An Overview of Front of Neck Access (FONA)
Front of neck access (FONA), also known as an emergency surgical airway, is a last-resort medical procedure performed in life-threatening situations where a person cannot be intubated or oxygenated by conventional means. This critical intervention is reserved for "cannot intubate, cannot oxygenate" (CICO) scenarios, where a patient's oxygen levels are dangerously low and other options, such as using a bag-valve mask or supraglottic airway device, have been unsuccessful. A FONA procedure involves creating an opening into the trachea through the anterior neck, typically via the cricothyroid membrane, a small anatomical landmark located between the thyroid and cricoid cartilages.
Key Techniques for Front of Neck Access
There are several recognized techniques for performing a FONA, with the choice often depending on the specific emergency situation, the available equipment, and the provider's training and expertise. The most common methods include the following:
Scalpel-Bougie Technique
This surgical approach is currently the most recommended method for emergency FONA by many medical societies, including the Difficult Airway Society. It is favored for its high success rate and ability to create a secure, definitive airway that can be ventilated with standard equipment. The technique involves:
- Patient Positioning: The patient's neck is extended to optimize anatomical exposure.
- Laryngeal Handshake: A provider stabilizes the larynx to identify the cricothyroid membrane (CTM).
- Transverse Incision: A horizontal incision is made through the skin and directly into the CTM using a scalpel blade.
- Tube Insertion: A bougie is inserted through the opening into the trachea, over which a cuffed endotracheal tube (typically 6.0 mm) is then advanced.
- Confirmation: Proper placement is confirmed using methods such as capnography and bilateral breath sounds.
Needle/Seldinger Technique
This technique uses a needle and guidewire to place a narrow-bore cannula into the trachea. It can be a rapid method for gaining temporary oxygen access, often followed by transtracheal jet ventilation. This is considered a temporary measure to buy time until a more definitive surgical airway can be established. However, some studies have shown lower success rates compared to surgical methods.
Surgical Tracheostomy
While not typically used for an immediate, high-stress emergency airway, a surgical tracheostomy is a more definitive surgical procedure that can be performed in an urgent, but less time-critical, situation. It involves creating an opening into the trachea lower than the cricothyroid membrane, often between the second and third tracheal rings, and is typically reserved for long-term airway management.
Indications and Contraindications
FONA is a critical procedure with specific applications, primarily in CICO emergencies. Common indications include:
- Severe Facial or Neck Trauma: Injuries that obscure anatomical landmarks or cause extensive swelling.
- Severe Oropharyngeal Swelling: Edema from anaphylactic shock, burns, or infection that prevents intubation.
- Foreign Body Obstruction: A complete airway blockage that cannot be cleared with other techniques.
- Upper Airway Obstruction: Conditions like laryngeal spasm or trauma.
- Failed Intubation Attempts: After multiple unsuccessful attempts at securing an airway through standard intubation.
Absolute contraindications for emergency cricothyrotomy are few in CICO situations, but relative contraindications exist. These may include a history of tracheal or laryngeal surgery, a laryngeal fracture, or laryngotracheal disruption. The procedure is also not recommended for infants and young children due to their smaller, funnel-shaped airway, where specialized equipment and alternative approaches are necessary.
Comparison: FONA vs. Tracheostomy
| Feature | Front of Neck Access (FONA) | Tracheostomy |
|---|---|---|
| Urgency | Emergency | Primarily Planned/Elective (can be urgent) |
| Location | Cricothyroid membrane (CTM) | Lower down the trachea (2nd-3rd tracheal ring) |
| Procedure Time | Fast (seconds to a few minutes) | Slower (performed in controlled setting) |
| Indications | CICO scenarios, severe obstruction | Long-term ventilation, airway obstruction |
| Equipment | Minimal (scalpel, bougie, tube) | More extensive surgical kit |
| Duration | Temporary; typically converted to a tracheostomy later | Long-term solution |
Risks and Complications
Despite its life-saving potential, FONA carries risks, particularly in a high-stress, emergency setting. Potential complications include:
- Bleeding: Hemorrhage at the incision site, which can be significant.
- False Tract Formation: The breathing tube is inserted into the wrong tissue plane instead of the trachea.
- Infection: Risk of local infection following the procedure.
- Endobronchial Intubation: The tube is advanced too far, entering only one lung.
- Subglottic Stenosis: Scarring and narrowing of the airway below the vocal cords.
- Posterior Tracheal Wall Injury: Puncture of the back of the windpipe.
The Importance of Preparedness and Training
Due to the infrequency and high-stakes nature of a CICO event, regular, standardized training is critical for all clinicians involved in airway management. The knowledge of when and how to perform a FONA is a core competency that can mean the difference between life and death for a patient. Simulation-based practice allows healthcare professionals to build confidence and muscle memory for this procedure, minimizing delays and potential errors during a crisis. Adherence to guidelines, using standardized kits, and effective teamwork are all crucial for success.
Conclusion
As a final, life-saving step in the difficult airway algorithm, the front of neck access procedure serves as a vital intervention when all other methods fail. Whether through a surgical approach or a needle technique, FONA provides a crucial pathway for oxygenation and ventilation, preventing brain injury and death in the most critical of situations. While serious airway emergencies are rare, proper training and a thorough understanding of the indications and techniques are essential for any medical professional who might face a CICO crisis.
For more detailed information and educational videos on this procedure, visit the Difficult Airway Society website.
