Anaesthesia
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A - ANZCA Guidelines Evidence

Difficult Ventilation - Can't Intubate Can't Ventilate (CICV) Management

Immediate Recognition of Can't Intubate Can't Ventilate (CICV/CICO): Failed intubation: Multiple attempts unsuccessful Failed face mask ventilation: Cannot achieve chest movement, EtCO2, or SpO2 Failed SGA rescue:...

Updated 3 Feb 2026
30 min read
Citations
86 cited sources
Quality score
55 (gold)

Clinical board

A visual summary of the highest-yield teaching signals on this page.

Urgent signals

Safety-critical features pulled from the topic metadata.

  • Inability to achieve oxygenation despite multiple attempts at face mask ventilation
  • Failed intubation AND failed SGA insertion
  • Deteriorating SpO2 with inability to ventilate
  • No chest movement despite positive pressure

Exam focus

Current exam surfaces linked to this topic.

  • ANZCA Final Written
  • ANZCA Final Viva

Editorial and exam context

ANZCA Final Written
ANZCA Final Viva
Clinical reference article

Quick Answer

Immediate Recognition of Can't Intubate Can't Ventilate (CICV/CICO):

  • Failed intubation: Multiple attempts unsuccessful
  • Failed face mask ventilation: Cannot achieve chest movement, EtCO2, or SpO2
  • Failed SGA rescue: Cannot insert or ventilate via supraglottic airway
  • Deteriorating oxygenation: SpO2 falling despite attempts

Immediate Management (Vortex Approach / ANZCA Guidelines):

STEP 1: Optimise Face Mask Ventilation (30 seconds):

  1. Two-person technique (mandatory)
  2. Adjust head position (extension if not contraindicated)
  3. Oral/nasal airways (Guedel, nasopharyngeal)
  4. High-flow oxygen pre-oxygenation if available
  5. Different mask size/shape

STEP 2: Insert SGA (60 seconds):

  1. Insert supraglottic airway (i-gel, LMA Supreme/ProSeal)
  2. Confirm placement: Chest movement, EtCO2, SpO2
  3. If successful: Wake patient OR proceed with surgery via SGA
  4. If failed: Proceed immediately to next step

STEP 3: Front of Neck Access - FONA (Emergency Surgical Airway):

  1. Call for ENT/Thoracic/General surgeon (if immediately available)
  2. Position: Neck extended, head midline
  3. Scalpel-bougie-tube technique (ANZCA recommended):
    • Scalpel: Horizontal stab incision at cricothyroid membrane (CTM)
    • Bougie: Introduce through incision, angled caudally
    • Tube: Rail-road 6.0 cuffed ETT over bougie into trachea
  4. Confirm: EtCO2, bilateral chest movement, auscultation
  5. Secure: Tape firmly, chest X-ray

Critical Points:

  • Don't delay FONA trying repeatedly what has failed
  • No more than 3 attempts at any technique in CICV
  • Time critical: If SpO2 <80%, proceed immediately to FONA
  • Scalpel-bougie-tube preferred over needle cricothyrotomy

Indigenous Health Considerations

Difficult ventilation and CICV management present unique challenges for Aboriginal, Torres Strait Islander, and Māori populations, particularly regarding anatomical variations, remote health service delivery, and cultural safety during life-threatening airway emergencies. For Aboriginal and Torres Strait Islander peoples, higher rates of obesity (particularly central adiposity), obstructive sleep apnoea, and mandibular retrognathia may increase the incidence of difficult mask ventilation and difficult intubation. Limited access to pre-operative assessment in remote communities means high-risk airways may not be identified before emergency procedures, increasing CICV risk.

Remote and rural health considerations fundamentally impact CICV outcomes. Regional hospitals serving Indigenous populations may lack immediate availability of experienced anaesthetists trained in emergency surgical airway techniques. Scalpel-bougie-tube equipment must be immediately available in all locations performing airway management, including rural emergency departments and retrieval services. RFDS transfer teams require training in emergency FONA procedures, as prolonged transfer times may exceed safe apnea tolerance.

