C. Macrow, S. Sen

Mid Yorkshire Hospitals NHS Trust, Wakefield, UK


Although extremely rare (1), emergency paediatric front-of-the-neck access (FONA) may be the only life-saving option in a “Cannot intubate, cannot oxygenate” (CICO) situation.

A recent case, in a complex unwell child, prompted us to evaluate our current District General Hospital (DGH) guidance and equipment. This child presented acutely to our hospital, underwent a difficult intubation before being transferred out and then subsequent emergency FONA.


Several guidelines for paediatric FONA exist. These offer different advice on the technique to be used in a child of a given age or weight (2), and limited information on specific equipment sizing. These include The Difficult Airway Society’s (DAS) algorithm for 1-8 year old's, The Vortex Approach to Airway Management, The Advanced Paediatric Life Support (APLS) approach and The Advanced Trauma Life Support (ATLS) approach. This variability increases cognitive burden in a time critical situation.

Accessible guidance for theatre staff on how to prepare emergency Paediatric rigid bronchoscopy was also required.

Additionally, within our hospital a method for alerting all available anaesthetists to attend an airway emergency was not established.

Strategy for change

A departmental survey of consultants and trainees (N=47), with regular paediatric exposure, revealed that 91% had never received paediatric FONA training,  and that 87% felt that this would be useful. 64% felt this should be refreshed at least annually. Confidence levels for selecting the appropriate method and size of equipment in 12, 6, 3 and 1 year old's was also collected. Confidence significantly dropped with age.

Actions Taken:

  • Locally agreed paediatric FONA algorithm, with age ranges and equipment listed
  • Age-range FONA grab bags with preselected equipment ( <1, 1-3, 4-8, >8 years)
  • SOP for an “Airway Emergency” 2222 call
  • Grab Bag with instructions for Rigid Bronchoscope assembly and Location
  • Paediatric airway skills Tea-trolley teaching program
  • Funding secured for departmental paediatric airway manikin
  • Algorithm and SOP Presented at joint Paediatric and Anaesthetic Departmental meeting

Measure of improvement

A survey of confidence levels in selecting appropriate equipment and age appropriate methods post teaching will be completed.

Lessons learnt

Paediatric FONA is very rare, with significant risk of iatrogenic injury. Concerns were raised within the survey regarding its relevance to DGH Anaesthetics, and a possible “Dunning-Kruger effect” via teaching, increasing confidence without improving competence, leading to possible unnecessary FONA . This was addressed by making the focus of teaching Basic paediatric airway skills and emphasizing optimization, before familiarization with the new FONA algorithm.

Message for others

In emergencies, especially out of hours, the ability to get appropriate help is essential. A 2222 “airway emergency” may improve this.

Rare, but life threatening emergencies require planning. The availability of equipment and age appropriate grab-bags in paediatrics should reduce cognitive burden and human factors in a highly stressful situation.


  1. Engelhardt T, Virag K, Veyckemans F, Habre W. Airway management in paediatric anaesthesia in Europe-insights from APRICOT (Anaesthesia Practice In Children Observational Trial): a prospective multicentre observational study in 261 hospitals in Europe. Br J Anaesth. 2018 Jul;121(1):66-75.

2.Berger-Estilita J, Wenzel V, Luedi MM, Riva T. A Primer for Pediatric Emergency Front-of-the-Neck Access. A A Pract. 2021 Apr 6;15(4):e01444.

Scroll to top