In critically ill patients, the principal goals of airway management are to maintain oxygenation and avoid life-threatening complications before, during, and immediately after placement of a definitive artificial airway, usually an endotracheal tube. Not surprisingly, hypoxemia (oxygen saturation <90%) becomes a life threat in the apneic patient when initial attempts at intubation are unsuccessful and rescue ventilation at the mouth and nose (bag-mask device) or glottis (supraglottic airway device [SAD]) also fail to maintain or restore oxygenation. This is a failed airway, specifically a can’t intubate, can’t oxygenate (CICO) scenario. It is imperative that the clinician immediately intervene to restore gas exchange before cardiac arrest, typically by performing a cricothyrotomy (see Chapter 27, Surgical airways).

The first cardinal rule outlined in Chapter 1 is: “Do not wander, or rush, into failure,” and the third core action is to recognize and manage failure. The first two core actions are geared at identifying and managing difficulty to avoid a failed airway. The distinction between a difficult airway and a failed airway is important because they represent different situations, invoke different actions, and arise at different points in the airway management timeline. A difficult airway is one in which laryngoscopy and tube placement, mask ventilation, or rescue oxygenation is challenging and requires planning and preparation with the goal of placing a definitive airway. A failed airway is one in which laryngoscopy and tube placement and or mask/rescue oxygenation have become impossible and require immediate maneuvers with the goal of restoring oxygenation and ventilation.

When we wander or rush into failure it is usually a consequence of approaching an airway with an almost robotic-like repetition without assessing or planning for difficulty. When we experience the difficulty that leads to failure, we then have to troubleshoot it and come up with the next plan while under stress. We sometimes perseverate on troubleshooting difficulties when we should be recognizing and managing failure.

Studies of failed airways that have resulted in patient harm, such as the NAP4 project and legal claims analyses, have made it clear that human factors (lapses in clinician judgment, communication, and team dynamics), (see Chapter 39, Human factors) impede timely and effective management of a failed airway.^1,2 If we scan our personal memories for troubling airway experiences, we may find examples of breakdowns in these human factors. From a clinician’s perspective, a failed airway is one of the scariest things that can happen in a person’s medical career. A failed airway carries an extremely high risk of death for the patient and psychological trauma for the clinician. It is necessary to emphasize that the term “failed airway” may carry a negative connotation but is not an admonishment of the “failure” of an individual. Rather, difficult and failed airways, in addition to being established terms in the literature,³ should be viewed in the context of the critical care delivery systems we have designed and implemented, and systems-level solutions sought.

It is fairly easy to see how inflexibility and complacency regarding the intubation procedure can develop over time as the overall incidence of failed airways is quite low. A failed airway where a patient can’t be intubated or oxygenated in preselected operating room intubations occurs once in approximately 5,000 to 20,000 intubations.¹ The true incidence of a failed airway during emergency intubation outside of the operating room is unknown but it is likely substantially more common, given patient acuity, lack of preselection, and a higher rate of difficult airway characteristics among critically ill patients. In addition, cricothyrotomy incidence has declined precipitously to <1% of intubation attempts in nonoperating room settings with the advent of video laryngoscopy (VL) and various rescue devices.^4,5,6 This makes preparation and vigilance all the more important to high-quality airway management. This chapter will focus on recognizing and managing the failed airway.

A failed airway typically occurs after RSI when an experienced intubator decides that they can’t intubate the trachea after a reasonably short period of time, assuming intubation was the intended approach. The intubator must provide rescue ventilation using 100% oxygen while assessing if alveolar oxygenation can or can’t be maintained (Fig. 29.1).

Can’t Intubate, Can Oxygenate: There is time to evaluate and execute various options because the patient can be oxygenated by ventilation through a mask or a supraglottic airway. This is referred to as a failed intubation, and occurs under the following scenarios:

Can’t-intubate, can’t–oxygenate (CICO): Rescue oxygenation cannot be accomplished by mask ventilation or a supraglottic airway and the airway needs to be secured immediately with a cricothyrotomy. A CICO scenario occurs when: