If the basic manoeuvres fail, then more invasive options are required. Oral intubation may be difficult or impossible:

• Details on the bedhead sign
• Remember that upper airway obstruction may be the reason for the tracheostomy

Again, your area of expertise and patient factors will dictate where to start. An established surgical stoma may be easier to re-insert than attempting oral intubation. If the patient is conscious, then manipulation of the stoma is likely to be much better tolerated than upper airway manoeuvres.

Two airway teams may be required, one for the face and one for the neck.