Consider the following real-life example. Imagine you're working in the ICU as the primary medical professional responsible for a critically ill patient. The patient's status declines rapidly, prompting a need for emergency intubation. Despite multiple attempts, intubation is unsuccessful. Simultaneously, the patient's oxygen saturation is rapidly falling, and concern builds for an imminent cannot intubate, cannot oxygenate event. It's a heart-pounding scenario, and one that we should never take lightly. This is exactly what happened to me on April 30, 2023.
There is a distinct, bone-chilling fear that accompanies the realization that your critical care patient is facing a life-threatening emergency: the inability to intubate and oxygenate. As intensivists, we are trained to handle high-stress situations, but nothing quite prepares you for the weight that settles on your chest when you encounter this dire scenario. The urgency to act, combined with the knowledge that you have been down this path before, is enough to make even the most seasoned professional feel overwhelmed.
This blog post aims to explore the difficulties and challenges associated with managing a patient who cannot be intubated and oxygenated, drawing from personal experience to illuminate the complexities of these cases. We will delve into the intricacies of decision-making, the importance of maintaining composure, and the valuable lessons that can be learned from these heart-stopping experiences. With every second counting in the race to save a life, it's essential that we, as intensivists, acknowledge and understand the weight of these situations and how they can impact our abilities to provide the best possible care.
The morning had been progressing quite smoothly in the ICU, as I made my round to assess each patient, discuss their conditions with the nursing staff, and devise plans for the day. When I reached the bedside of a patient who had been intubated for aspiration pneumonia and remained on mechanical ventilation for the past 13 days, I was initially encouraged by how well the patient was doing with of the spontaneous breathing trial, leading me to give the order for extubation. However, shortly after extubation, the patient went into respiratory distress, seemingly due to an upper airway obstruction. Despite administering racemic epinephrine, the situation did not improve. Consequently, I made the decision to reintubate the patient.
As I prepared for intubation, the process seemed routine at first, with etomidate and succinylcholine administered for rapid sequence induction (RSI). I employed the Glidescope for vocal cord visualization, but neither a size 8 nor a size 7 endotracheal tube (ETT) could be passed. Realizing the gravity of the situation, I urgently called for anesthesia and initiated the critical airway code. Alarmingly, the patient's oxygen saturation levels failed to improve with bag-mask ventilation and rapidly plummeted below 50%. Left alone in the room and unable to intubate or oxygenate, I knew that further attempts would only waste precious time and potentially result in anoxic encephalopathy or even death. I swiftly changed my position to the side of the table, and a nurse handed me the cricothyroidotomy kit. In less than two minutes, I performed a tracheotomy and established airway access (I opted for a tracheotomy rather than cricothyrotomy as he has very good landmarks and I felt I can easily change to a regular tracheostomy later). As we began bagging through the new airway, the patient's saturation levels gradually improved to 100%. To my immense relief, the patient opened his eyes and communicated appropriately.
With the arrival of the anesthesiologist and a temporary reprieve from the crisis, we decided to reevaluate the possibility of establishing endotracheal intubation and replacing the temporary tracheotomy with a regular one. Employing the Glidescope once more, we were still unable to pass a size 6 ETT. However, after multiple attempts, we managed to introduce a bougie which was then exchanged with a size 6 endotracheal tube. At this point, I proceeded to replace the temporary tracheotomy with a size 8 permanent tracheostomy, using the standard procedure for percutaneous placement.
Once again, after the sedation wore off, the patient woke up and responded appropriately. The harrowing experience reinforced the importance of adaptability and swift decision-making in critical care situations, reminding us that even the most routine procedures can sometimes present unforeseen challenges.
Failed Airway: Cannot Intubate and Cannot Oxygenate
To intubate someone, it is crucial to visualize the vocal cords and successfully insert the endotracheal tube into the trachea. A difficult airway is a clinical situation in which a healthcare professional skilled in airway management encounters challenges in accomplishing this task using one or more standard airway management techniques. These techniques may involve either direct laryngoscopy, which requires a direct line of sight to the vocal cords, or indirect methods such as video laryngoscopy, which utilizes a camera to visualize the airway.
In these situations, the practitioner's expertise in airway management plays a crucial role in guaranteeing patient safety and avoiding complications resulting from unsuccessful or challenging intubation attempts. Confronted with a difficult airway, healthcare professionals must be ready to implement alternative airway management approaches, utilizing less common techniques and relying on a specialized team or equipment to secure the patient's airway and ensure sufficient oxygenation.
A failed airway, on the other hand, refers to a situation in which a healthcare professional is unable to secure the airway despite multiple attempts and the use of various techniques or equipment. This is a life-threatening emergency that requires immediate action to prevent severe hypoxia, brain damage, and even death. A failed airway can be a consequence of a difficult airway but can also occur unexpectedly in patients with seemingly normal airway anatomy.
