Can't Intubate Can't Oxygenate (CICO)

Quick Answer

What is it? Can't Intubate Can't Oxygenate (CICO) is a life-threatening airway emergency where tracheal intubation has failed AND oxygenation cannot be achieved via facemask or supraglottic airway (SGA). This represents the final common pathway of failed airway management requiring emergency front-of-neck access (FONA) [1].

Why does it matter? CICO is the most feared complication in airway management. Without prompt recognition and intervention, hypoxic brain injury and cardiac arrest ensue within minutes. The 4th National Audit Project (NAP4) of the Royal College of Anaesthetists identified CICO scenarios as a major cause of airway-related morbidity and mortality [2].

Key points:

• CICO is declared after failed intubation attempts AND failed oxygenation via facemask and SGA
• This is NOT can't intubate CAN oxygenate—different management pathway
• Declare CICO early—verbal declaration triggers transition to FONA algorithm
• First-line FONA: Scalpel-bougie-cricothyroidotomy (or needle cricothyroidotomy if expertise limited)
• Time is critical: commence FONA within 3 minutes of CICO declaration
• Prevention through thorough airway assessment and planning is paramount [3]

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Indigenous Health Considerations

Aboriginal and Torres Strait Islander Health

Airway emergencies present unique challenges for Aboriginal and Torres Strait Islander patients due to geographical, linguistic, and physiological factors. Remote and rural Indigenous populations experience higher rates of obesity, diabetes, and cardiovascular disease—independently increasing difficult airway incidence [4]. These comorbidities complicate both airway management and crisis response.

Language barriers during CICO scenarios create profound risks. Emergency airway management relies on rapid, clear communication. Patients with limited English proficiency may not understand urgency, consent processes, or instructions during awake intubation attempts [5]. Family members often serve as interpreters, but their distress during crises impairs translation accuracy. Standardised communication tools and translated emergency phrases are rarely available in remote settings.

Cultural concepts regarding medical emergencies differ significantly from Western frameworks. Some Aboriginal communities conceptualise illness through spiritual and social lenses rather than biomedical models. This can influence help-seeking behaviour and emergency response expectations. Healthcare providers must deliver technically excellent care while remaining culturally humble and respectful.

Remote practice limitations dramatically affect CICO outcomes. Many remote Indigenous communities lack immediate specialist anaesthetic support. Flying specialist teams face weather delays and extended response times. Local primary care practitioners may manage airways beyond their usual scope during emergencies. Telemedicine support and regional retrieval protocols attempt to bridge these gaps but cannot replicate immediate specialist presence [6].

Historical healthcare experiences create justified wariness of emergency interventions. Past experiences of culturally unsafe care, forced medical procedures, and separation from family during medical transfers generate fear and resistance. Patients may delay presentation until crises are advanced, or refuse interventions that could be life-saving. Trauma-informed crisis communication acknowledges these historical contexts while delivering urgent care.

Māori Health (Aotearoa New Zealand)

Māori populations demonstrate elevated rates of obesity (48% vs 30% non-Māori), sleep apnoea, and obstructive airway disease—independently increasing difficult mask ventilation and intubation risks [7]. These physiological factors compound during airway emergencies, making CICO scenarios more likely and more challenging to resolve successfully.

Whānau-centred care models face unique tensions during CICO emergencies. While Māori cultural frameworks emphasise collective decision-making involving extended family, airway emergencies demand immediate action without consultation time. This creates potential conflicts between cultural protocols and medical necessity. Advance care planning and culturally grounded advance directives may help navigate these tensions, though many Māori patients have not completed such planning.

Language revitalisation efforts mean increasing numbers of Māori speakers, particularly among older generations. Medical emergencies involving these speakers require interpreter services, but emergency airway management rarely permits interpreter-mediated communication. The principle of whanaungatanga (relationship-based care) suggests that established relationships with healthcare providers improve emergency outcomes, yet many Māori patients lack consistent primary care relationships [8].

Marae-based or rural Māori communities face similar geographic barriers to remote Aboriginal communities. Specialist anaesthetic services centralise in urban centres, requiring significant travel for specialist procedures. Emergency airway management in these settings depends on generalist practitioners, often managing beyond their comfort zone. Regional networks and telemedicine support provide guidance but cannot substitute for hands-on expertise during CICO scenarios.

Institutional racism within acute care settings compounds physiological risks. Māori patients report feeling judged, dismissed, or stereotyped in emergency departments. These experiences create justified healthcare avoidance and may delay presentation during developing airway crises. When emergencies do occur, patient anxiety and provider bias may impair communication and technical performance. Cultural safety training and Māori health workforce development address these systemic issues [9].

Shared Indigenous Considerations

Both Aboriginal and Māori populations demonstrate higher smoking rates, contributing to airway pathology including laryngeal oedema, tumour burden, and chronic obstructive pulmonary disease. These factors increase both the incidence of difficult airways and the speed of desaturation during apnoeic periods. Shorter safe apnoea times demand faster decision-making and technique execution.

Post-tonsillectomy airway emergencies present particular risks in Indigenous children. Higher rates of obstructive sleep apnoea, obesity, and possibly differences in tonsillar anatomy contribute to postoperative airway obstruction and bleeding requiring emergency airway management. Remote communities face particular challenges managing these emergencies when tertiary care is hours away [10].

