Scalpel-bougie FONA

Claas Siegmueller


Several slight variations of this technique exist mostly depending on how the scalpel is used (vertical skin followed by horizontal CTM stab incision or scalpel twist technique) and whether a tracheal hook is used or not.

This is one suggested workflow:

1. Position the patient

Head and neck should be extended or even hyper-extended to reveal as much of the anterior neck as possible. In practice this means removing any support/ pillow from under the head.

2. Position yourself

If you are right-handed, stand at the patient's left schoulder. If you are left-handed, vice versa. The non-dominant hand palpates the anatomy and identifies the cricothyroid membrane, the dominant hand uses the scalpel.

3. Open and prepare the kit

We strongly suggest a pre-packaged kit (either from a commercial supplier or 'home-made'). One advantage of this technique is that it does not require a lot of equipment or equipment preparation.

4. Identify cricothyroid membrane

Palpate with your non-dominant hand. We suggest to start palpating at the sternal notch with your thumb and index finger, and move upwards along the tracheal rings until the cricoid cartilage is encountered. The 'ditch' above the cricoid cartical is the CTM. Keep your fingers spread slightly to 'fix' the larynx in the midline and keep the CTM between your fingers.  This maneuver has been described as the 'laryngeal handshake'Don't move your hand for steps 5 and 6.

5. Skin incison over CTM

Make a generous vertical skin incision of at least 3cm over the CTM from caudad to cranial.  Make sure the incision is deep enough to extend all the way down to the laryngeal structures. It will bleed a bit!

6. Tissue dissection down to CTM and horizontal CTM incision

Tissue dissection down to the CTM can be done bluntly with the index finger of the dominant hand, the Trusseau dilator, or the handle end of the scalpel. Once the CTM itself is identified visually or by palpation, make a generous horizontal incision of the membrane. The CTM has a cartilage border laterally which will stop the scalpel blade straying too far to each side.

Alternatively, you can use a stab-twist scalpel motion technique (described below) to get to the CTM and open it.

The scalpel-bougie technique is the FONA approach recommended by the UK Difficult Airway Society (DAS) over 'needle' or 'surgical' methods. They recommend a 'stab-twist-bougie-tube' technique which relies on a scalpel rotation move followed by tissue retraction with the blade to create a passage for the bougie. The DAS has published an excellent training video outlining the technique.

7. Tracheal hook insertion and retraction

The tracheal hook is inserted horizontally through the (also horizontal) incision in the CTM and then rotated 90 degrees so the tip sits underneath the thyroid cartilage. Pull anteriorly and cranially with the tracheal hook to increase the CTM space between the cricoid and thyroid cartilages and bring the axis of the trachea forward for easier cannulation (see below).

Effect of retraction of the thyroid cartilage with a tracheal hook (blue), increasing the CTM opening and bringing the tracheal axis anteriorly for easier cannulation


With the scalpel-bougie technique usage of the tracheal hook is optional.

8. Bougie and ET tube insertion

Insert the gum-elastic bougie into the trachea and then 'railroad' the ET tube over the bougie.

9. Oxygenate

Any anesthetic breathing system can obviously be connected to the ET tube.

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