The failed airway in adults
- Ron M Walls, MD, FRCPC, FAAEM
Ron M Walls, MD, FRCPC, FAAEM
- Editor-in-Chief — Adult and Pediatric Emergency Medicine
- Section Editor — Adult Resuscitation
- Neskey Family Professor of Emergency Medicine
- Harvard Medical School
- Brigham and Women's Hospital
- Michael F Murphy, MD, FRCPC
Michael F Murphy, MD, FRCPC
- Professor and Chair of Anesthesia and Pain Medicine
- University of Alberta
A failed airway exists when there is a failure on the part of the operator to effect gas exchange in a patient that cannot do so on their own. In the clinical arena, this most often occurs when there is an inability to intubate the patient's trachea (even after only a single failed attempt) and an inability to ventilate the patient adequately with a bag and mask to maintain oxyhemoglobin saturations above 90 percent. This is the "can't intubate, can't oxygenate" (CICO) type of failed airway. The term "failed airway", therefore is applied at any point at which the primary selected airway management technique is unsuccessful, and alternative techniques are not able to maintain oxygenation.
A second form of failed airway has been defined for emergency intubation, and exists when there have been three failed attempts to intubate by an experienced operator, even when bag and mask ventilation is capable of maintaining adequate oxyhemoglobin saturation . This is the "can't intubate, can oxygenate" type of failed airway. When either of these two situations arises during emergency airway management, the clinician must take effective action immediately to avoid oxygen desaturation with resultant cerebral hypoxia.
A failed airway can arise during a rapid sequence intubation, during management of a difficult airway, or during management of a crash airway. Regardless of the circumstances leading to the airway failure, a deliberate approach must be used to ensure that oxygenation is preserved, and that the airway is ultimately secured.
This topic review will discuss management of the failed airway. Discussions of other aspects of airway management are found elsewhere. (See "Rapid sequence intubation for adults outside the operating room" and "The difficult airway in adults" and "The difficult pediatric airway" and "Emergency endotracheal intubation in children".)
INCIDENCE OF THE FAILED AIRWAY
The true incidence of the failed airway, as defined above, is not known for emergency department (ED) airway management, nor for patients undergoing anesthesia in the operating room. Analysis of over 17,000 ED intubations  in the National Emergency Airway Registry (NEAR III) found that rapid sequence intubation is successful in three or fewer attempts in over 98 percent of cases for which it is the first method chosen, and that surgical cricothyrotomy (also called cricothyroidotomy) is required in approximately 0.3 percent of all emergency intubations [3,4]. (See "Emergency surgical cricothyrotomy (cricothyroidotomy)".)
- Walls RM. The Emergency Airway algorithms. In: Manual of Emergency Airway Management, 4th, Walls RM, Murphy MF. (Eds), Lippincott Williams & Wilkins, Philadelphia 2012. p.22.
- Brown CA 3rd, Bair AE, Pallin DJ, et al. Techniques, success, and adverse events of emergency department adult intubations. Ann Emerg Med 2015; 65:363.
- Sagarin MJ, Barton ED, Chng YM, et al. Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. Ann Emerg Med 2005; 46:328.
- Walls RM, Brown CA 3rd, Bair AE, et al. Emergency airway management: a multi-center report of 8937 emergency department intubations. J Emerg Med 2011; 41:347.
- Cook TM, Woodall N, Harper J, et al. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. Br J Anaesth 2011; 106:632.
- Sakles JC, Chiu S, Mosier J, et al. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med 2013; 20:71.
- Hasegawa K, Shigemitsu K, Hagiwara Y, et al. Association between repeated intubation attempts and adverse events in emergency departments: an analysis of a multicenter prospective observational study. Ann Emerg Med 2012; 60:749.
- The airway management algorithms cited in this review are reproduced with permission from: The Difficult Airway Course™: Emergency, and Walls, RM, Murphy, MF. Manual of Emergency Airway Management, 4th ed, Lippincott Williams & Wilkins, Philadelphia 2012.
- Dunn S, Connelly NR, Robbins L. Resident training in advanced airway management. J Clin Anesth 2004; 16:472.