Arguments still remain about the best FONA plan. The options are generally considered as:

• 'Surgical', where a hole is cut with a scalpel
• 'Needle', where a needle is used to enter the trachea. This can be connected to oxygen or a new cannulae inserted over a wire through the needle, i.e. Seldinger technique

Traditional teaching was that anaesthetists are more familiar (and therefore more likely to succeed) with a needle technique, and a scalpel approach may be better suited to surgeons.

However, recent opinion has challenged this and the limitations of needle techniques are becoming more apparent.

NAP4 shows that:

• Of 58 FONA attempts in the theatre setting, only 25 were conducted by anaesthetists and only 9 were successful
• Of 80 FONA attempts across all areas, 37 needle cricothyroidotomies were attempted, of which 22 failed, i.e. 60% failure rate
• Of the 9 reported surgical cricothyrotomies, 33% failed. These 3 cases were ICU patients and both needle cricothyroidotomy and surgical tracheostomy also failed