What is the recommended algorithm for managing a failed tracheal intubation?

Failed Intubation Algorithm

When tracheal intubation fails, immediately proceed through a structured four-plan algorithm: attempt supraglottic airway device (SAD) rescue (Plan B), then final facemask ventilation (Plan C), and if all oxygenation methods fail, perform emergency front-of-neck airway (eFONA) via scalpel cricothyroidotomy (Plan D). 1

Plan A: Failed Intubation Recognition

• Declare intubation failure after a maximum of 3-4 attempts or when further attempts are deemed futile 1, 2
• Stop all intubation attempts immediately to prevent airway trauma and edema that worsen subsequent rescue attempts 1
• Call for senior help and open the emergency front-of-neck airway kit at the bedside 1, 3

Plan B: Supraglottic Airway Device Rescue

• Insert a second-generation supraglottic airway device (e.g., LMA Supreme, i-gel) as the primary rescue technique 1, 2
• Limit SAD insertion attempts to a maximum of three 1
• Successful oxygenation is confirmed by waveform capnography and maintenance/improvement of oxygen saturations 1
• Ensure full neuromuscular blockade and adequate depth of anesthesia to optimize SAD placement 1

If SAD ventilation succeeds: Stop, think, and communicate with senior clinicians to determine whether to:

• Wake the patient (default option) 2
• Proceed with surgery via SAD if appropriate 1
• Consider controlled front-of-neck airway with senior surgical presence 1

If SAD ventilation fails after three attempts: Immediately declare failed SAD ventilation and move to Plan C 1

Plan C: Final Facemask Ventilation Attempt

• Make one final optimized attempt at facemask ventilation 1, 2
• Maximize success by:
  • Ensuring full neuromuscular blockade 1
  • Optimizing patient positioning (head extension, ear-to-sternal-notch alignment) 1
  • Using both oropharyngeal and nasopharyngeal airways 1
  • Employing two-person mask ventilation technique 1
• Recognize that rapid progression to Plan D (eFONA) may be necessary at any point 1

If facemask ventilation succeeds: Consider the same options as successful SAD ventilation, but recognize that proceeding to FONA may still be appropriate given the high-risk scenario 1

If facemask ventilation fails: This is a cannot intubate, cannot oxygenate (CICO) scenario—proceed immediately to Plan D 1, 2

Plan D: Emergency Front-of-Neck Airway (eFONA)

CICO is declared when all methods of oxygenation (intubation, SAD, facemask) have failed. 1

Immediate Actions:

• Declare CICO loudly to the team 1, 2
• Assign roles: eFONA operator, assistant, and someone to continue upper airway oxygen delivery attempts 1
• Do not attempt eFONA without full neuromuscular blockade 1
  • If sugammadex was already given, administer a non-steroidal neuromuscular blocker (not rocuronium/vecuronium) 1

Technique:

• Scalpel cricothyroidotomy (scalpel-bougie-tube technique) is the recommended first-line eFONA method 1, 3, 2
• Position the patient in maximal neck extension (push pillow beneath shoulders) 1
• When time permits, use ultrasound to locate and mark the cricothyroid membrane 3
• The scalpel technique has superior success rates compared to needle techniques in both clinical and simulation studies 1

Critical Pitfalls:

• Avoid multiple intubation attempts that cause airway trauma, bleeding, and edema—these dramatically reduce the success of subsequent rescue techniques 1
• Do not delay eFONA once CICO is recognized; hypoxic brain injury or death will ensue within minutes 1
• Reversal of neuromuscular blockade can worsen airway obstruction and make facemask ventilation more difficult 1
• In trauma patients with suspected cervical spine injury, securing the airway supersedes theoretical spinal concerns 3

Equipment Preparation

• Videolaryngoscopy should be first-line for anticipated difficult airways and trauma patients 3, 4
• A bougie should be immediately available, with first-pass success rates of 96% versus 82% with stylet alone 3
• Second-generation SADs must be stocked and all airway managers must maintain competence in their use 1
• The eFONA kit (scalpel-bougie-tube) must be immediately accessible in all locations where airway management occurs 1, 3

Special Considerations

• Limit total airway interventions to prevent trauma; blind techniques (blind bougie insertion through SAD) have been superseded by video- or fiber-optically guided methods 2
• In prehospital settings, the same algorithm applies with gum elastic bougie as first rescue, followed by intubating LMA, then cricothyroidotomy 5
• All anesthetists and emergency physicians must regularly practice and maintain competence in scalpel cricothyroidotomy 1, 2