Research representation in difficult airway literature remains inadequate. Most airway management studies recruit from urban tertiary centres with predominantly non-Indigenous populations. Evidence-based algorithms may not reflect the physiological diversity and resource constraints of Indigenous patient care. Practitioners must apply clinical judgment and adapt evidence-based approaches to their specific contexts.

Training and maintenance of emergency airway skills presents workforce challenges. Indigenous health workforce development programmes aim to increase Aboriginal and Māori representation in anaesthesia, but progress remains slow. Cultural mentorship and support for Indigenous trainees navigating predominantly non-Indigenous training environments improves retention and ultimately service provision for Indigenous communities.

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Clinical Overview

Definition and Recognition

CICO Declaration: CICO is declared when the following conditions are met simultaneously [11]:

1. Tracheal intubation has failed after optimal technique (maximum 3 attempts by experienced operator)
2. Facemask ventilation is inadequate or impossible
3. Supraglottic airway (SGA) insertion and ventilation has failed
4. Patient cannot maintain adequate oxygenation (SpO₂ falling, <90%)

This represents transition from "can't intubate CAN oxygenate" (safe situation allowing alternative approaches) to "can't intubate CAN'T oxygenate" (life-threatening emergency requiring immediate FONA).

Critical Distinction: The Vortex Approach and other airway algorithms emphasise that maintaining oxygenation is the primary goal—not intubation. A patient who cannot be intubated but CAN be oxygenated via facemask or SGA is in a stable, manageable situation. Only when oxygenation fails does CICO exist [12].

Time Criticality:

• Brain: Irreversible damage begins after 4-6 minutes of severe hypoxia
• Heart: Cardiac arrest typically occurs within 5-10 minutes of profound hypoxia
• Decision-to-FONA time should be <3 minutes after CICO declaration
• Each additional attempt at failed techniques consumes oxygen reserves and delays definitive management

Epidemiology

Incidence:

• Difficult intubation: 1.5-8% of general anaesthetics (higher in obstetrics, 8-12%) [13]
• CICO scenario: 1:5,000 to 1:50,000 general anaesthetics (approximately 0.002-0.02%)
• Cannot intubate, cannot ventilate: 1:2,000 to 1:5,000 emergency department intubations
• Cannot intubate, cannot oxygenate requiring emergency surgical airway: 1:10,000 to 1:50,000

Mortality and Morbidity:

• NAP4 report: Airway complications accounted for 1/5th of all anaesthesia-related deaths
• CICO situations associated with 20-40% mortality when emergency FONA delayed or failed
• Hypoxic brain injury occurs in survivors with prolonged CICO time (>5 minutes)
• 70% of airway-related deaths occurred during routine general anaesthesia (not anticipated difficult airways) [14]

Risk Factors:

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Prevention and Preparation

Airway Assessment

Thorough preoperative assessment aims to identify potential difficult airways before induction:

History:

• Previous difficult intubation or airway management
• Snoring, sleep apnoea symptoms
• Previous head/neck surgery or radiotherapy
• Ankylosing spondylitis, rheumatoid arthritis (cervical spine)
• Acromegaly, obesity, pregnancy

Physical Examination:

Mouth opening:

• Inter-incisor distance <3 cm (3 finger breadths) suggests limited space
• <4 cm significantly increases intubation difficulty

Mallampati classification:

• Class III (soft palate only visible) or IV (hard palate only) predicts difficulty
• Best assessed with patient sitting, head neutral, tongue protruded, no phonation
• Sensitivity limited (predicts only 50% of difficult intubations) [15]

Thyromental distance:

• <6 cm or <3 finger breadths indicates reduced mandibular space
• Less reliable in obesity (tissue overlying landmarks)

Neck mobility:

• Atlanto-occipital extension critical for intubation positioning
• Reduced by cervical collars, arthritis, ankylosis, obesity

Upper lip bite test:

• Ability to bite upper lip with lower incisors predicts adequate mandibular subluxation
• More predictive than thyromental distance [16]

Investigations:

• C-spine imaging if trauma or instability suspected
• CT neck if tumour, abscess, or retropharyngeal pathology
• Sleep study if OSA suspected
• Arterial blood gas if respiratory compromise

Planning and Equipment

Strategy Selection: Based on airway assessment, select appropriate strategy before induction:

Equipment Requirements:

• Multiple laryngoscopes (direct and video)
• Bougie (gum elastic bougie or Eschmann stylet)
• Supraglottic airways (size-appropriate, at least 2 types: e.g., LMA Supreme, i-gel)
• Facemask with ORAM (oropharyngeal airway) adjuncts
• Difficult airway trolley with emergency surgical airway equipment
• High-flow nasal oxygenation (THRIVE) capability
• Capnography mandatory for all airway management [17]

Personnel:

• Experienced assistant (familiar with difficult airway algorithms)
• Second anaesthetist present for anticipated difficult airways
• Surgeon immediately available if CICO risk high
• Emergency protocols activated and understood

Awake Intubation

Awake fibreoptic or videolaryngoscopic intubation is the gold standard for anticipated difficult airways:

Indications:

