We all fear failed airway in the rare and catastrophic can’t intubate, can’t ventilate scenario (CICV). However, we often act as though it will never happen to us.
Airway emergencies are urgent, high-stakes events. Failure to secure the airway can rapidly cause hypoxia, brain injury, cardiac arrest, or death. Technical skill is vital, but effective leadership is equally essential. Poor leadership and decision making can turn a manageable crisis into a catastrophe.
The Case
My experience with CICV occurred in the early 1990s during a cesarean delivery for failure to progress in labor. The patient was otherwise healthy but morbidly obese, with a BMI of 45 kg/m2. The infant had developed a non-reassuring fetal tracing. I first met the patient in the operating room. After several unsuccessful spinal attempts, the obstetrician requested general anesthesia because of concern that further delay could harm the baby.
Because I did not anticipate difficulty, I failed to position this morbidly obese patient optimally before rapid sequence induction. Direct laryngoscopy with a MAC 3 blade produced a Cormack-Lehane grade 4 view, and switching to a Miller 2 produced the same result. As her oxygen saturation fell rapidly, I tried but could not ventilate her. No anesthesia help was immediately available, there was no gum elastic bougie in the operating room, and 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) Laryngeal Mask Airway (LMA), 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 LMA.
The Importance of Leadership and Teamwork in Airway Emergencies
Airway emergencies demand coordinated action from anesthesiologists, nurses, operating room staff, and sometimes surgeons. Effective leadership directs the team, prioritizes interventions, assigns resources, and preserves situational awareness. In a crisis, the leader must communicate clearly, make timely decisions, and keep the team aligned with established difficult airway algorithms. Leadership in this setting requires more than just technical expertise.
In hindsight I analyzed my mistakes:
- Failure to do an adequate airway exam in this emergency C-section scenario.
- Failing to optimally position the patient
- Failure to have common emergency airway equipment, such as a bougie, in the room
- Failure to have an emergency airway cart nearby in this predictably difficult airway
- Failure to ask for help from the obstetric team when I first encountered trouble
- Failure to practice with an LMA before needing one in an emergency
Humbled by this experience, I learned a valuable lesson: Take no intubation for granted—always prepare for failure.
Case #2 Planning and Communicating the Optimal Way
I was called to the ICU to exchange an ETT in a septic ARDS patient with a blown endotracheal tube cuff and major leak. The 75-year-old had severe kyphosis from ankylosing spondylitis and had been difficult to intubate because his head was flexed nearly to his chest. He required 20 cm H2O PEEP and 100% FiO2 to keep oxygen saturation at 90%, so even brief apnea risked severe hypoxia.
Because we could still ventilate despite the leak, I organized the team and equipment. The difficult airway cart, GlideScope, fiber-optic bronchoscope, suction, and crash cart with cricothyrotomy tray were readied. I assigned roles: I would visualize the larynx with the GlideScope, the CRNA would stabilize an oxygenated ETT exchanger once passed, I would exchange the tube under direct vision, the respiratory therapist would manage suction, and the ICU nurses would assist and call out vital signs and oxygen saturation.
The exchange took less than a minute because everyone knew the plan and their role. We did not need every precaution, but that was the point: always prepare for failure.
Failed Airway Statistics
Intubation is common and usually safe, but its routine nature can create false reassurance. In 2010, an estimated 25 million intubations occurred in the United States and more than 50 million worldwide. Even a reported difficult-intubation rate of 0.15% could mean about 37,500 cases annually in the United States. CICV is rarer—less than 1 in 5,000 routine general anesthetics in U.K. closed claims data—but could still represent about 5,000 U.S. cases each year. Emergency surgical airway occurred in about 1 in 50,000 cases yet accounted for up to 25% of anesthesia-related deaths.
Airway loss remains a leading cause of injury and death in ASA Closed Claims data. Both the Difficult Airway Society and American Society of Anesthesiologists algorithms emphasize early supraglottic airway use in failed airway management.
My review article, 10 Rules for Approaching Difficult Intubation: Always Prepare for Failure, provides case examples and discusses strategies to avoid difficult intubations.
Poor Leadership Can Worsen Failed Airway Events
Leadership is a skill like any other. Effective leadership includes recognizing deteriorating conditions, calling for help early, delegating responsibilities appropriately, and fostering an environment where team members can voice concerns. Failure in any of these areas may compromise patient outcomes. Common errors in emergencies include:
Delayed Decision Making
One common factor is delayed decision-making. An anesthesiologist may persist with repeated unsuccessful intubation attempts instead of switching to alternative airway techniques or following established difficult airway guidelines. Doing the same thing over and over again expecting a different outcome has been described as the definition of insanity. This fixation can result in prolonged hypoxia and increased patient risk.
Poor Communication
Poor communication is another major contributor. Anesthesia providers do not always keep their team members in the loop. Team members may not understand the clinical situation, available options, or contingency plans. Inadequate communication can lead to confusion, duplication of tasks, and delays in critical interventions.
Loss of Situational Awareness
During an emergency like a failed airway, time can feel distorted: seconds may pass unnoticed, and minutes can slip away quickly. When leaders focus too narrowly on a single technical task, they can overlook worsening oxygen saturation, unstable vital signs, or the need for emergency surgical airway access. They lose track of the big picture.
