Emergency Airway Failure (CICV)
Recognize and respond to Cannot Intubate / Cannot Ventilate (CICV) — the most critical airway emergency. Review immediate action steps including emergency front-of-neck airway (eFONA) and prevention strategies.
Based on: DAS 2015 · ASA 2022
Input
Recognition
- ✗Cannot intubate — multiple laryngoscopy attempts have failed
- ✗Cannot ventilate — mask ventilation and LMA are both ineffective
- ✗Oxygenation is worsening despite all attempts
Immediate Action
- 1
Call for help immediately
Alert the full team. Do not manage CICV alone.
- 2
Optimize oxygenation
Two-person mask technique, jaw thrust, OPA/NPA, high-flow oxygen.
- 3
Proceed to eFONA
Emergency front-of-neck access (surgical cricothyrotomy) is the definitive rescue. Do not delay.
Why This Is Critical
- ⚠Oxygen reserves are exhausted within minutes
- ⚠Brain injury begins within 4–5 minutes of critical hypoxia
- ⚠Cardiac arrest may follow if eFONA is delayed
Action Principle
- →Stop repeating failed attempts — each attempt causes swelling and worsens conditions
- →Declare the situation clearly: "This is CICV"
- →Act decisively — hesitation is the danger
Contributing Factors
- •Failure to anticipate a difficult airway before induction
- •Repeated intubation attempts without maintaining oxygenation
- •Delayed recognition and failure to escalate
- •No backup plan prepared before induction
Preventive Insight
Most CICV situations are preventable with systematic airway planning before induction.
Teaching Point
If the plan fails, change the plan — not the effort. When CICV occurs, eFONA is the only path forward.
Overview
Cannot Intubate / Cannot Ventilate (CICV) is a rare but life-threatening airway emergency. Immediate recognition and decisive action — including emergency front-of-neck access — are required.
Evidence Summary
CICV is defined as the inability to intubate the trachea and maintain oxygenation by any means. The 4th National Audit Project (NAP4) identified failure to anticipate difficulty and repeated failed attempts as the most common contributing factors.
- Emergency front-of-neck access (eFONA) is the definitive rescue for CICV
- Surgical cricothyrotomy is preferred over needle techniques in adults (DAS 2015)
- Supraglottic airways (LMA) should be attempted before declaring CICV
- Maintaining oxygenation during all attempts extends the decision window