Cultural safety considerations are essential during CICV crisis management. Indigenous patients may have heightened anxiety about medical procedures due to historical trauma and institutional racism. Clear communication through Aboriginal Liaison Officers is critical when managing a CICV emergency, ensuring family understanding of the critical situation and the need for emergency surgical airway if required. The prospect of front-of-neck access can be particularly distressing for patients and families, requiring sensitive, rapid communication.

Māori health considerations in Aotearoa New Zealand include higher rates of obesity and OSA, contributing to difficult airway physiology. Whānau-centred care during airway emergencies requires rapid, clear communication with extended family about the severity of the situation. Māori Health Workers provide essential cultural brokerage during crisis situations. Access to karakia (prayers) and spiritual support during emergency procedures aligns with Te Tiriti o Waitangi obligations.

Healthcare providers must recognise the intersection of anatomical vulnerability and reduced access to advanced airway expertise in Indigenous populations. Regional centres must have robust difficult airway protocols with immediate access to FONA equipment, regular simulation training for CICV scenarios, and clear escalation pathways. Cultural protocols for managing airway emergencies should include family communication pathways, recognition of Indigenous healthcare rights, and access to pastoral/spiritual care during critical situations. The relatively simple equipment required for scalpel-bougie-tube technique makes it feasible for even small rural hospitals to maintain adequate resources for emergency FONA.

Clinical Overview

Definitions and Terminology

Can't Intubate Can't Ventilate (CICV) or Can't Intubate Can't Oxygenate (CICO) represents the most feared scenario in airway management where all conventional techniques fail to secure the airway or achieve oxygenation. [1,2] It is the indication for emergency front-of-neck airway (FONA) access.

ANZCA Definitions: [3,4]

  • Can't Intubate: Failure to achieve tracheal intubation despite optimal attempt
  • Can't Ventilate: Failure to achieve effective face mask or SGA ventilation
  • Can't Oxygenate: Failure to maintain oxygenation (SpO2 <90%) despite attempts
  • CICO: Can't Intubate Can't Oxygenate - indication for emergency FONA

The Vortex Approach: [5,6] A cognitive aid developed by Dr Nick Chrimes that conceptualises airway management as three non-surgical techniques (face mask, SGA, endotracheal intubation) that can be attempted in any order, with limitation on attempts (max 3 at each), culminating in FONA if all fail.

Incidence: [7,8]

  • CICV/CICO: 1:5,000 to 1:10,000 general anaesthetics
  • Difficult mask ventilation: 0.9-5% of general anaesthetics
  • Impossible mask ventilation: 0.01-0.15%
  • Emergency surgical airway: 1:50,000 to 1:100,000

Risk Factors for Difficult Ventilation

Patient Factors: [9,10]

Anatomical:

  • Obesity (BMI >30, especially BMI >35)
  • Beard/male pattern hair distribution
  • Edentulous (loss of oral seal)
  • Prominent incisors (can't seal mask)
  • Short thyromental distance (<6 cm)
  • Limited mouth opening
  • Neck pathology (tumour, infection, radiation)
  • Upper airway obstruction (tumour, epiglottitis, angioedema)

Pathophysiological:

  • Obstructive sleep apnoea (OSA)
  • Pregnancy (especially late third trimester)
  • Acute airway obstruction
  • Laryngospasm
  • Bronchospasm

Technique/Equipment Factors:

  • Light anaesthesia (inadequate depth)
  • Inadequate muscle relaxation
  • Incorrect mask size
  • One-person technique (should always be two-person if difficulty)
  • No oral/nasal airway adjuncts

Predictors of Impossible Mask Ventilation: [11,12]

Risk FactorScoreSignificance
Neck radiation changes1Each point increases risk
Male sex1≥3 points = high risk
Sleep apnoea1
Beard1
Edentulous1
Age >551

MOANS Score (Difficult Mask Ventilation): [13,14]

  • Mask seal: Beards, facial trauma, crusted blood
  • Obstruction: Upper airway pathology
  • Apnea: Obesity, pregnancy, OSA
  • No teeth: Edentulous (paradoxically can be difficult)
  • Siffness: Cervical spine rigidity, ankylosing spondylitis

Recognition of CICV

Early Warning Signs

During Intubation Attempts: [15,16]

  • Multiple failed intubation attempts (>3)
  • Deteriorating SpO2 during attempts
  • Inability to achieve EtCO2 after intubation attempt
  • No chest movement with positive pressure

