What is an emergency backup airway adjunct for a failed airway during intubation?

Emergency Backup Airway Adjunct for Failed Intubation

A supraglottic airway device (SGA), specifically a laryngeal mask airway (LMA) or intubating laryngeal mask airway (ILMA), is the primary emergency backup airway adjunct when intubation fails. 1

Immediate Action After Failed Intubation

When intubation attempts fail, the priority shifts immediately to maintaining oxygenation rather than persisting with intubation attempts. 1

First-Line Rescue: Supraglottic Airways

• Insert an SGA (LMA/ILMA) after declaring failed intubation to establish immediate oxygenation and ventilation 1
• SGAs provide successful rescue ventilation in 94.1% of failed intubation cases 1
• The device maintains airway patency while allowing continuous oxygenation between further management attempts 1
• Limit SGA insertion attempts to a maximum of two to avoid airway trauma and progression to "can't intubate, can't oxygenate" (CICO) 1

Alternative: Facemask Ventilation

• Facemask ventilation with optimal technique (two-person approach, oral/nasal airways, CPAP, neuromuscular blockade) serves as an alternative rescue method 1
• Maximum of three facemask ventilation attempts are permitted with changes in technique between attempts 1
• Neuromuscular blockade significantly improves facemask ventilation success, particularly with laryngospasm, chest wall rigidity, or obesity 1

Critical Decision Points After Successful Rescue Oxygenation

Once an SGA or facemask provides adequate ventilation (confirmed by waveform capnography and stable/improving oxygen saturation), you have three options: 1

1. Wake the patient (safest option if surgery can be postponed)
2. Wait for expert help while maintaining oxygenation
3. Proceed to front-of-neck airway (FONA) if clinical situation demands definitive airway

When to Proceed Directly to FONA

Even with successful SGA ventilation, proceed immediately to FONA if: 1

• Marginal oxygenation despite SGA
• Active aspiration risk
• Difficult ventilation through the SGA
• Patient requires definitive airway and cannot be awakened

Progression to CICO and Emergency Surgical Airway

If both SGA and facemask ventilation fail, you have a CICO situation requiring immediate FONA. 1

FONA Preparation Protocol ("Priming for FONA")

The British Journal of Anaesthesia recommends a staged approach: 1

1. Get the FONA set to bedside after one failed intubation attempt
2. Open the FONA set after one failed SGA or facemask attempt
3. Perform FONA immediately when CICO is declared

Recommended FONA Technique

• Scalpel cricothyroidotomy (scalpel-bougie-tube technique) is the preferred emergency surgical airway 1
• This technique is fast, reliable, has high success rates, uses familiar equipment, and provides a definitive airway with aspiration protection 1
• Transition to FONA should occur within 60 seconds of recognizing failed ventilation 1

Additional Rescue Options (Context-Dependent)

Fibreoptic-Guided Intubation Through SGA

• If time permits and expertise available, single attempt at fibreoptic intubation through a successfully placed SGA 1
• Use Aintree Intubation Catheter technique to allow larger (7.0mm) tracheal tube placement 1
• This is NOT appropriate in CICO situations—maintain oxygenation and proceed to FONA instead 1

Adjuncts During Intubation Attempts

• Tracheal tube introducers (bougies) show 96% first-attempt success in difficult airways versus 82% with stylets 1
• Video laryngoscopy provides 92-100% success rates after failed direct laryngoscopy 1
• These should be employed during initial intubation attempts, not after declaring failed intubation 1

Critical Pitfalls to Avoid

• Do not persist with multiple intubation attempts—limit to maximum four laryngoscope insertions total 1
• Do not delay FONA due to procedural reluctance—delayed transition causes more morbidity than the procedure itself 1
• Do not rely on oxygen saturation alone—use waveform capnography to confirm ventilation success 1
• Do not wait for life-threatening hypoxemia before transitioning to FONA—establish emergency airway before profound hypoxemia occurs 1
• Ensure adequate neuromuscular blockade before FONA attempts to maximize success 1