• Predicted difficult mask ventilation + predicted difficult intubation
• Airway compromise from tumour, trauma, infection, or oedema
• Unstable cervical spine
• Severe respiratory failure where apnoea intolerable
• Morbid obesity with other risk factors

Technique:

1. Preparation:

   • Detailed informed consent (explain awake nature, cooperation required)
   • Antisialagogue (glycopyrrolate 200 μg IV)
   • Topical anaesthesia: 4-10% lignocaine via nebuliser, atomiser, or "spray-as-you-go"
   • Bilateral superior laryngeal nerve blocks if needed
   • Transtracheal lignocaine injection (optional, 2-3 mL 2% via cricothyroid membrane)

2. Sedation (if required):

   • Goal: cooperative, responsive, airway reflexes maintained
   • Remifentanil infusion 0.05-0.1 μg/kg/min (airway tolerance without respiratory depression)
   • Dexmedetomidine 0.5-1 μg/kg/hr (anxiolysis without respiratory depression)
   • Avoid benzodiazepines or propofol (risk of respiratory obstruction and loss of cooperation)

3. Intubation:

   • Fibreoptic bronchoscope with loaded endotracheal tube
   • Gentle advancement through nasal or oral route
   • Visualisation of laryngeal structures; identify vocal cords
   • Advance scope through cords; railroad tube over scope
   • Confirm position (visualisation of carina, ETCO₂, bilateral chest movement)

4. Induction:

   • Only after confirmation of tube position and ability to ventilate
   • Caution: tube displacement during positioning for surgery

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CICO Algorithm and Management

The Vortex Approach

The Vortex Approach provides a structured cognitive framework for emergency airway management [18]:

Three Non-Surgical Airway Techniques:

1. Facemask ventilation (with adjuncts: oropharyngeal/nasopharyngeal airways, two-hand technique)
2. Supraglottic airway (LMA Supreme, i-gel, King LT, laryngeal tube)
3. Tracheal intubation (direct laryngoscopy, videolaryngoscopy, bougie, stylet)

Crisis Limit:

• Maximum 3 attempts at each non-surgical technique (by experienced operator)
• Best attempt at each technique before moving to next
• After 3 attempts at each without oxygenation success → CICO declared

Green Zone (Safe):

• Any successful oxygenation via facemask, SGA, or ETT
• Patient can maintain SpO₂ >90-95%
• Time available for alternative strategies, optimisation, or waking patient

CICO (Red Zone):

• All 3 techniques failed
• Oxygenation impossible
• Immediate transition to emergency FONA

CICO Declaration

Verbal Declaration: The verbal statement "This is a CICO situation" serves critical functions [19]:

• Acknowledges life-threatening emergency
• Triggers transition from intubation attempts to FONA
• Mobilises all available resources and assistance
• Communicates urgency to entire team
• Prevents further futile attempts at failed techniques

Timing:

• Declare when oxygenation failing despite best non-surgical attempts
• Do NOT wait until cardiac arrest
• Earlier declaration allows preparation and execution of FONA before critical hypoxia
• CICO declared within 3 minutes of oxygenation failure

Immediate Actions Upon CICO Declaration

Positioning:

• Extend neck, optimise sniffing position if not contraindicated
• Ensure head elevated/forward ("ramped" position in obesity)
• Remove cervical collar if applied (manual inline stabilisation if trauma)

Call for Help:

• Alert surgeon, senior anaesthetist, emergency team
• Request surgical airway equipment if not immediately present
• Activate institutional emergency protocols (e.g., Code Blue)

Oxygenation Optimisation:

• 100% oxygen via facemask (while preparing FONA)
• Two-hand mask technique with oropharyngeal airway
• Attempt bag-mask ventilation with PEEP valve
• Consider apnoeic oxygenation via nasal cannulae at 15 L/min (buys 1-2 minutes)

FONA Preparation:

• Identify cricothyroid membrane (ultrasound if available and time permits)
• Prepare surgical airway equipment:
  • Scalpel (size 10 blade)
  • Bougie (gum elastic or dedicated cricothyroidotomy bougie)
  • Cuffed tube (6.0 mm ETT or dedicated cricothyroidotomy cannula)
  • Syringe, tape, sutures

Medications:

• Consider small dose induction agent (ketamine 0.5-1 mg/kg) if patient conscious but agitated—prevents aspiration and facilitates FONA
• Avoid paralysing doses of NMBA (no advantage; may worsen situation if FONA fails)
• Atropine available for vagal response during FONA

Front-of-Neck Access (FONA)

FONA is the definitive management of CICO. Two main techniques exist:

Scalpel-Bougie-Cricothyroidotomy (Recommended First-Line)

This technique is recommended by Difficult Airway Society (DAS) and Australian and New Zealand College of Anaesthetists (ANZCA) [20]:

Equipment:

• Scalpel with size 10 blade (broad blade for clean incision)
• Bougie (standard gum elastic bougie or dedicated cricothyroidotomy introducer)
• Cuffed tracheal tube (6.0 mm internal diameter)

Technique:

1. Palpation and stabilisation:

   • Identify cricothyroid membrane (depression between thyroid and cricoid cartilages)
   • Stabilise larynx with non-dominant hand (thumb and middle finger on thyroid cartilage, index finger on cricoid)

