Cuff puncture also presented a particular concern for us due to risk of aerosol generation and potential for prolonged loss of ventilation.  This highlighted an important point that cuffs for endotracheal tubes used on ICU are longer than commonly used in the theatre setting. In response, our anaesthetic colleagues, who are now increasingly providing airway management during procedures, have developed a specific action card (Figure 4), utilising real-time ultrasound to minimise risk.  A standardised protocol, modified processes in response to early learning, and a multi-disciplinary approach have enabled us to safely deliver this service.