Face Mask Ventilation Failure: [17,18]

  • No chest movement despite positive pressure
  • No EtCO2 waveform
  • No misting in mask
  • Tightness/resistance to bag compression
  • Increasing peak airway pressure required
  • Paradoxical movement: Chest and abdomen moving in opposite directions
  • No improvement with optimisation techniques

SGA Rescue Failure: [19,20]

  • Unable to insert SGA
  • Inserted but:
    • No EtCO2
    • No chest movement
    • High airway pressures required
    • Gastric insufflation (epigastric auscultation)
    • Leak around device

CICO Declaration Criteria

When to Declare CICO and Proceed to FONA: [21,22]

  • Failed intubation: Optimal attempt unsuccessful
  • Failed face mask ventilation: Despite optimisation
  • Failed SGA rescue: Cannot insert or ventilate
  • Deteriorating oxygenation: SpO2 falling
  • Time critical:
    • Healthy patient: SpO2 <80% or falling rapidly
    • Obese/pregnant/child: SpO2 <90% (desaturate faster)

The 3-3-3 Rule: [23,24]

  • No more than 3 attempts at any technique by experienced operator
  • No more than 3 different techniques before declaring CICO
  • No more than 3 minutes of hypoxia (SpO2 <90%) before FONA

Emergency Management

Optimisation Techniques (Before Declaring CICV)

Face Mask Ventilation Optimisation: [25,26]

Two-Person Technique (MANDATORY if difficulty):

  • Person 1: Holds mask with both hands (C-E technique)
  • Person 2: Squeezes bag, monitors chest movement, SpO2, EtCO2

Head Position:

  • Extension (if no cervical spine injury)
  • Jaw thrust (forward displacement)
  • Chin lift

Adjuncts:

  • Oral airway: Guedel (size appropriate)
  • Nasal airway: If mouth breathing/open
  • Different mask: Smaller often better (especially pediatric on adult)

High-Flow Oxygen:

  • If available, use before/during attempts
  • May provide apneic oxygenation

Neuromuscular Blockade:

  • Ensure adequate depth
  • Check TOF - may need additional NMBA
  • DO NOT give suxamethonium if difficult mask ventilation (may worsen)
  • Rocuronium preferred (reversible with sugammadex)

Supraglottic Airway (SGA) Rescue

Indication: [27,28] Failed face mask ventilation or failed intubation with acceptable SpO2

Device Selection:

First Generation (Basic):

  • Classic LMA: Basic seal, higher leak
  • Insert technique: Standard, rotate if resistance

Second Generation (With Gastric Access):

  • ProSeal LMA: Separate gastric channel
  • Supreme LMA: Pre-curved, gastric channel
  • i-gel: No cuff, thermoplastic, gastric channel

Preferred for Rescue: [29,30]

  • i-gel: Fast insertion, good seal, gastric channel
  • LMA Supreme: Good seal, gastric channel, bite block
  • ProSeal LMA: High seal pressure, gastric drainage

Insertion Technique:

  1. Deflate cuff (if applicable)
  2. Lubricate posterior surface
  3. Insert along hard palate (not down midline)
  4. Rotate during insertion if resistance
  5. Inflate cuff (if applicable) to appropriate pressure
  6. Confirm placement:
    • EtCO2 waveform
    • Chest movement
    • Leak pressure test (>20 cmH2O)
    • Gastric tube insertion (if 2nd generation)

If SGA Fails:

  • Different SGA device
  • Different size
  • Re-optimise position
  • If still failing → Proceed to FONA

Front of Neck Access (FONA)

ANZCA PG61(A) Guidelines: [31,32]

Indication:

  • CICO declared
  • Failed all supraglottic techniques
  • Deteriorating oxygenation

Timing:

  • DO NOT DELAY trying repeatedly what has failed
  • Healthy patient: SpO2 <80%
  • At-risk patient: SpO2 <90% (obese, pregnant, child)

Techniques:

Equipment: [33,34]

  • Scalpel (No. 10 or 11 blade)
  • Bougie (intubating stylet)
  • 6.0 cuffed ETT
  • Syringe (cuff inflation)
  • Capnography

Technique: [35,36,37]