2. Incision:

   • Vertical skin incision (3-4 cm) over cricothyroid membrane
   • Vertical orientation avoids anterior jugular veins and allows extension if needed
   • Through skin, subcutaneous tissue, through cricothyroid membrane

3. Bougie insertion:

   • Insert bougie through incision into trachea
   • Confirmation: resistance felt as bougie passes cricoid ring and enters tracheal lumen
   • Advance bougie distally (anterior tracheal wall sensation confirms correct position)

4. Railroad tube:

   • Load 6.0 mm cuffed ETT over bougie
   • Advance tube into trachea
   • Remove bougie
   • Inflate cuff

5. Confirmation:

   • Capnography (waveform confirms tracheal placement)
   • Auscultation bilateral breath sounds
   • SpO₂ improvement
   • Secure tube (tape or ties); note depth at teeth/lips

Advantages:

• Rapid (can be performed in <30 seconds with practice)
• High success rate (90-95% in cadaver and manikin studies)
• Uses familiar equipment (scalpel, bougie, ETT)
• Cuffed tube provides secure airway with protection against aspiration
• Larger diameter (6.0 mm) allows suctioning and spontaneous breathing

Needle Cricothyroidotomy

Indications:

• Operator unfamiliar with surgical cricothyroidotomy
• Paediatric patients (<10 years, smaller cricothyroid membrane)
• Anatomical distortion preventing scalpel technique
• Severe coagulopathy (though surgical technique still usually preferred)

Equipment:

• Large bore intravenous catheter (14G or 16G; purpose-built cricothyroidotomy cannula preferred—4-6 mm diameter)
• Syringe (10-20 mL)
• Saline for confirmation
• High-pressure oxygen source (jet ventilation system or modified bag-valve device)

Technique:

1. Identify and stabilise cricothyroid membrane
2. Attach syringe with saline to catheter (fluid facilitates aspiration confirmation)
3. Insert catheter through cricothyroid membrane at 45° angle, caudal direction
4. Aspirate air bubbles confirms intratracheal placement
5. Advance catheter, remove needle
6. Attach oxygen delivery system

Jet Ventilation:

• Connect to high-pressure oxygen source (50 psi, wall outlet or dedicated jet ventilator)
• Intermittent insufflation: 1 second on, 2-4 seconds off
• FiO₂ 1.0, driving pressure 25-50 psi
• Observe chest rise; passive expiration (venturi effect entrains air)
• Continuous capnography essential (but limited value due to venturi entrainment)

Advantages:

• Less invasive; smaller skin incision
• Familiar equipment (IV catheter)
• May be quicker for inexperienced operators

Disadvantages:

• Narrow lumen limits exhalation (risk of barotrauma, pneumothorax, pneumomediastinum)
• Requires high-pressure oxygen source (not always immediately available)
• Risk of posterior tracheal wall perforation, oesophageal injury
• Kinking, displacement, obstruction common
• Aspiration risk (uncuffed, high-pressure system)
• Carbon dioxide elimination inadequate for prolonged use (>30-45 minutes causes severe hypercapnia)

Rapid Ventilation via Intrinsic Tubing (RAVITT): Modified technique using 4 kPa oxygen via standard anaesthetic machine tubing (avoids jet ventilation risks) [21]

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Post-FONA Management

Immediate Care

Confirmation and Stabilisation:

• Confirm tracheal placement (capnography, auscultation, chest X-ray)
• Secure tube (tape/ties); document depth
• Ventilate with 100% oxygen
• Anaesthesia induction (if not already performed during FONA)
• Arterial blood gas assessment

Complication Management:

• Bleeding from incision site: direct pressure; sutures if needed
• Pneumothorax (if needle technique used): chest drain if tension
• Subglottic stenosis risk: plan for early conversion to formal tracheostomy or extubation
• Infection: prophylactic antibiotics (controversial; give if contamination or prolonged use)

Conversion to Definitive Airway

Options:

1. Extubation when safe:

   • If original indication for intubation resolved (e.g., CICO during elective case, no airway oedema)
   • Requires airway oedema assessment (cuff leak test, fibreoptic inspection)
   • Extubate over airway exchange catheter or bougie (facilitates re-intubation if needed)

2. Conversion to formal tracheostomy:

   • If prolonged intubation anticipated (>7 days)
   • Reduces subglottic stenosis risk
   • Performed in controlled theatre setting (not emergency bedside)
   • Usually 48-72 hours after cricothyroidotomy when patient stable [22]

3. Surgical airway revision:

   • If cricothyroidotomy cannula causing complications
   • If upper airway obstruction persists

Documentation and Review

Documentation:

• Detailed record of CICO sequence: timing, attempts, techniques used, oxygen saturation trends
• FONA technique used, equipment, complications
• Post-procedure care and outcomes
• Patient and family communication

Debriefing:

• Immediate team debriefing (within 24-48 hours)
• Root cause analysis if protocol deviations or system failures
• Morbidity and mortality review presentation
• Lessons learned and protocol updates

Follow-up:

• Patient counselling regarding event and implications
• Airway alert documentation (alert bracelet, electronic health record flags)
• Future airway management planning (awake intubation for all future procedures)
• Psychological support for patient and staff if needed

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Indigenous Health and Emergency Airway Management

Cultural Considerations in Crisis

Airway emergencies involving Indigenous patients require cultural safety integration even during time-critical interventions.

