of the airway. The person holding the catheter must ensure that the catheter does not kink or slip out of position.

For more prolonged use you can securely tape the hub into contact with the skin. Dedicated cricthyroidotomy catheters typically have a flange on the hub to allow securing the catheter.

Resource Videos: Jet Ventilation Technique

Transtracheal Jet Ventilation: Cadaver Model

Percutaneous Transtracheal Jet Ventilation

Potential Complications

Jet ventilation can be lifesaving. However, you must be vigilant when using jet ventilation because of the potential for serious complications such as:

• hematoma, bleeding
• subcutaneous emphysema (which potential further airway compromise)
• barotrauma (such as pneumothorax from inadequate exhalation)
• catheter kinking/obstruction
• esophageal perforation
• pulmonary aspiration

During PCJV, the catheter must be inside the trachea, not in the surrounding soft tissue. Mild subcutaneous emphysema may occur, especially after multiple puncture attempts, but high-pressure gas delivered into soft tissue can cause severe subcutaneous emphysema and possible mediastinal emphysema. Mediastinal emphysema can impair venous return and reduce cardiac output. If placement is uncertain, stop ventilating and reconfirm that the catheter is intratracheal before continuing.

Teamwork During Ongoing Intubation Attempts

Percutaneous jet ventilation can support oxygenation while intubation attempts continue. The person operating the jet must watch chest movement and vital signs, allowing the intubator to focus on securing a definitive airway. This requires clear communication and coordinated teamwork.

One study found two key benefits when PTJV was used successfully during ongoing intubation attempts. It maintained effective oxygenation while allowing time to visualize the upper airway and suction oropharyngeal secretions. It also made subsequent tracheal intubation easier, possibly because gas insufflation increased tracheal pressure and opened a collapsed glottis (2).

Pitfalls with needle cricothyroidotomy and Melker kits in CICO crises

If a Jet Ventilator Is Not Available

Using the Anesthesia Machine Oxygen Flush Valve

Depending on the anesthesia machine model, the oxygen flush valve delivers approximately 35–75 psi. A catheter-over-needle cricothyrotomy (CONC) can be connected to the anesthesia circuit using commonly available operating room supplies, allowing use of the flush valve to substitute for the jet.

One option is to place the connector from a size 3 endotracheal tube into the hub of an intravenous catheter. Although this creates a snug fit, the assembly is small and can be difficult to hold while squeezing the bag.

A more secure setup is to insert the connector from a size 7–7.5 endotracheal tube into the barrel of a 3 mL syringe. The syringe barrel then connects to the catheter hub, providing a larger, more stable handhold once the percutaneous catheter is positioned in the trachea.

Another option is to place an endotracheal tube inside the barrel of a 10 mL syringe and inflate the cuff to help maintain the connection.

Using a Manual Ventilation Bag

If a jet ventilator is unavailable—or if peak pressure must be limited in an infant or small child—ventilation can still be assisted through the catheter. Although this approach is not ideal, reports suggest that some patients may breathe spontaneously for several minutes through a 10-gauge catheter.

Regardless of the connector used, ventilation must be forceful enough to deliver adequate oxygen through the catheter. Expect gas to escape through the mouth.

You can also place an endotracheal tube within the barrel of a ten ml syringe and inflate the cuff to maintain the connection.

No matter which connector you use, you must ventilate vigorously to pass enough oxygen through the catheter. Gas will escape through the mouth.

For video of how to ventilate through the cricothyroid membrane using a needle over catheter and a ventilation bag see: How To: MacGyver a Jet Insufflation/Ventilation Setup with Homemade Cric Trainer Note: This video demonstration simplifies the procedure by omitting confirmation that the catheter is in the trachea. This step is essential; always verify placement.

Note: Hypercarbia Will Develop Without A Jet Ventilator

Although hypoxia is avoided with any of these non-jet ventilator techniques, hypercarbia will develop. This can cause significant respiratory acidosis if use of these techniques is prolonged. However, any oxygen supplied during emergency treatment of airway obstruction is useful.

Percutaneous jet ventilation is a lifesaving skill for anyone involved in advanced airway management. Although you may never need to perform it, you should know how it works and be familiar with the equipment used for percutaneous transtracheal jet ventilation. Your team must also be familiar with the equipment and how to assist you.

In an emergency, this preparation can help you recognize PCJV as an option and feel ready to use it. When assisting during a respiratory crisis, speak up and suggest it when appropriate. Remember, prioritize oxygenation, don’t fixate on the definitive airway.

For more on managing the difficult airway and how to avoid such events see:

10 Rules for Approaching Difficult Intubation, Always Prepare for Failure

Summary

• Oxygenation is the priority in a failed-airway emergency. In a can’t intubate, can’t ventilate crisis, the urgent goal is restoring oxygen delivery—not simply achieving intubation.
• Percutaneous jet ventilation can buy critical time. PCJV may rapidly oxygenate a patient through front-of-neck access while the team continues efforts to establish a definitive airway or awaken the patient.
• PCJV should be reserved for emergency situations when conventional ventilation fails or is not possible. It carries serious risks and should not be used when safer, noninvasive airway options remain available.
• Correct catheter placement is essential. The catheter must be intratracheal, confirmed by freely aspirating air before ventilation begins and reconfirmed if placement is uncertain.
• Use the largest appropriate catheter and secure it carefully. A stable, patent catheter helps reduce the risk of kinking, dislodgment, obstruction, and soft-tissue insufflation.
• Jet ventilation requires short bursts and full exhalation. Watch chest rise, allow the chest to deflate completely between bursts, and avoid excessive pressure to reduce the risk of barotrauma.
• The upper airway must allow exhalation. If the patient cannot exhale adequately, tension pneumothorax and cardiovascular collapse can occur.
• Subcutaneous emphysema is a warning sign. It may indicate catheter displacement or gas delivery into soft tissue; ventilation should stop until catheter placement is confirmed.
• Team coordination is critical. One clinician should focus on operating the jet and monitoring ventilation while others continue definitive airway management.
• Alternative oxygen-delivery setups may help when a jet ventilator is unavailable, but they are less ideal. Non-jet methods may support oxygenation temporarily but can lead to hypercarbia if prolonged

May The Force Be With You

Christine E. Whitten MD, author:

Anyone Can Intubate: A Step-by-Step Guide, 5th Edition
Pediatric Airway Management: A Step-by-Step Guide
Basic Airway Management: A Step-by-Step Guide

Further Reading

1. L. Bourgain, E. Desruennes, M. Fischler, P. Ravussin. Transtracheal high frequency jet ventilation for endoscopic airway surgery: a multicentre study. Br. J. Anaesth. (2001) 87 (6): 870-875
2. Patel RG .Percutaneous transtracheal jet ventilation: a safe, quick, and temporary way to provide oxygenation and ventilation when conventional methods are unsuccessful. Chest. 1999 Dec;116(6):1689-94.
3. Dhoon TJ, Shah D, Villaluz E, Rajan G. Preventing Anoxic Brain Injury During Airway Emergencies: Rapid Oxygen Insufflation Through Catheter-Over-Needle Cricothyrotomy.Anesthesiology News. (2026). Anesthesiology News. Anesthesiologynews.Com. https://www.anesthesiologynews.com/a/vjsbaa