Step 1: Positioning

  • Extend neck (if not contraindicated)
  • Stabilise larynx with non-dominant hand
  • Identify cricothyroid membrane (CTM)

Step 2: Incision

  • Horizontal stab incision through CTM
  • Scalpel held like dagger
  • Tongue depressor or hand to stabilise
  • Cut through skin, subcutaneous tissue, CTM

Step 3: Bougie Insertion

  • Insert bougie through incision
  • Angle caudally (toward carina, not cephalad)
  • Feel for resistance (tracheal rings)
  • Advance to 10-15 cm (approximately to carina)

Step 4: Tube Placement

  • Rail-road 6.0 cuffed ETT over bougie
  • Rotate tube 90 degrees if resistance at thyroid cartilage
  • Advance to appropriate depth
  • Remove bougie
  • Inflate cuff

Step 5: Confirmation

  • EtCO2 (gold standard)
  • Bilateral chest movement
  • Bilateral breath sounds
  • No gastric insufflation
  • Chest X-ray (confirm position, check for complications)

Advantages: [38,39]

  • Faster than surgical cricothyrotomy
  • More reliable than needle cricothyrotomy
  • Equipment always available
  • High success rate in experienced hands
  • Suitable for emergency use

Indication: [40,41]

  • Only if scalpel technique not possible
  • Pediatric patients (rarely)

Technique:

  • 14G or 16G cannula through CTM
  • Caudal angulation
  • Confirm air aspiration
  • Connect to high-pressure oxygen (barbotage)
  • MAJOR LIMITATION: Inadequate ventilation, only oxygenation
  • High failure rate

Complications:

  • Malposition (not in trachea)
  • Kinking of cannula
  • Barotrauma
  • Inadequate ventilation

3. Surgical Cricothyrotomy (Open Technique)

Indication: [42,43]

  • If scalpel-bougie fails
  • Invasive
  • Requires more time

Technique:

  • Vertical skin incision
  • Dissect to expose CTM
  • Horizontal incision through CTM
  • Insert tracheal hook (retract cricoid)
  • Insert tracheostomy tube or 6.0 ETT

Complications: [44,45]

  • Bleeding
  • Posterior tracheal wall perforation
  • Oesophageal perforation
  • Subglottic stenosis (late)
  • Voice changes

Post-FONA Management

Immediate: [46,47]

  • Confirm tube position (EtCO2, auscultation, CXR)
  • Secure tube firmly
  • Continue anaesthesia or wake patient
  • Document procedure
  • Inform patient/family

Follow-up: [48,49]

  • ENT review: Assess airway, voice
  • Speech therapy: If voice affected
  • Imaging: CXR, CT if complications suspected
  • Patient counseling: Future anaesthesia implications
  • Difficult airway alert: National database, medical records

Prevention and Preparation

Pre-Operative Assessment

History: [50,51]

  • Previous difficult intubation
  • Snoring/OSA
  • Previous neck surgery/radiation
  • Congenital syndromes
  • Acute airway symptoms (stridor, dysphonia)

Examination: [52,53]

MOANS (Mask Ventilation):

  • Mask seal, Obstruction, Aged, No teeth, Stiffness

LEMON (Laryngoscopy):

  • Look externally, Evaluate 3-3-2, Mallampati, Obstruction, Neck mobility

ROMAN (Risk of aspiration):

  • Reflux, Obesity, Mucus, Anxiety, Non-fasted

RODS (Difficult SGA):

  • Restricted mouth opening, Obstruction, Disrupted airway, Stiffness

Investigations: [54,55]

  • CT/MRI airway if pathology suspected
  • Flexible nasendoscopy if available
  • Ultrasound (thyroid/cricoid cartilage visualisation)

Preparation for High-Risk Airway

Equipment: [56,57]

  • Difficult airway trolley (standardised, checked)
  • Multiple SGA sizes/types
  • FONA equipment (scalpel, bougie, 6.0 ETT) - immediately available
  • Tracheostomy set (if time permits)
  • Emergency drugs (sugammadex, atropine, adrenaline)

Personnel: [58,59]

  • Experienced assistant (skilled in airway management)
  • ENT/General surgeon immediately available (if predicted difficult)
  • Second anaesthetist (if available)
  • Trained in FONA (regular simulation training)

Position: [60,61]