Communication During Crisis: When patients are conscious during CICO scenarios, clear communication is essential but culturally grounded. Aboriginal patients may communicate distress differently—silence or withdrawal may indicate severe anxiety rather than calm. Maintaining eye contact protocols varies across cultural groups. Healthcare providers should remain culturally humble while delivering urgent care, acknowledging that their cultural framework may not match the patient's [23].

Family Involvement: Cultural protocols regarding family presence during medical emergencies differ significantly. Many Aboriginal and Māori families expect to be present, offering spiritual and emotional support. However, airway emergencies requiring FONA may be distressing to witness. Balancing cultural expectations with patient safety requires sensitive negotiation—offering family presence during preparation but requesting temporary absence during the most invasive FONA steps may represent a respectful compromise.

Spiritual and Religious Considerations: During life-threatening airway emergencies, patients and families may request spiritual interventions. For Māori patients, karakia (prayers) before emergency procedures provide comfort. Aboriginal patients may request smoking ceremonies or connection to traditional healers. Where possible, accommodating these requests (even briefly) supports holistic care without significantly compromising emergency response time.

Addressing Health System Barriers

Remote Practice Limitations: Indigenous populations disproportionately reside in remote and rural areas with limited specialist services. Emergency airway management in these contexts depends on generalist practitioners—GP anaesthetists, rural emergency physicians, or retrieval teams. CICO scenarios in these settings present particular challenges: limited equipment, delayed surgical support, and protracted retrieval times [24].

Competency maintenance for occasional practitioners is difficult. Simulation training, telemedicine support, and standardised emergency airway kits partially address these gaps. Regional retrieval services provide specialist backup but cannot always arrive within the critical 3-5 minute window for CICO resolution.

Workforce Diversity: Increasing Indigenous representation in anaesthesia and emergency medicine improves culturally safe emergency care. Cultural mentorship programmes support Indigenous trainees navigating predominantly non-Indigenous training environments. Community-based training rotations enable Indigenous practitioners to serve their own communities, reducing cultural barriers during emergencies [25].

Institutional Response: When CICO emergencies occur in Indigenous patients, institutions must examine whether systemic factors contributed. Were warning signs missed due to cultural communication barriers? Was there delay in escalation due to implicit bias? Root cause analyses should include cultural safety assessment alongside technical review.

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SAQ Practice Questions

SAQ 1: CICO Scenario Management (25 marks)

You are anaesthetising a 45-year-old man for elective laparoscopic cholecystectomy. Following induction, you are unable to intubate using direct laryngoscopy (Cormack-Lehane grade 4 view). Bag-mask ventilation is attempted but unsuccessful. An i-gel supraglottic airway is inserted but fails to achieve a seal or enable ventilation. The patient's oxygen saturation has fallen from 98% to 72% over 3 minutes.

a) What is your diagnosis and immediate management priorities? (8 marks)

b) Describe the scalpel-bougie-cricothyroidotomy technique in detail (10 marks)

c) What are the potential complications of emergency cricothyroidotomy and how would you manage them? (7 marks)

Model Answer

a) Diagnosis and Immediate Management (8 marks)

Diagnosis (2 marks):

• This is a Can't Intubate Can't Oxygenate (CICO) emergency
• All three non-surgical airway techniques have failed (intubation, facemask, SGA)
• Patient cannot maintain oxygenation (SpO₂ 72% and falling)
• This requires immediate declaration of CICO and transition to emergency front-of-neck access (FONA)

Immediate priorities (6 marks):

1. Verbal declaration: State clearly "This is a CICO situation"—communicates emergency to team and triggers FONA protocol [26]
2. Call for help: Alert surgeon, request emergency airway trolley if not present, summon additional experienced staff
3. Positioning: Ensure optimal head position (sniffing position, head elevated in obesity), remove any cervical collar
4. Continue oxygenation attempts: Two-person bag-mask with oropharyngeal airway, 100% oxygen, PEEP valve if available—buys time during FONA preparation
5. FONA preparation: Immediate preparation of scalpel-bougie-tube equipment; identify cricothyroid membrane by palpation
6. Cease futile attempts: No further attempts at intubation or SGA insertion—consume oxygen reserves and delay definitive management

b) Scalpel-Bougie-Cricothyroidotomy Technique (10 marks)

Preparation (2 marks):

• Equipment: Size 10 scalpel blade (broad blade), gum elastic bougie, 6.0 mm cuffed ETT, syringe, securing tape
• Patient position: Supine with head extended (if not contraindicated); shoulder roll may improve access
• Identify cricothyroid membrane: palpate between thyroid and cricoid cartilages; stabilise larynx with non-dominant hand

Step-by-step technique (6 marks):

1. Skin incision: Vertical incision (3-4 cm) over cricothyroid membrane; vertical orientation avoids vessels and allows extension if needed; through skin and subcutaneous tissue
2. Membrane incision: Incise through cricothyroid membrane horizontally; use broad sweeping motion with scalpel; stabilise cricoid with fingers to prevent movement
3. Bougie insertion: Insert bougie through incision into tracheal lumen; feel for resistance as bougie passes over cricoid ring anteriorly; advance distally confirming anterior tracheal wall sensation (not posterior oesophageal wall)
4. Tube railroading: Load 6.0 mm cuffed ETT over bougie; advance tube into trachea while holding bougie steady; ensure tube passes easily (do NOT force)
5. Bougie removal: Remove bougie while securing tube position
6. Cuff inflation and confirmation: Inflate cuff; confirm tracheal placement via continuous capnography (waveform), bilateral chest auscultation, SpO₂ improvement; secure tube at appropriate depth (typically 20-22 cm at teeth in adult)

Post-procedure (2 marks):

• Ventilate with 100% oxygen; anaesthesia induction if not performed
• Arterial blood gas to assess acid-base status and oxygenation
• Chest X-ray to confirm tube position and exclude complications
• Document procedure, complications, and post-operative plan

c) Complications and Management (7 marks)

Immediate complications (4 marks):

• Haemorrhage: Anterior jugular veins or thyroid vessels; manage with direct pressure; surgical ligation if persistent; rarely requires formal surgical exploration
• Posterior tracheal wall perforation/oesophageal injury: Forceful technique or blind puncture; avoid by feeling anterior tracheal wall with bougie; presents with surgical emphysema, pneumomediastinum; conservative management usually; surgical repair if large defect
• Pneumothorax: Particularly with needle cricothyroidotomy (barotrauma); tension pneumothorax requires immediate needle decompression then chest drain
• Subglottic stenosis: Long-term risk from cricothyroidotomy (cricoid cartilage injury); plan early conversion to tracheostomy or extubation; ENT follow-up if prolonged intubation

Procedural failures (2 marks):

• False passage creation: Bougie in pretracheal space rather than trachea; no CO₂ on capnography; immediate recognition by lack of chest rise and falling SpO₂; re-attempt FONA if time permits or convert to needle technique
• Tube displacement: During positioning or transport; maintain manual in-line stabilisation; secure tube with tape/ties; confirm position after any movement

Long-term complications (1 mark):

• Voice change/dysphonia: Cricothyroid muscle injury; usually temporary; ENT follow-up if persistent
• Scarring/cosmetic deformity: Small scar from incision; improves with time
• Psychological trauma: Patient and staff debriefing essential; psychological support if needed

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SAQ 2: Awake Intubation vs CICO Prevention (20 marks)

A 55-year-old man with obesity (BMI 42), severe obstructive sleep apnoea, and limited mouth opening (2.5 cm inter-incisor distance) presents for total knee replacement. Airway examination reveals Mallampati Class IV, thyromental distance 5 cm, and thick neck circumference.

a) What is your airway management strategy for this patient? (8 marks)

b) How does this strategy prevent progression to CICO? (6 marks)

c) Describe your approach if the patient refuses awake intubation and insists on "being put to sleep" (6 marks)

Model Answer

a) Airway Management Strategy (8 marks)

Risk assessment (2 marks):

• This patient has multiple predictors of difficult airway:
  • Difficult intubation: Mallampati IV, limited mouth opening (<3 cm), reduced thyromental distance
  • Difficult mask ventilation: obesity, OSA, thick neck
  • CICO risk: combination of predicted difficult intubation AND difficult mask ventilation
• Risk stratification: This is a potentially CICO scenario requiring awake intubation with surgical backup [27]

Strategy selection (4 marks):

• Recommended approach: Awake fibreoptic intubation (or videolaryngoscopy) under topical anaesthesia
• Technique:
  • Preoperative: Glycopyrrolate 200 μg IV (reduce secretions), thorough topicalisation with 10% lignocaine (nebulised, atomised, spray-as-you-go)
  • Sedation: Remifentanil infusion 0.05-0.1 μg/kg/min (provides airway tolerance without respiratory depression) OR dexmedetomidine 0.5-1 μg/kg/hr
  • Avoid heavy sedation or GA (risk of airway obstruction and loss of cooperation)
  • Fibreoptic bronchoscope with loaded endotracheal tube; nasal route often preferred in limited mouth opening
  • Bilateral superior laryngeal nerve blocks if topicalisation incomplete
  • Confirm tube position with capnography, visualisation of carina
  • ONLY induce anaesthesia after confirmation of position and ventilation ability

Backup plans (2 marks):

• Plan B: If awake intubation fails, maintain oxygenation via facemask or SGA; cancel surgery; do NOT proceed to general anaesthesia with uncertain airway
• Surgical standby: Surgeon present in theatre; prepared for emergency tracheostomy if CICO occurs despite awake approach
• Alternative locations: If no confidence in awake technique, refer to centre with expertise or consider regional anaesthesia alone if surgery amenable

b) Prevention of CICO Progression (6 marks)

Maintaining oxygenation throughout (3 marks):

• Awake technique ensures patient maintains spontaneous ventilation and oxygenation throughout airway manipulation
• If intubation fails at any point, patient continues breathing—no apnoeic period or desaturation
• This maintains the "CAN oxygenate" status indefinitely, preventing transition to CICO
• Contrast with asleep approach: once paralysed, if intubation and mask ventilation fail, CICO exists immediately

Controlled gradual approach (2 marks):

• Awake intubation allows multiple attempts with patient feedback
• Can abort and reassess if difficulty encountered
• Time to call for help, gather additional resources, consider alternatives
• No time pressure of desaturating paralysed patient

