Attempts to manage the upper airway, via trans-laryngeal intubation, or oxygenation, via a second generation supra-glottic airway device or bag-valve-mask system, should be optimized by administering a neuromuscular blocking agent to paralyse the muscles.

This is especially important if failure to oxygenate is occurring: a CICO situation. Before attempting a cricothyroidotomy, the patient should therefore be paralysed.

However, there are exceptions, which could include:

• The arrested patient
• If the upper airway appears impossible to manage, e.g. severe facial trauma, a decision to move straight to FONA may be taken
• FONA performed outside of a controlled environment, e.g. on the battlefield or out of hospital
• Elective cricothyroidotomy, which is usually performed with the patient breathing spontaneously