  • Ramp/head-up (if obese)
  • Left lateral tilt (if pregnant)
  • Optimise first attempt (best chance)

Strategy for Known Difficult Airway

Options: [62,63]

  1. Awake fibreoptic intubation (gold standard for known difficult)
  2. Regional anaesthesia (avoid airway altogether)
  3. Elective tracheostomy (extreme cases)
  4. IV anaesthesia with spontaneous ventilation (maintain until airway secure)

If General Anaesthesia Required:

  • Maintain spontaneous ventilation until airway secured
  • Topical anaesthesia to airway
  • Gentle laryngoscopy (minimise stimulation)
  • Video laryngoscope first line
  • Bougie stylet available
  • Surgical backup in theatre

Special Scenarios

CICV in Pregnancy

Unique Challenges: [64,65]

  • Full stomach: High aspiration risk
  • Difficult anatomy: Large breasts, breast engorgement
  • Reduced FRC: Rapid desaturation
  • Aortocaval compression: Reduced cardiac output
  • Two patients: Maternal AND fetal considerations

Management:

  • Left lateral tilt throughout
  • RSI with cricoid pressure (if intubating)
  • Lower SpO2 threshold for FONA (desaturate faster)
  • Sugammadex available (reverse rocuronium if needed)
  • Neonatal resuscitation team if viable gestation

CICV in Paediatrics

Unique Challenges: [66,67]

  • Rapid desaturation: High O2 consumption, low FRC
  • Difficult landmarks: Smaller CTM
  • Equipment: Smaller sizes required
  • Technique: Percutaneous tracheal access more difficult

Management:

  • Lower threshold for FONA (SpO2 <90%)
  • Needle cricothyrotomy may be used (14G cannula)
  • Jet ventilation or transtracheal O2 insufflation
  • Surgical tracheostomy (preferred if time)
  • Very experienced operator required

CICV with Cervical Spine Injury

Challenges: [68,69]

  • Immobilisation: Collar restricts access
  • Manual in-line stabilisation: May be needed during FONA
  • Positioning: Neutral neck position

Management:

  • Remove collar for FONA (maintain manual stabilisation)
  • Surgical cricothyrotomy may be preferred (no neck movement)
  • Post-procedure: Re-immobilise

Indigenous Health Considerations

Note: This section expands on the Quick Answer section above for comprehensive cultural safety training.

Aboriginal and Torres Strait Islander Health: [70,71,72]

Anatomical Considerations:

  • Higher rates of obesity: BMI >35 increases difficult ventilation risk
  • OSA prevalence: Higher rates in remote communities
  • Mandibular retrognathia: May increase difficult intubation
  • Limited pre-operative assessment: Remote locations, late presentation

Remote Service Delivery Challenges: [73,74,75]

Staffing Issues:

  • Limited senior anaesthetic cover: Regional hospitals
  • Infrequent CICV exposure: Less experience with emergency FONA
  • Equipment availability: Scalpel-bougie-tube must be in all locations
  • Training: Regular simulation for CICV scenarios

RFDS Considerations:

  • Airway emergencies during transfer: Limited options
  • Equipment: Portable FONA kit in all retrieval vehicles
  • Training: Retrieval doctors trained in emergency FONA
  • Communication: Ground support from tertiary centres

Cultural Safety in Emergency: [76,77,78]

Communication:

  • Rapid family notification: Through ALOs
  • Clear explanation: Why emergency airway needed
  • Reassurance: Support available, calm atmosphere
  • Language: Interpreters if needed

During Crisis:

  • Cultural support persons: When possible
  • Family presence: If appropriate and safe
  • Traditional healing: Alongside Western interventions
  • Respectful care: Dignity maintained throughout

Post-Crisis: [79,80,81]

  • AMS follow-up: Connection to Aboriginal Medical Services
  • Community support: Family, community liaison
  • Cultural protocols: If adverse outcomes
  • Patient education: Future anaesthesia implications
  • Sorry Business: Appropriate protocols if death occurs

Māori Health (Aotearoa New Zealand): [82,83,84]

Māori Airway Health Profile:

  • Higher obesity rates: 48% vs 29% non-Māori
  • OSA prevalence: Undiagnosed in many
  • Reduced pre-operative assessment: Access barriers

Whānau-Centred CICV Management: [85,86,87]

