Failed airway exists when there is failure to perform gas exchange in a patient who can’t do so on their own. Failed airway is everyone’s nightmare. “Can’t intubate-can’t ventilate” is a common scenario. The intubation is more difficult than expected. Ventilation is difficult, then impossible. The oxygen saturation drops precipitously. The pulse oximeter sounds lower and lower pitched beeps into a room filled with providers afraid of impending cardiac arrest.
We all fear failed airway in the catastrophic can’t intubate, can’t ventilate scenario (CICV). However, in the heat of the emergency we can forget that inserting a supraglottic airway (SAD), such as a laryngeal mask airway (LM Airway), can often allow successful ventilation. This rescue buys time to reassess airway management.
My personal CICV experience occurred in the early 1990s. The case was a cesarean delivery for failure to progress in labor in an otherwise healthy but morbidly obese woman, with a body mass index (BMI) of 45 kg/m2. The infant had developed a not-reassuring fetal tracing. My multiple attempts at a spinal were not successful. Our obstetrician requested general anesthesia, concerned that further delay might harm the baby.
Without taking the time to optimally position this morbidly obese patient because I didn’t anticipate problems, I induced anesthesia using a rapid sequence induction. Direct laryngoscopy with a MAC 3 blade gave me a Cormack-Lehane grade 4 view. Switching to a Miller 2, I again saw a grade 4 view. With oxygen saturation now dropping rapidly, I attempted to ventilate the patient, but couldn’t. There was no anesthesia help immediately available. There was no gum elastic bougie in the operating room. The emergency airway cart with the jet ventilator was downstairs. I was terrified.
Fortunately for my patient, my hospital had just acquired the brand new (for us) LM Airway, and I had one in my cart. I had never used one clinically before. Fate was kind because it slid in without any problem and allowed easy ventilation. We delivered the infant and finished surgery using the LM airway.
Humbled by this experience, I learned a valuable lesson: Take no intubation for granted—always prepare for failure.
Some Sobering Failed Airway Statistics
Intubation is a very common and safe procedure. In 2010, there were an estimated 25 million intubations in the United States and more than 50 million worldwide. The fact that intubation is routine, and usually uneventful, can lull us into a false sense of security. The incidence of difficult intubation has been reported as 0.15%. That sounds like a small number, but it calculates to 1.5 in 1,000 intubations, or multiplied by 25 million, would theoretically predict 37,500 occurrences per year in the United States alone. The CICV scenario is even more rare, and closed claims statistics in the United Kingdom show less than 1 in 5,000 routine general anesthetics. Emergency surgical airway (ESA) occurred in about 1 in 50,000 cases but accounted for up to 25% of anesthesia-related deaths. However, 1 in 5,000 would predict 5,000 CICV scenarios annually in the United States, with 500 ESAs.
Loss of the airway is one of the leading causes of injury and death in the ASA Closed Claims database. Half of the perioperative claims related to airway complications, and all the claims in other settings involved death or brain damage. The Difficult Airway Society’s and the American Society of Anesthesiologists’ Difficult Airway Algorithm both emphasize the use of a supraglottic airway early in the failed airway algorithm.
My review article, 10 Rules for Approaching Difficult Intubation: Always Prepare for Failure, provides case examples and discusses strategies to avoid difficult intubations.
Failed Airway Management
When faced with a failed airway, our first thoughts often fixate on completing an intubation to provide definitive airway protection. Instead, we should immediately shift gears to concentrate on the fastest way to provide oxygenation and ventilation. Once you have oxygenation and ventilation, you have time to strategize next steps.
Call For Help: Alert Your Team to The Problem
Teamwork and communication are essential for both prevention of problems and management of emergencies. Seriously, your team can’t help you if they don’t know there’s a problem. It’s human nature to rely on yourself to fix the problem by yourself. However, seconds count in an airway emergency, and wasted seconds can lead to brain cells lost to hypoxia. You need your team to provide additional hands, grab the crash cart or the difficult airway cart, and help prepare your equipment.
