Airway management

Failed intubation and CICO (can't intubate, can't oxygenate)

Reviewed Nov 2026·3 references
New· views rounded down, updated weekly

Limit attempts, switch promptly between tube, SGA and face mask to oxygenate, call 'Code D', and perform scalpel-bougie-tube cricothyroidotomy without delay when all three fail.

At the bedside

Timed steps
  1. 1

    Call for help

    Attempt 1 fails

    Announce 'failed intubation', call 'Code D' / senior. Re-oxygenate with BMV (2-person, OPA/NPA) between attempts.

  2. 2

    Change one thing

    Optimise

    Position, full paralysis, external laryngeal manipulation, different blade or device, more experienced operator. Maximum 3 attempts at intubation (+1 by expert) while SpO2 is maintained.

  3. 3

    Second-generation SGA

    Plan B

    Up to 3 attempts. If it works: stop and think (wake? intubate via SGA with fibreoptic? FONA?).

  4. 4

    Face mask

    Plan C

    2-person technique with adjuncts; ensure paralysis. AIDAA 2025: no fixed hierarchy between tube, SGA and mask; switch rapidly to whichever ventilates.

  5. 5

    Declare it

    CICO

    Ventilation fails by tube, SGA and mask: declare CICO. AIDAA 2025: complete ventilation failure (even if SpO2 still holds) is the trigger.

  6. 6

    Front-of-neck access

    Plan D

    Scalpel-bougie-tube: extend neck, identify cricothyroid membrane (laryngeal handshake), transverse stab incision with No. 10 blade, rotate 90°, bougie, rail a 6.0 cuffed tube. Vertical skin incision first if membrane is impalpable.

Red flag · call your senior now
SpO2 falling below 80% with failing mask ventilation: prepare FONA immediately.
Red flag
Repeated laryngoscopy attempts cause airway oedema and turn 'can't intubate' into 'can't oxygenate'.
Pitfall
Fixation on intubation while SpO2 falls.
Pitfall
Needle cricothyroidotomy without a high-pressure source (inadequate ventilation).
Pitfall
Missing paralysis: giving sugammadex reflexively in the ICU when waking is not realistic.
Pearl
Mark the cricothyroid membrane with a pen (or ultrasound) before induction in predicted difficult airways.
Pearl
Keep a FONA kit (No. 10 scalpel, bougie, 6.0 cuffed tube) on every airway trolley.

References

  1. 1

    Myatra SN, Shah AP, Ramkumar V, et al. All India Difficult Airway Association 2025 guidelines for the management of unanticipated difficult airway in adults under general anaesthesia. Indian J Anaesth. 2025;69(11):1117-1141

  2. 2

    Higgs A, McGrath BA, Goddard C, et al. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth. 2018;120(2):323-352

  3. 3

    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(6):827-848

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