Failed Intubation Management Algorithm
Overview of the Four‑Plan Rescue Sequence
- When tracheal intubation fails, a structured four‑plan algorithm should be followed: attempt a second‑generation supraglottic airway device (SAD) rescue (Plan B), then a final optimized facemask ventilation attempt (Plan C), and if oxygenation remains impossible, perform emergency front‑of‑neck airway (eFONA) via scalpel cricothyroidotomy (Plan D) 1.
Plan A – Recognition of Failed Intubation
- Declare intubation failure after a maximum of three to four attempts, or earlier when further attempts are deemed futile, and stop all attempts to avoid airway trauma and edema that impair subsequent rescue techniques 1.
- Immediately summon senior assistance and open the emergency front‑of‑neck airway kit at the bedside 1.
Plan B – Supraglottic Airway Device (SAD) Rescue
- Insert a second‑generation SAD (e.g., LMA Supreme, i‑gel) as the primary rescue intervention 1.
- Limit SAD insertion attempts to no more than three 1.
- Confirm successful oxygenation by waveform capnography and by observing maintenance or improvement of oxygen saturation 1.
- Ensure full neuromuscular blockade and adequate depth of anesthesia to optimise SAD placement 1.
- If SAD ventilation succeeds, the team may (i) awaken the patient (default), (ii) continue surgery through the SAD if appropriate, or (iii) consider a controlled front‑of‑neck airway with senior surgical presence 1.
- If SAD ventilation fails after three attempts, proceed to Plan C 1.
Plan C – Final Optimised Facemask Ventilation
- Perform one final, optimised facemask ventilation attempt 1.
- Maximise success by:
- Recognise that rapid progression to Plan D may be required at any point 1.
- If facemask ventilation succeeds, the same options as after successful SAD use apply, although proceeding to eFONA may still be considered given the high‑risk context 1.
- If facemask ventilation fails, the situation is classified as “cannot intubate, cannot oxygenate” (CICO) and Plan D should be initiated immediately 1.
Plan D – Emergency Front‑of‑Neck Airway (eFONA)
- CICO is declared when all prior oxygenation methods (intubation, SAD, facemask) have failed 1.
- Immediate actions: loudly announce CICO, assign clear roles (eFONA operator, assistant, and a team member to continue upper‑airway oxygen attempts), and do not attempt eFONA without full neuromuscular blockade; if sugammadex has been administered, use a non‑steroidal neuromuscular blocker 1.
- The scalpel‑bougie‑tube technique (scalpel cricothyroidotomy) is the recommended first‑line eFONA method 1.
- Position the patient in maximal neck extension by placing a pillow beneath the shoulders 1.
- The scalpel technique demonstrates superior success rates compared with needle techniques in both clinical and simulation studies 1.
- Avoid multiple intubation attempts that cause trauma, bleeding, and edema, as these markedly reduce the success of subsequent rescue methods 1.
- Do not delay eFONA once CICO is recognised; hypoxic brain injury or death can occur within minutes 1.
- Reversal of neuromuscular blockade can worsen airway obstruction and impede facemask ventilation 1.
Equipment Preparation
- Second‑generation SADs must be stocked in all airway locations, and all airway providers should maintain competence in their use 1.
- The eFONA kit (scalpel‑bougie‑tube) must be immediately accessible wherever airway management is performed 1.
Training and Competence
- All anesthetists and emergency physicians should regularly practice and maintain competence in scalpel cricothyroidotomy 1.