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Emergency Front of Neck Airway: Overcoming the Challenges

What are the barriers to performing eFONA and how can they be overcome?​ Dr Kirstie McPherson, UCLH offers some answers and top tips.
Emergency Front Of Neck Airway Overcoming The Challenges

In the previous step we heard from clinicians who have performed or assisted in an emergency Front of Neck Airway (eFONA) situation. In this article, Dr Kirstie McPherson, Consultant Anaesthetist at UCLH describes some of the difficulties we need to overcome when faced with a “Can’t Intubate, Can’t Oxygenate” situation.

The authors of the NAP4 report asked two important questions when investigating complications of airway management in the United Kingdom:

  • What is the nature of the major airway complications that lead to serious harm or death?
  • What can we learn from them, in order to reduce their frequency and improve outcomes?
In Week 1 we learnt about Human Factors and Ergonomics, these contributed to adverse outcomes in 40% of the cases reported to NAP4. Common themes were identified when they analysed the reports of the patients who were harmed:

Delay in performing eFONA when facemask ventilation, supraglottic airway and tracheal intubation had failed.

The clinician’s reluctance to perform eFONA is a major contributor to morbidity and mortality in CICO situations [1].
It can be difficult to accept that attempts at oxygenation have failed, and this can delay the decision to take that final, invasive step and access the trachea through the front of the neck. Many factors contribute to a reluctance to perform eFONA, the most important are: lack of preparation and planning for failure, lack of training in skills and drills, lack of awareness or understanding of guidelines and cognitive aids, the effect of stress on performance, and equipment issues.

Lack of preparation and planning for failure

Fortunately, the “Can’t Intubate, Can’t Oxygenate” (CICO) emergency is rare. NAP4 estimated that it occurs with in 1 in 5,000 to 10,000 cases. Although it is uncommon, the consequences are often catastrophic, and CICO accounts for 25% of all anaesthesia-related deaths. In Step 2.2 we learned that it is important to carry out a thorough airway assessment to identify patients in whom bag mask ventilation, supraglottic airway insertion or tracheal intubation might be difficult. On the other hand, we know that airway assessment is sometimes unreliable and difficult airway management is often unanticipated[2].
This is why guidelines emphasise the importance of approaching every intervention with an airway strategy, a structured and organised plan that includes a plan for failure.

Lack of training in skills and drills

In NAP4, poor training and education was one of the commonest contributory causes to serious airway events. Clinicians must train and maintain skills for rare but life-threatening emergencies. We are hardly ever faced with these events on our own which is why we should train with our multi-disciplinary team. Decision-making, planning, preparation, and technical proficiency all improve with practice. Regular training in both technical and non-technical elements helps reinforce and retain skills which we don’t use routinely. In a crisis, cognitive overload makes it hard to make decisions; we are more likely to succeed if we follow a simple plan which we have rehearsed. Regular refresher training helps prevent skill fade.

Lack of shared understanding of guidelines and cognitive aids

Earlier in this week, we looked at the role of guidelines, algorithms and cognitive aids in airway management. The DAS Guidelines for unanticipated difficult intubation is a teaching and learning tool and the Vortex Approach is a simple cognitive aid designed to be used in a crisis, and also in training for crisis, team work and human factors are improved if everyone shares the same plan.


When a CICO situation arises, hypoxia develops rapidly, and will ultimately lead to cardiac arrest and death. As you can imagine, this is a very stressful situation and it may be hard to make the decision to perform eFONA. When we are stressed it is difficult to perform even simple tasks, or to communicate effectively, this is called cognitive overload. Decision making, motor skills and peripheral vision decline, task fixation is common. Team based training to learn technical skills, to recognise an impending failure, and to feel able to speak up and declare a crisis, improve our ability to manage stressful situations.


Knowing where to find the equipment we need is vital in a time critical emergency. The location of eFONA kit should be standardised in every area where airway management is performed and it should be clearly signposted. eFONA packs, containing essential equipment and prompt cards are helpful. The DAS 2015 Guidelines recommend that all anaesthetists learn a surgical cricothyroidotomy technique but some organisations choose a cannula technique as their initial approach. It’s important that local skills training and equipment reflects the preferred technique.

Do you feel prepared to perform eFONA? Do you know what equipment you would need and where to find it? Has anything been done in your workplace to make it easier to perform eFONA? Move to the next discussion step to share your thoughts and experiences of eFONA.


  1. Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the Difficult Airway: A Closed Claims Analysis. Anesthesiology 2005;103(1):33-39.
  2. Nørskov AK, Rosenstock CV, Wetterslev J, Astrup G, Afshari A, Lundstrøm LH. Diagnostic accuracy of anaesthesiologists’ prediction of difficult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database. Anaesthesia 2015;70:272–81. 10.1111/anae.12955..
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