Surgical backup readiness (1 mark):

• Surgeon present and scrubbed if emergency surgical airway needed
• Equipment prepared before airway manipulation begins
• Can proceed immediately to tracheostomy if CICO develops (though prevented by awake approach)

c) Management of Refusal (6 marks)

Informed consent and explanation (2 marks):

• Explain risks clearly: "With your airway anatomy, if we put you to sleep and cannot intubate or ventilate, you could suffer brain damage or die within minutes"
• Use visual aids, diagrams, or educational videos showing airway anatomy and risks
• Involve family members in discussion if patient wishes (cultural considerations)
• Emphasise that awake technique is safest option, well-tolerated, and standard practice for this situation

Options if continued refusal (2 marks):

• Regional anaesthesia: If surgery amenable (knee replacement can often be performed under spinal or combined spinal-epidural with sedation)
  • Avoids airway manipulation entirely
  • May require anaesthetist presence for sedation management
• Postpone surgery: If no safe alternative and patient refuses awake intubation
  • Document refusal and risks explained
  • Refer for second opinion or airway clinic assessment
  • Patient may reconsider after further reflection and information

If must proceed against recommendation (2 marks):

• Document thoroughly: patient's refusal of recommended approach, risks explained, witnesses present
• Proceed with maximum preparation:
  • Experienced anaesthetist (most senior available)
  • Video laryngoscopy first-line
  • Multiple SGAs available
  • Emergency FONA equipment ready
  • Surgeon scrubbed and present
  • Consider intubating in semi-upright position
  • Spontaneous ventilation technique (inhalational induction with sevoflurane) maintaining breathing until airway secured
• This represents "acceptance of risk" not "standard care"; careful documentation essential

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SAQ 3: Paediatric CICO (15 marks)

A 4-year-old child presents for emergency evacuation of post-tonsillectomy haemorrhage. The child is bleeding actively from the mouth, agitated, and has vomited blood. Oxygen saturation is 88% on room air.

a) What are the specific challenges in this scenario? (5 marks)

b) Describe your airway management plan (6 marks)

c) If you progress to CICO, how would your FONA technique differ from adults? (4 marks)

Model Answer

a) Specific Challenges (5 marks)

Anatomical/physiological (2 marks):

• Paediatric airway: narrower, more anterior, more cephalad; higher risk of obstruction from blood, oedema, or soiling
• Rapid desaturation: higher metabolic rate, lower functional residual capacity—safe apnoea time significantly shorter than adults (1-2 minutes vs 3-5 minutes)
• Smaller cricothyroid membrane: more difficult to identify and access; scalpel technique more challenging

Clinical scenario (2 marks):

• Full stomach (blood ingestion) with high aspiration risk
• Active haemorrhage obscuring airway anatomy
• Hypovolaemia from bleeding (reduced blood volume 80 mL/kg; significant blood loss rapidly causes shock)
• Agitated, uncooperative child (difficult to preoxygenate, position, or perform awake assessment)
• Parental distress complicating team communication

Technical (1 mark):

• Emergency surgery with full stomach but cannot delay (ongoing haemorrhage)
• Limited equipment sizes available for paediatric FONA
• Less experienced with paediatric emergency surgical airway (rarely performed)

b) Airway Management Plan (6 marks)

Preparation (2 marks):

• Call for help: paediatric anaesthetist, ENT surgeon, paediatric emergency team
• Two IV cannulas, cross-match blood, fluid resuscitation (20 mL/kg crystalloid bolus; blood products if shocked)
• Position: left lateral head-down (Tonsil position) to facilitate drainage of blood; suction ready (Yankauer and fine suction)
• Rapid sequence induction plan with criocoid pressure (aspiration risk)
• Difficult airway trolley with paediatric equipment (multiple blade sizes, bougie, paediatric SGAs)

Induction technique (2 marks):

• Preoxygenation: 100% oxygen via facemask with head-down left lateral position (maximise FRC despite agitation)
• RSI technique: propofol 3-5 mg/kg or ketamine 1-2 mg/kg (ketamine maintains haemodynamics better if hypovolaemic); suxamethonium 1.5-2 mg/kg (rapid onset, short duration)
• Cricoid pressure (Sellick manoeuvre) until intubation confirmed
• Video laryngoscopy preferred (better view, less stimulation)
• Active suction of blood during laryngoscopy (assistant with Yankauer)
• Have surgeon ready for surgical haemorrhage control if intubation fails

Backup plans (2 marks):

• Failed intubation: Maintain cricoid pressure, facemask ventilation with oropharyngeal airway; avoid repeated attempts (desaturation risk)
• Cannot intubate, cannot ventilate: Insert paediatric SGA (size 1.5-2) through which child can breathe (leak around tube expected); continue cricoid pressure
• CICO: Prepare for needle cricothyroidotomy (scalpel technique challenging in small cricothyroid membrane); surgeon may proceed to tracheostomy if airway inaccessible

c) Paediatric FONA Differences (4 marks)

Technique modifications (3 marks):