During Emergency:

  • Whānau communication: Rapid, clear, honest
  • Māori Health Workers: Essential support
  • Karakia: Spiritual support when possible
  • Whānau presence: Where appropriate

Cultural Considerations:

  • Tapu and noa: Respecting concepts in airway management
  • Wairua (spirit): Spiritual wellbeing during crisis
  • Whakawhanaungatanga: Maintaining relationships even in emergency
  • Mana: Preserving dignity during invasive procedures

Systemic Issues: [88,89,90]

Equity in Outcomes:

  • Data collection: Māori CICV outcomes tracked
  • Workforce: Māori in anaesthesia training
  • Access: Equitable access to difficult airway services
  • Accountability: For equitable care

Quality Improvement:

  • Māori-led initiatives: Addressing disparities
  • Cultural safety: Mandatory for all airway teams
  • Community engagement: Building trust
  • Te Tiriti obligations: Partnership, protection, participation

ANZCA Exam Focus

Written Examination (SAQ)

High-Yield Topics:

  1. CICO declaration criteria (when to proceed to FONA)
  2. Scalpel-bougie-tube technique (step-by-step)
  3. Difficult mask ventilation predictors (MOANS score)
  4. Vortex approach (3 techniques, limited attempts)
  5. SGA rescue (devices, confirmation, failure criteria)

Common SAQ Scenarios:

Scenario 1: "During an elective procedure, you are unable to intubate the patient and then find you cannot ventilate via face mask or SGA. Describe your management including the technique for front-of-neck access. (20 marks)"

Scenario 2: "List five predictors of difficult mask ventilation and five measures to optimise face mask ventilation. (15 marks)"

Viva Voce Examinations

Expected Viva Themes:

Theme 1: Recognition

  • "How would you recognise a can't intubate can't ventilate situation?"
    • Key points: Failed intubation, failed SGA, deteriorating SpO2

Theme 2: SGA Rescue

  • "What supraglottic airway would you use for rescue ventilation and why?"
    • Key points: i-gel or Supreme, gastric channel, fast insertion

Theme 3: FONA Technique

  • "Describe the scalpel-bougie-tube technique for emergency front-of-neck access."
    • Key points: Horizontal stab incision, bougie caudally, rail-road ETT

Theme 4: Prevention

  • "How would you prepare for a known difficult airway?"
    • Key points: Awake fibreoptic, equipment, personnel, surgical backup

Viva Scenario Example

Examiner: "You are anaesthetising a patient when you fail to intubate. After two attempts, you try to ventilate via face mask but cannot achieve chest movement or EtCO2. What do you do?"

Candidate Response Framework:

  1. Immediate Actions:

    • "I would call for help immediately"
    • "Optimise face mask ventilation with two-person technique"
    • "Insert oral/nasal airway, adjust head position"
    • "100% oxygen, check depth of anaesthesia"

  2. SGA Rescue:

    • "Insert a second-generation SGA - i-gel or Supreme"
    • "Confirm placement with EtCO2, chest movement"
    • "If successful, wake patient or proceed via SGA"

  3. If SGA Fails:

    • "Declare CICO - can't intubate can't oxygenate"
    • "If SpO2 falling below 80%, proceed immediately to front-of-neck access"

Examiner Follow-up: "Describe the technique for emergency front-of-neck access."

Candidate: "I would use the scalpel-bougie-tube technique: horizontal stab incision through the cricothyroid membrane, insert a bougie angled caudally, feel for tracheal ring resistance, then rail-road a 6.0 cuffed ETT over the bougie into the trachea. Confirm with EtCO2 and auscultation."

