Success and Time to Oxygen Delivery for Scalpel-Finger-Cannula and Scalpel-Finger-Bougie Front-of-Neck Access: A Randomized Crossover Study With a Simulated "Can't Intubate, Can't Oxygenate" Scenario in a Manikin Model With Impalpable Neck Anatomy

Anesth Analg. 2022 Aug 1;135(2):376-384. doi: 10.1213/ANE.0000000000005969. Epub 2022 Mar 4.


Background: Emergency front-of-neck access (FONA) is particularly challenging with impalpable neck anatomy. We compared 2 techniques that are based on a vertical midline neck incision, followed by finger dissection and then either a cannula or scalpel puncture to the cricothyroid membrane.

Methods: A manikin simulation scenario of impalpable neck anatomy and bleeding was created. Sixty-five anesthesiologists undergoing cricothyrotomy training performed scalpel-finger-cannula (SFC) and scalpel-finger-bougie (SFB) cricothyrotomy in random order. Primary outcomes were time to oxygen delivery and first-attempt success; data were analyzed using multilevel mixed-effects models.

Results: SFC was associated with a shorter time to oxygen delivery on univariate (median time difference, -61.5 s; 95% confidence interval [CI], -84.7 to -38.3; P < .001) and multivariable (mean time difference, -62.1 s; 95% CI, -83.2 to -41.0; P < .001) analyses. Higher first-attempt success was reported with SFC than SFB (47 of 65 [72.3%] vs 18 of 65 [27.7%]). Participants also had higher odds at achieving first-attempt success with SFC than SFB (odds ratio [OR], 10.7; 95% CI, 3.3-35.0; P < .001). Successful delivery of oxygen after the "can't intubate, can't oxygenate" (CICO) declaration within 3 attempts and 180 seconds was higher (84.6% vs 63.1%) and more likely with SFC (OR, 5.59; 95% CI, 1.7-18.9; P = .006). Analyzing successful cases only, SFC achieved a shorter time to oxygen delivery (mean time difference, -24.9 s; 95% CI, -37.8 to -12.0; P < .001), but a longer time to cuffed tube insertion (mean time difference, +56.0 s; 95% CI, 39.0-73.0; P < .001). After simulation training, most participants preferred SFC in patients with impalpable neck anatomy (75.3% vs 24.6%).

Conclusions: In a manikin simulation of impalpable neck anatomy and bleeding, the SFC approach demonstrated superior performance in oxygen delivery and was also the preferred technique of the majority of study participants. Our study findings support the use of a cannula-based FONA technique for achieving oxygenation in a CICO situation, with the prerequisite that appropriate training and equipment are available.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Airway Management* / methods
  • Cannula*
  • Cricoid Cartilage / surgery
  • Cross-Over Studies
  • Humans
  • Intubation, Intratracheal
  • Manikins
  • Oxygen


  • Oxygen