Track time closely, and ask the team to help monitor elapsed time, vital signs, and key events.
Failure to Ask for Help
Not using available resources can weaken the emergency response. Ego may make anyone hesitate to ask for help, but delaying assistance from experienced colleagues or surgeons can postpone life-saving care. In high-risk situations, effective leaders escalate early.
Ignoring Crisis Management Tools
Emergency algorithms and manuals exist for a reason. Under acute stress, especially with time pressure, the brain is less capable of managing complex problem solving and decision making. It’s easy to forget treatment steps and medication doses during rare events.
Failure to Consider Waking the Patient
We humans hate admitting defeat, especially if we have an audience. One more try will surely succeed. The temptation to keep going until we succeed can be difficult to overcome. But stopping and waking the patient up, if you can, in such an emergency is not defeat, it’s smart patient care.
Management of a Failed Airway
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.
Limit the Number of Intubation Attempts
Each successive attempt at intubation increases the risk of complications, including trauma, and reduces the likelihood of success. Make the first attempt the best attempt. One common guideline for failed airways is 3 attempts followed by a fourth and final attempt by a more experienced colleague. Each attempt should change something in the technique. Don’t just keep doing the same thing over and over expecting better results!
Call For Help: Alert Your Team to a Failed Intubation or Difficult Ventilation
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 needs to:
- bring the crash cart or the difficult airway cart
- call for any additional help not already present
- provide additional helping hands
- help prepare your equipment.
- assist with monitoring vital signs
Mask Ventilate
Start with the basics for ventilation. 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 the case of a failed airway here basics saved the day:
Airway Emergency: Start With The Basics of Airway Management
Insert a Supraglottic Airway Device (SAD) Early With A Failed Airway
If bag-valve-mask ventilation fails, move immediately to a supraglottic airway. In a failed airway emergency, it can restore oxygenation and ventilation.
Keep the correct-size SAD immediately available before any induction or anesthetic, including regional or conscious sedation. It need not be opened, but the team must know where it is and how to prepare it quickly—seconds matter.
After failed intubation, an SAD can maintain oxygenation and ventilation, buy time for definitive airway management, and be reinserted between attempts. Although less protective than an endotracheal tube, an SAD carries less risk of gastric insufflation and aspiration than bag-valve-mask ventilation. Some SADs also allow gastric decompression.
You can also use SADs as an guide to assist intubation. For additional discussion of LMAs see:
- Tips For LMA Insertion
- LMA Supreme: Great Invention But Insert It Gently
- Tips for Mastering The LMA Fastrach
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 in vital signs.
Maintain Emotional Control
First, take stock of the situation and yourself. Even experienced intubators get excited in emergency situations, but we control our excitement and let the adrenaline work for us instead of against us. Remain in control of your own sense of alarm. The leaders, which include the person in control of the airway, must stay calm. If you appear panicked, the rest of your team will follow your lead.
Intubation is a team effort, a coordinated effort by a small group of people with a common goal. To succeed, everyone needs to know the problem and the plan, especially when you are expecting difficulty. If your helpers don’t know the plan, then they either could fail to do what you need them to do or could even accidentally sabotage your efforts.
Invasive Airway Options
If SAD fails, and one last attempt at mask ventilation fails, move to an emergency front of neck airway. If you’re in an operating room, don’t forget you have your surgeon there as a resource. Two rapid options are percutaneous jet ventilation (PCJV) and emergency cricothyrotomy.
PCTV is a bridging strategy. Choose PCTV for:
- pediatric patient
- adult temporary rescue, bridging to a more definite solution, including wake up
- avoid in complete upper airway obstruction or tracheal trauma
Cricothyrotomy is a more invasive definitve airway. Choose Cricothyrotomy for:
- adult CICV emergencies
- necessity for a large bore ventilation tube
- avoid if airway obstruction is below the cricoid ring, large neck tumors
Jet Ventilation in Failed Airway
Percutaneous jet ventilation (PCJV), or needle cricothyrotomy, 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. A prior article covers technique here:
Don’t Be Afraid To Use Percutaneous Jet Ventilation In An Emergency
Video of the PCJV technique can be found here:
Trastracheal jet— cadaver model
Cricothyrotomy
A surgical airway, such s cricothyrotomy, is another option. 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.
Key Takeaways
- Airway emergencies, particularly failed airway scenarios, require swift action to prevent severe outcomes like brain injury or death.
- Leadership and teamwork are crucial during failed airway events; effective communication and prompt decision-making can greatly influence patient outcomes.
- Common pitfalls during these emergencies include delayed decision-making, poor communication, and failure to utilize available resources.
- Inserting a supraglottic airway device (SAD) early can provide essential ventilation after failed intubation attempts.
- Emergency procedures like jet ventilation and surgical airway access are vital when conventional methods fail, as they can quickly restore oxygenation.
When a patient is genuinely difficult to ventilate or intubate, document it in the chart. Note the cause of the difficulty and the steps that successfully managed the airway. Inform the patient as well, ideally with a letter explaining the issue. This supports future providers and helps protect the patient.