Short Answer Questions

SAQ 1: CICV Recognition and Management

Question: (20 marks) During an elective laparoscopic cholecystectomy, you are unable to intubate the patient after three attempts. You then try to ventilate via face mask but cannot achieve chest movement or EtCO2.

a) What is the most likely diagnosis? List three criteria that would prompt you to declare a CICO situation. (5 marks)

b) Describe your step-wise management from this point until the airway is secured. (10 marks)

c) Describe the scalpel-bougie-tube technique for emergency front-of-neck access. (5 marks)

Model Answer:

a) Diagnosis and Criteria (5 marks):

Diagnosis: Can't Intubate Can't Ventilate (CICV) or Can't Intubate Can't Oxygenate (CICO) [1 mark]

CICO Declaration Criteria: [4 marks - any 4]

  1. Failed intubation after optimal attempt(s) [1]
  2. Failed face mask ventilation despite optimisation [1]
  3. Failed SGA insertion or ventilation [1]
  4. Deteriorating oxygenation (SpO2 falling) [1]
  5. SpO2 <80% in healthy patient (<90% if obese/pregnant/child) [1]
  6. No more than 3 attempts at any technique [0.5]
  7. Time-critical deterioration [0.5]

b) Step-Wise Management (10 marks):

Step 1: Optimise Face Mask (2 marks):

  1. Call for help immediately [0.5]
  2. Two-person technique mandatory [0.5]
  3. Insert oral/nasal airway [0.5]
  4. Adjust head position (extension) [0.5]
  5. Different mask size [0.5]

Step 2: SGA Rescue (2 marks): 6. Insert second-generation SGA (i-gel/Supreme) [0.5] 7. Confirm: EtCO2, chest movement, leak test [0.5] 8. If successful: Wake patient or proceed via SGA [0.5] 9. If unsuccessful: Proceed immediately to FONA [0.5]

Step 3: FONA Preparation (1.5 marks): 10. Position: Neck extended, head midline [0.5] 11. Equipment ready: Scalpel, bougie, 6.0 ETT [0.5] 12. Call for ENT/surgeon if immediately available [0.5]

Step 4: Scalpel-Bougie-Tube (3 marks): 13. Horizontal stab incision through CTM [0.5] 14. Insert bougie angled caudally [0.5] 15. Feel for tracheal ring resistance [0.5] 16. Rail-road 6.0 ETT over bougie [0.5] 17. Confirm: EtCO2, bilateral chest movement [0.5] 18. Secure tube, CXR [0.5]

Step 5: Post-Procedure (1.5 marks): 19. Continue anaesthesia or wake patient [0.5] 20. Document procedure [0.5] 21. Inform patient/family [0.5]

c) Scalpel-Bougie-Tube Technique (5 marks):

Preparation:

  • Position: Neck extended, stabilise larynx [0.5]
  • Equipment: No. 10/11 scalpel, bougie, 6.0 cuffed ETT [0.5]

Technique:

  1. Incision: Horizontal stab incision through cricothyroid membrane (CTM) [1]
  2. Bougie insertion: Insert through incision, angle caudally (toward carina) [1]
  3. Confirmation: Feel for tracheal ring resistance [0.5]
  4. Tube placement: Rail-road 6.0 cuffed ETT over bougie [0.5]
  5. Remove bougie, inflate cuff [0.5]
  6. Confirm: EtCO2, bilateral chest movement, auscultation [0.5]

SAQ 2: Difficult Mask Ventilation

Question: (15 marks) You are assessing a patient pre-operatively who has a beard, is obese (BMI 38), edentulous, and has a history of snoring.

a) What is the MOANS score and how does it predict difficult mask ventilation? (5 marks)

b) What specific measures would you take to optimise face mask ventilation in this patient? (6 marks)

c) What rescue strategy would you employ if face mask ventilation failed? (4 marks)

Model Answer:

a) MOANS Score (5 marks):

M - Mask Seal:

  • Beards, facial trauma, crusted blood compromise seal [0.5]
  • Score 1 point if present

O - Obstruction/Obesity:

  • Upper airway pathology [0.5]
  • Obesity, pregnancy, OSA reduce FRC and compliance [0.5]
  • Score 1 point

A - Aged:

  • Age >55 years [0.5]
  • Score 1 point

N - No Teeth:

  • Edentulous (paradoxically difficult - loss of oral seal) [0.5]
  • Can also make mask easier (less obstruction) [0.5]
  • Score 1 point

S - Stiffness:

  • Cervical spine rigidity, ankylosing spondylitis [0.5]
  • Reduced compliance, limited positioning [0.5]
  • Score 1 point

Interpretation: [0.5]

  • ≥3 points = High risk for difficult mask ventilation
  • This patient scores at least 4/5 (beard, obesity, edentulous, OSA history)

b) Optimisation Measures (6 marks):

