Sir,“Cannot ventilate, cannot intubate” (CVCI) situation is a nightmare for all clinicians who manage airways with an incidence of 0.01-2 in 10 000 cases.[1] Despite marked improvement in airway management in the last decade, the continued existence of CVCI can possibly be attributed to lack of specificity and low predictive value of current techniques for predicting difficult airway.[2] The initial surgical airway includes standard open surgical cricothyrotomy, cricothyrotomy, and cannula-over-needle cricothyrotomy with or without jet ventilation with 100% oxygen.[3]A 55-kg, 37-year-old man, a diagnosed case of acute intestinal obstruction, was scheduled for exploratory laparotomy. The patient was conscious, well oriented, and without any medical comorbidity. Airway examination revealed mouth opening of 4 cm, thyromental distance of 7 cm, full range of neck movements, and Mallampati grade was III.After premedication with inj. fentanyl (100 μg), inj. midazolam (2 mg), inj. ondansetron (4 mg), inj. hydrocortisone (100 mg), and inj. glycopyrrolate (0.2 mg), patient was preoxygenated with 100% oxygen. Induction was with inj. thiopentone (250 mg) and paralysis with inj. succinylcholine (75 mg). Laryngoscopy attempt was taken with MacIntosh size 3 blade. First intubation attempt with size 8.0 tube was failed and according to laryngoscopist, it was Cormack and Lehane grade IIIb. Second attempt was taken inserting a malleable stylet inside the endotracheal tube, but the tube could not be passed below the epiglottis. At that time (7:30 pm), patient started desaturating and SpO2 reached 68%. Then, an Laryngeal Mask Airway (LMA) size 4 was placed but ventilation was still not achieved. The patient became progressively hypoxemic. The Laryngeal Mask Airway (LMA) was removed and needle cricothyrotomy was done with a 14 G needle attached to a saline-filled syringe. Proper placement was confirmed by aspiration of air bubble. Then, the needle was attached to a 3-ml syringe barrel to a 7.0 tracheal tube adapter to circuit. This enabled connection of the anesthesia circuit and the patient was manually ventilated.When spontaneous respiration was returned, needle cricothyrotomy unit was removed and patient was delivered 100% oxygen through bag and mask. Patient's saturation finally reached 99% and settled. He regained consciousness, vocalized, and followed commands. Surgery was postponed.The “cannot ventilate, cannot intubate” emergency situation is responsible for a previously irreducible 1-28% of all deaths associated with anesthesia. Needle cricothyrotomy followed by transtracheal jet ventilation or surgical cricothyrotomy are the recommended final life-saving treatments in the CVCI emergency by both the American Society of Anesthesiologists (ASA) and the Difficult Airway Society.[45]During airway examination of our patient, we found no significant predictor which could be a warning of difficult airway except Mallampati class III. There was also no predictor of difficult bag and mask ventilation. Recent strategies to deal with ‘cannot ventilate, cannot intubate’ situation include multiple new alternative airway devices like Laryngeal Tube and ProSeal Laryngeal Mask Airway (LMA).In the “can’t intubate, can’t ventilate” scenario, cricothyrotomy can be a life-saving procedure. Consideration of the anatomy and good patient positioning will increase the chances of success.