The All-Wales Airway Group

Dr David Lacquiere

AWAG Position Statement

AWAG’s position regarding Plan D of the 2015 DAS guidelines for the management of unanticipated difficult intubation in adults

Since May 2015 AWAG has been trying to standardise the approach to the Can’t Intubate, Can’t Oxygenate’ scenario, across hospitals in Wales. An algorithm was developed in Australia through regular live animal simulation [1]. It is framed around emergency reoxygenation, using techniques that match the anaesthetist’s skill set, and encourages attempts at both cannula and scalpel (a scalpel-bougie technique) if required, in a logical order [2]. Through the network of AWAG Linkmen and other interested parties, AWAG is promoting use of this algorithm together with the equipment requirements, and rigorous training programmes. The equipment set-up and training sessions held at Aneurin Bevan University Health Board are being used as a template [3].

The 2015 Difficult Airway Society (DAS) guidelines recommend that anaesthetists perform a scalpel-bougie technique should they encounter a CICO scenario [4] but also state ‘there are, however, other valid techniques for front-of-neck access, which may continue to be provided in some hospitals where additional equipment and comprehensive training programmes are available.’ Given this explicit support in the DAS guidelines, AWAG is continuing to advocate the Australian approach, as described above.

More details about this approach and the reasons we recommend it will be appearing on this website soon.

Dr David Lacquiere

AWAG Secretary, on behalf of the AWAG committee.


  1. Heard AMB, Green RJ, Eakins P. The formulation and introduction of a ‘can’t intubate, can’t ventilate’ algorithm into clinical practice. Anaesthesia 2009; 64: 601–8
  2. Heard A. Percutaneous Emergency Oxygenation Strategies in the ‘Can’t Intubate, Can’t Oxygenate’ Scenario. Smashworks Editions; 2013. Available from (accessed 22 December 2015)
  3. Mincher N, Richards C. ‘Can’t Intubate, Can’t Oxygenate’ (CICO): A course for practical management. Poster presented at World Airway Management Meeting, Dublin, 2015
  4. Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth 2015; 115: 827-48

Are there any plans to do a can't intubation can't ventilate course?


Hi Adrian

sorry only just saw this question! CICO provider courses are run in a number of Welsh hospitals. In Abergavenny (Nevill Hall Hospital) these are open to people from outside the hospital to attend. AWAG also runs CICO Instructor Courses twice a year.

Dave Lacquiere

AWAG Secretary

Dr David Lacquiere
Consultant Anaesthetist
Nevill Hall Hospital
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