  1. Two-person technique mandatory [1]
  2. Head position: Ramp/head-up (if obese), slight extension [1]
  3. Oral airway: Guedel (large size, ensures oropharyngeal patency) [1]
  4. Nasal airway: If mouth breathing [0.5]
  5. Mask selection: Smaller mask may seal better on edentulous patient [0.5]
  6. Beard management: Moistened gauze over beard, silicone mask, or gentle pressure to compress beard [0.5]
  7. Neuromuscular blockade: Ensure adequate depth and relaxation [0.5]
  8. Position: Reverse Trendelenburg/ramp position for obesity [0.5]
  9. High-flow oxygen: Pre-oxygenation if available [0.5]

c) Rescue Strategy (4 marks):

If Face Mask Ventilation Fails:

  1. Immediate SGA rescue: Insert second-generation SGA (i-gel/Supreme) [1]
    • These patients often ventilate well via SGA
  2. Confirm SGA position: EtCO2, chest movement [0.5]
  3. If SGA successful: Wake patient OR proceed with surgery via SGA [0.5]
  4. If SGA fails: Declare CICO and proceed to front-of-neck access [1]
    • Scalpel-bougie-tube technique
  5. Call for help early in this high-risk patient [0.5]

Alternative:

  • Consider awake fibreoptic intubation for this high-risk airway [0.5]

SAQ 3: Prevention and Preparation

Question: (15 marks) You are planning anaesthesia for a patient with known difficult airway (Mallampati IV, limited mouth opening, previous difficult intubation).

a) List three non-surgical techniques that could be used to manage this airway and one surgical option. (4 marks)

b) What equipment should be immediately available for this case? (6 marks)

c) Describe the Vortex approach to airway management. (5 marks)

Model Answer:

a) Techniques (4 marks):

Non-Surgical: [3 marks - any 3]

  1. Awake fibreoptic intubation [1]
  2. Video laryngoscopy (McGrath, C-MAC, GlideScope) [1]
  3. Supraglottic airway as primary technique [1]
  4. Spontaneous ventilation induction [1]
  5. Regional anaesthesia (avoid airway) [1]

Surgical Option: [1 mark] 6. Elective tracheostomy under local anaesthesia [1]

b) Equipment (6 marks):

Airway Equipment: [3 marks]

  1. Video laryngoscope with multiple blade sizes [0.5]
  2. Multiple SGA sizes/types (i-gel, Supreme, ProSeal) [0.5]
  3. Bougie stylet [0.5]
  4. Flexible bronchoscope (if awake technique used) [0.5]
  5. Different ETT sizes (including 6.0 for FONA) [0.5]
  6. Oral/nasal airways (multiple sizes) [0.5]
  7. Face masks (multiple sizes) [0.5]

Emergency FONA Equipment: [2 marks] 8. Scalpel (No. 10, 11 blades) [0.5] 9. Bougie (intubating stylet) [0.5] 10. 6.0 cuffed ETT [0.5] 11. Tracheostomy set available [0.5]

Drugs: [1 mark] 12. Sugammadex (for rocuronium reversal) [0.5] 13. Atropine, adrenaline (emergency) [0.5] 14. Local anaesthetic for awake technique [0.5]

c) Vortex Approach (5 marks):

Concept: [1 mark]

  • Cognitive aid developed by Dr Nick Chrimes
  • Three non-surgical techniques that can be attempted in any order
  • Crescendo of attempts culminating in FONA if all fail

Three Non-Surgical Techniques: [2 marks]

  1. Face mask ventilation [0.5]
  2. Supraglottic airway (SGA) [0.5]
  3. Endotracheal intubation [0.5]
  4. Can be attempted in any order based on clinical scenario [0.5]

Limitation Rule: [1 mark]

  • Maximum 3 attempts at each technique by most experienced operator
  • If unsuccessful after 3 attempts, move to next technique
  • Do not repeat failed technique indefinitely

CICO Threshold: [1 mark]

  • If all three techniques fail (9 attempts total)
  • OR if oxygenation deteriorating (SpO2 <80% healthy, <90% at-risk)
  • Declare CICO and proceed to front-of-neck access (FONA)

Visual Concept:

  • Spiral "vortex" moving downward toward FONA
  • Escape at any level if technique successful
  • Time-critical progression

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