It is essential to distinguish between two distinct scenarios: the first is a situation where the operator cannot intubate the trachea and is unable to facilitate gas exchange for a patient who cannot do it independently (cannot intubate and cannot oxygenate: CICO) using a bag and mask or extraglottic device. In such cases, healthcare providers need to be prepared to quickly implement rescue methods like cricothyrotomy or emergency tracheostomy to guarantee sufficient oxygenation and ventilation.
The second condition involves a failed airway where intubation is unsuccessful, but maintaining adequate oxyhemoglobin saturation is possible (can't intubate, can oxygenate). In this situation, the operator has time to wait for the critical airway team to arrive at the bedside and carry out the appropriate interventions.
While both difficult and failed airways present challenges in airway management, the key difference lies in the degree of urgency and potential consequences. In a difficult airway, the complications are often anticipated, allowing providers to plan and prepare for alternative approaches. A failed airway, however, represents an unanticipated emergency that necessitates rapid decision-making and action to prevent life-threatening consequences. Understanding these distinctions is essential for healthcare professionals, as it informs their approach to airway management and guides them in making critical decisions to ensure patient safety.
An even more challenging scenario is the CICO situation, which can be highly complex. The operator may not possess the necessary skills to perform an emergent cricothyrotomy, and the emotional stress experienced by the intensivist, coupled with potential chaos in the ICU room, can further complicate matters.
When a patient cannot be adequately oxygenated using a bag and mask, despite optimal bagging techniques and adjunct airway devices (i.e., CICO), an immediate cricothyrotomy is indicated. While an alternative airway device might rescue the patient without requiring a cricothyrotomy, the extremely limited time available before cerebral hypoxia occurs warrants prompt surgical intervention. Multiple unsuccessful attempts to establish an alternative airway may delay the initiation of cricothyrotomy, potentially leading to hypoxic brain injury. As such, in an emergency setting, "can't intubate, can't oxygenate" is equated with the need for cricothyrotomy.
In the face of situations as terrifying as this, delayed response or unpreparedness can lead to dire consequences, including hypoxic brain injury or even death. This emphasizes the need for prompt and accurate identification of the problem, assessment of the available resources, and the effective execution of well-planned strategies to mitigate the disastrous effects of "cannot intubate and cannot oxygenate" situations.
In practice, airway assessment can be highly subjective, with even expert clinicians struggling to accurately predict challenging cases. Some studies suggest that over 90% of difficult airways are unanticipated. National and international organizations like the American Society of Anesthesiology and the Difficult Airway Society have outlined algorithms for managing difficult airways, providing a basic pathway for challenging intubation situations. It is essential that all clinicians attempting intubation be familiar with the required equipment and techniques for successful intubation.
According to the Closed Claims Analysis conducted by the American Society of Anesthesiology, failed intubation remains a significant cause of morbidity and mortality. Therefore, it is vital for healthcare professionals to be well-versed in airway management strategies and to closely follow established guidelines for handling difficult airways. This will help minimize the risk of complications and improve patient outcomes in complex cases .
To tackle these challenges, medical professionals should have a ready plan in their ICU for the evidence-based approach of such cases:
Early identification of difficult airways: Recognizing potential difficult airways prior to initiating the procedure and promptly developing alternative strategies can dramatically alter the outcome of "cannot intubate, cannot oxygenate" situations.
Ensure access to essential resources: Ensuring that critical care settings have access to airway equipment such as emergency surgical airway kits can significantly improve the odds of success.
Utilize standardized algorithms: Following structured algorithms, such as the Difficult Airway Society's or the American Society of Anesthesiologists' pathways, can streamline your decision-making process and guide you towards the appropriate interventions.
Provide crisis resource management training: Developing the ability to work as a team, efficiently allocate resources, and communicate effectively in high-stress scenarios is crucial for managing these situations.
The followings are the Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. C. Frerk, V. S. Mitchell, A. F. McNarry, C. Mendonca, R. Bhagrath, A. Patel, E. P. O’Sullivan, N. M. Woodall and I. Ahmad, Difficult Airway Society. intubation guidelines working group, British Journal of Anaesthesia, 115 (6): 827–848 (2015) doi:10.1093/bja/aev371:
As individual medical professionals, it is our shared responsibility to ensure that we are prepared for the unthinkable. While the phrase "cannot intubate, cannot oxygenate" may evoke fear and anxiety, proper planning, resources, and expertise can make the difference between life and death.
Let us prioritize preparation, implement necessary precautions, establish effective protocols, and strive to increase the chances of survival in these potentially devastating situations.
1. Kollmeier BR, Boyette LC, Beecham GB, Desai NM, Khetarpal S. Difficult Airway. 2023 Feb 4. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 29261859. Link
2. C. Frerk, V. S. Mitchell, A. F. McNarry, C. Mendonca, R. Bhagrath, A. Patel, E. P. O’Sullivan, N. M. Woodall and I. Ahmad, Difficult Airway Society. intubation guidelines working group, British Journal of Anaesthesia, 115 (6): 827–848 (2015) doi:10.1093/bja/aev371. Link
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