• Needle cricothyroidotomy preferred: Cricothyroid membrane in 4-year-old is approximately 2-3 mm high and 6-8 mm wide—scalpel-bougie technique extremely challenging
• Equipment: 14G or 16G IV catheter (purpose-built paediatric cricothyroidotomy cannula if available); 3.0-3.5 mm uncuffed ETT may be used via surgical opening if scalpel technique possible
• Jet ventilation: Lower driving pressures (15-25 psi vs 50 psi in adults); shorter insufflation times (0.5 seconds); higher risk of barotrauma in small lungs—extreme caution
• Surgical tracheostomy: ENT surgeon may prefer to proceed directly to formal tracheostomy if airway accessible under general anaesthesia (scalpel cricothyroidotomy technically difficult in small neck)

Physiological considerations (1 mark):

• Rapid desaturation means FONA must be performed extremely quickly (<60 seconds from declaration)
• High metabolic rate and cardiac output—profound bradycardia with hypoxia; atropine 20 μg/kg IV should be immediately available
• Post-procedure: early conversion to formal tracheostomy or extubation; subglottic stenosis risk higher in paediatric patients with cricothyroid cartilage injury

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Viva Voce Scenarios

Viva Scenario 1: CICO Declaration and FONA

Examiner: "You are in theatre attempting intubation of a patient for routine elective surgery. You have failed intubation with direct laryngoscopy and a bougie. Mask ventilation is proving difficult with falling oxygen saturations. You've inserted a supraglottic airway which also fails to ventilate. The oxygen saturation is now 75% and falling. What is your immediate management?"

Model Answer:

"This is a Can't Intubate Can't Oxygenate (CICO) emergency requiring immediate declaration and transition to front-of-neck access (FONA).

My immediate actions are:

First, I would verbally declare the CICO situation: 'This is CICO—we need emergency front-of-neck access now.' This acknowledges the life-threatening emergency, mobilises the team, and prevents further futile attempts at techniques that have already failed.

I would call for immediate help—alert the surgeon, summon any available senior assistance, and ensure the emergency airway trolley is present if not already available.

While preparing for FONA, I would continue attempts at oxygenation: two-person facemask ventilation with 100% oxygen and oropharyngeal airway, as this may buy 30-60 seconds of partial oxygenation while FONA is prepared.

I would immediately begin the scalpel-bougie-cricothyroidotomy technique:

1. Position the patient with head extended if possible
2. Identify the cricothyroid membrane by palpation—the depression between the thyroid and cricoid cartilages
3. Using a size 10 scalpel blade, make a vertical incision (3-4 cm) over the cricothyroid membrane, cutting through skin and subcutaneous tissue
4. Sweep the scalpel horizontally through the cricothyroid membrane
5. Insert a gum elastic bougie through the incision, feeling for the resistance of passing into the tracheal lumen
6. Railroad a 6.0 mm cuffed endotracheal tube over the bougie into the trachea
7. Confirm placement with capnography and commence ventilation

This technique can be performed in under 60 seconds with practice and provides a definitive cuffed airway. The needle cricothyroidotomy is an alternative but has significant limitations including barotrauma risk and inadequate carbon dioxide elimination.

Throughout, I would maintain team communication and prepare for post-procedure stabilisation, including arterial blood gas and chest X-ray to exclude complications."

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Viva Scenario 2: Difficult Airway Assessment

Examiner: "You are assessing a patient preoperatively. Describe how you would evaluate whether this patient is at risk of CICO, and what factors would make you choose an awake intubation technique."

Model Answer:

"I would approach this systematically, assessing both the likelihood of difficult intubation and difficult mask ventilation, as the combination creates CICO risk.

For difficult intubation, I would assess:

• Mouth opening: inter-incisor distance should be at least 3 finger breadths; less than this increases difficulty significantly
• Mallampati classification: looking at the oropharyngeal view with the patient sitting, mouth open, tongue protruded. Class III (soft palate only) or IV (hard palate only) predicts difficulty
• Thyromental distance: from thyroid notch to menton should be at least 6 cm or 3 finger breadths
• Neck mobility: ability to extend at the atlanto-occipital joint; reduced mobility from arthritis, ankylosis, or cervical collar increases difficulty
• Upper lip bite test: can the patient bite their upper lip with their lower incisors? This tests mandibular subluxation ability

For difficult mask ventilation, I would look for:

• Obesity, particularly with high BMI and neck circumference
• Presence of beard or edentulous state
• Obstructive sleep apnoea history
• Age >55 years
• History of snoring or witnessed apnoeas

Risk factors that would mandate awake intubation include:

• Predicted difficult intubation combined with predicted difficult mask ventilation—this combination creates immediate CICO risk if the patient is anaesthetised and paralysed
• Airway compromise from tumour, trauma, infection, or oedema where obstruction may worsen with anaesthesia
• Cervical spine instability where movement could cause spinal cord injury
• Severe respiratory failure where even brief apnoea would be poorly tolerated

The principle is: if I anticipate that I might not be able to intubate or ventilate, I must ensure the patient remains breathing throughout airway manipulation. Awake intubation—usually fibreoptic or videolaryngoscopy with topical anaesthesia and careful sedation—maintains spontaneous ventilation and oxygenation, preventing the 'Can't Oxygenate' component of CICO even if intubation proves difficult.

I would also ensure surgical backup is immediately available for any anticipated difficult airway, with equipment prepared for emergency cricothyroidotomy before induction."

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ANZCA Syllabus Mapping

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