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eFONA in Obesity — FRCA Final MCQ

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HardAirway ManagementeFONA in ObesityFRCA Final

A 50-year-old woman with a BMI of 48 kg.m−2 is undergoing induction of general anaesthesia for bariatric surgery. Tracheal intubation has failed despite videolaryngoscopy, and neither a second-generation supraglottic airway nor optimised two-person facemask ventilation is effective despite complete neuromuscular blockade. Her SpO2 is 65%, a cannot-intubate, cannot-oxygenate situation is declared, and DAS Plan D is initiated. With the shoulders supported and the neck fully extended, the laryngeal handshake cannot identify the cricothyroid membrane through the deep anterior neck tissues. What is the most appropriate modification to emergency front-of-neck access?

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Correct answer: A — Use an 8–10 cm vertical skin incision, finger dissection, then scalpel–bougie–tube cricothyroidotomy

The correct answer is A. In a CICO emergency with an impalpable cricothyroid membrane, DAS emergency front-of-neck access uses a long vertical midline skin incision to divide the thick soft-tissue layer. Finger or blunt dissection then permits identification and stabilisation of the larynx before the cricothyroid membrane is opened and a bougie and cuffed tracheal tube are inserted. Obesity markedly reduces the reliability of surface palpation. Moving the patient upright would delay oxygenation and impede access. Formal tracheostomy and percutaneous dilatational techniques are too slow and technically demanding for Plan D. Needle cricothyroidotomy with jet ventilation has important risks, including device failure, malposition, barotrauma and inadequate expiration, and is not the standard DAS technique. Pre-induction ultrasound marking is useful planning when landmarks are difficult, but it must not delay eFONA once CICO has occurred.

Reference: Ahmad I, et al. Difficult Airway Society 2025 guidelines for management of unanticipated difficult tracheal intubation in adults. Plan D: emergency front-of-neck airway. Published online 7 November 2025. https://pubmed.ncbi.nlm.nih.gov/41203471/