Start With the Basics
In emergencies people sometimes forget to start with the basics. Sometimes, oxygenating and ventilating really do just rely on the basics of opening an airway, oral/nasal airway insertion and effective bag-valve mask use. I describe those techniques applied to a case of failed airway here:
Insert a Supraglottic Airway Device (SAD) Early With A Failed Airway
It’s good practice to have the correct size SAD immediately available before any induction. It doesn’t need to be opened, but you and your team need to know where it is and how to prep it quickly. Seconds matter.
SADs are often used for primary airway management in patients in cardiac arrest until an intubation can be performed. Oxygenation and ventilation during CPR is as effective as with an endotracheal tube — with comparable mortality, neurologic outcome, and aspiration rates. Insertion does not interrupt chest compressions.
An SAD used as a rescue device following failed intubation allows for oxygenation and ventilation, buying time for more definitive airway management to occur. The SAD can also be reinserted between intubation attempts.
While not as protective as an endotracheal tube, the SAD has much less risk of gastric insufflation, and potential resultant aspiration, than bag-valve-mask. Some SADs allow decompression of the stomach.
You can also use SADs as an adjunct to assist intubation.
Finally, SAD placement requires less technical proficiency than intubation, making it easier for both physicians and non-physicians to perform. Use of an SAD can provide more effective oxygenation and ventilation than bag-valve-mask devices. SADs have proven efficacy in non-hospital settings by emergency management personnel.
Contraindications to SAD Use
SADs are not always appropriate. Contraindications to the use of SADs include:
- Presence of a gag reflex (risk of vomiting and aspiration); may be used in patients with gag reflex who are paralyzed as part of rapid sequence intubation.
- Trauma or disease of the oropharynx or proximal esophagus (risk of mucosal perforation), such as caustic ingestion, or known esophageal varices (risk of perforation or airway hemorrhage).
- Airway obstruction by a foreign body (risk of pushing a supraglottic foreign body into the trachea)
Stay Aware of Time and Oxygen Saturation
In a failed airway situation, the person managing the airway can become so hyperfocused that they lose track of time, vital signs, and even oxygen saturation. Stay aware. Use your team to help monitor the patient and alert you of changes.
Jet Ventilation in Failed Airway
Needle cricothyrotomy or percutaneous jet ventilation (PCJV) can truly be a life saving procedure. It is a fast, effective way of providing oxygen to a patient with an obstructed airway who does not respond to more conventional means of opening the airway. It can oxygenate the patient and buy you time to establish a more permanent airway such as an intubation or surgical airway if the patient is hypoxic.
However, percutaneous transtracheal jet ventilation carries some rare though potentially serious risks of worsening airway obstruction and cardiovascular collapse if the catheter is not correctly positioned within the trachea. Additionally, you may not have the high pressure oxygen injection device.
Description and videos of the technique can be found here:
Surgical Airway in Failed Airway
If you still can’t oxygenate or ventilate the patient, and awakening the patient is not an option, then proceed to a surgical airway. You have only minutes until life-threatening complications will occur, including brain damage and death. A surgical cricothyrotomy can be quickly and easily performed. Special kits are available. You can also perform the procedure using nothing more than a scalpel and a small, cuffed endotracheal tube. Cricothyrotomy is intimidating, but it can be done quickly. It can save lives.
This EMCrit podcast leads to a video tutorial of cricothyrotomy technique using a laryngeal model. Techniques for two people, one person, and a crash cricothyrotomy are described.
The link from this second EmCrit podcast shows video of an actual emergency awake cricothyrotomy followed by a critique of the technique used.
In a failed airway situation, you have only minutes until life-threatening complications will occur, including brain damage and death. Call for help and alert your team. Try various methods to improve mask ventilation. Try another quick attempt at intubation, using videolarygoscopy if available. But move quickly to inserting a supraglottic airway device to establish oxygenation and ventilation, if not contraindicated. An SAD can usually establish oxygenation and ventilation, thereby avoiding the need for more invasive treatment.
By the way, when you do find a patient who is truly difficult to ventilate or intubate, place that information in the patient’s chart along with information on why it was difficult and what you did to successfully manage the situation. Also tell the patient and optimally provide the patient with a letter describing the problem. This helps the next provider, and protects the patient.