Emergency front of neck airway access in adult cardiac arrest: ALS TF ScR

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Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: None applicable.

The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: None applicable.

Task Force Synthesis Citation

Aljanoubi M, Almazrua M, Drennan I, Reynolds, J, Soar J, Couper K, on behalf of the International Liaison Committee on Resuscitation Advanced Life Support Task Force. Emergency front of neck airway access in adult cardiac arrest: Task Force Synthesis of a Scoping Review [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, 2023 November 24. Available from:

Methodological Preamble and Link to Published Scoping Review

The continuous evidence evaluation process started with a scoping review conducted by the ILCOR ALS Task Force Scoping Review team. Evidence was sought and considered by the Advanced Life Support Task Force.


The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: Adult patients in cardiac arrest in any setting, where adequate ventilation cannot be rapidly achieved using basic/ advanced airway management strategies

Intervention: Front-of-neck airway access attempt

Comparators: Ongoing attempts at basic/advanced airway management strategies.

Outcomes: Any clinical outcome.

Study Designs: Randomised controlled trials, non-randomised studies (e.g. interrupted time series, controlled before-and-after studies and cohort studies), and case series with at least five patients were included. Animal studies, case series/ reports with fewer than five patients, editorials, protocols, review papers and letters were excluded.

Timeframe: All years

Literature search updated to 2nd November 2023

Search Strategies

Articles for review were obtained by searching MEDLINE, EMBASE, and the Cochrane library for all entries from database inception to November 2023 (last searched on November 2023).

Key search terms included tracheostomy, surgical airway, cricothyrotomy, CICO, CICV, failed intubation and difficult airway.

Inclusion and Exclusion criteria

Inclusion criteria:

  • Eligible study design
  • Study describes any use of emergency front-of-neck airway access in the pre-hospital or in-hospital setting.

Exclusion criteria:

  • Paediatric studies
  • Studies that describe non-emergency surgical airway
  • Animal studies

Data tables

Our initial and updated searches identified 21,565 papers, of which 69 studies were eligible for inclusion. Of the 69 included studies, there was one randomised controlled trial and there were 68 observational studies.

Studies were undertaken across the prehospital, in-hospital and battlefield settings.

The randomised controlled trial compared emergency cricothyrotomy and emergency percutaneous dilational tracheotomy in 169 patients with failed airway management in the emergency department of hospitals in Alexandria, Egypt (Beshey, 2014, 939). The success rate of percutaneous cricothyrotomy was not superior to that of percutaneous dilational tracheotomy (95.3% v 97.6%, p=0.45). Nine patients (5.3%) in the trial were in cardiac arrest.

Across all included studies, there were a total of 2285 emergency front-of-neck airway access (eFONA) attempts, with a median of 11.4 attempts (interquartile range 2.9 -31.5) per study. No study focused specifically on patients in cardiac arrest.

Data Tables: ALS FONA Table of eligible studies

The evidence was summarized across four domains: incidence, success rates, clinical outcomes, and complications.

  • Incidence of attempt:

Fifty three studies reported incidence. The denominator for calculating incidence varied markedly across studies (e.g. all EMS calls, tracheal intubation attempts, difficult airway). Reported incidence ranged from 0.06 to 436 attempts per 1,000 patients. The lowest incidence was reported in a registry-based study of patients undergoing anesthesia that received general anesthesia (Rosenstock, 2016, i75). The highest incidence was reported in the NAP4 study which focused on patients with a difficult airway (Cook, 2011).

  • Success rates of attempts:

Forty studies reported success rate. Six studies reported a success rate of less than 70%. Nine studies reported a 100% success rate. The median success rate across all settings was 91%.

  • Clinical outcomes:

Clinical outcomes were reported in 58 studies. Nine studies reported the outcome of return of spontaneous circulation in cardiac arrest patients who received a front of neck airway access attempt. Across studies, the return of spontaneous circulation rate ranged from 0% to 64%.

  • Twenty eight studies reported survival until hospital discharge or survival to 30 days. Across these studies, survival ranged from 4 to 82%. Ten studies reported survival to hospital discharge or 30 days with favorable neurological outcome, with the reported rate ranging from 0% to 44%.
  • Complications:

Thirty six studies reported complications. The reported complications were varied and there was a lack of consistency in reporting.

Task Force Insights

1. Why this topic was reviewed.

This topic was selected for review by the ALS Task Force due to ongoing uncertainty regarding optimal strategies for airway management in cardiac arrest. The task force was cognizant that recent trials of advanced airway management in cardiac arrest had led to some systems implementing limitations on which healthcare providers are permitted to perform tracheal intubation, which may limit choice of airway management strategies in some settings.

2. Narrative summary of evidence identified

The scoping review included 69 studies. We identified no study that included only patients in cardiac arrest. There was marked heterogeneity across studies in setting, provider, and patient case-mix.

The most common emergency front of neck airway intervention was surgical cricothyroidotomy.

Incidence of front of neck airway access attempts varied markedly across studies. The variability was predominantly driven by the denominator chosen for the study.

Success rates were typically high, with most studies reporting success rates in excess of 70%.

Outcomes varied markedly across studies. In cardiac arrest patients, rates of return of spontaneous circulation ranged from 0% to 64%.

The evidence on complications was challenging to interpret due to inconsistency in reporting.

The heterogeneity and indirectness of current evidence does not support progression to a systematic review.

3. Narrative Reporting of the task force discussions

The task force discussed the review findings and noted the following:

  • None of the available evidence directly addressed the review question.
  • There were no studies that specifically examined patients in cardiac arrest, such that the incidence of front of neck airway access attempts in the cardiac arrest population is uncertain.
  • The success rate of emergency front of neck airway access attempts was generally high.
  • Clinical outcomes across studies varied markedly.
  • The available evidence does not allow the task force to make comparisons across different front of neck airway access strategies.
  • The context of cardiac arrest (e.g. ongoing chest compressions, unreliability of pulse oximetry or other strategies to monitor oxygenation) may make it particularly challenging to rapidly identify a failure to achieve adequate ventilation and adequate oxygenation.
  • The task force recognized that the generation of high-quality data that directly address the review question would be challenging

The task force determined that based on the available evidence, the following good practice statement could be suggested:

In adults in cardiac arrest when standard airway management strategies (e.g. oropharyngeal airway and bag-mask/ supraglottic airway/ tracheal tube) have failed, it is reasonable for appropriately trained rescuers to attempt front of neck airway access using a cricothyroidotomy technique (Good practice statement).

Knowledge Gaps

There were no studies identified that directly addressed this research question.

There were no studies that reported the incidence or success rate of emergency front of neck airway access attempts in a cardiac arrest population.

There were no studies that reported any clinical outcome, other than return of spontaneous circulation, in a cardiac arrest population.

The optimal technique for achieving front of neck airway access is uncertain.


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