Every emergency physician eventually faces the nightmare scenario: the patient needs an airway, intubation is attempted, and it doesn’t work. Heart rates drop, saturations fall, panic rises. This is where the failed airway algorithm becomes your lifeline.
It is not about memorizing dozens of steps—it’s about having a clear, rehearsed pathway that guides you through chaos.
What Is a “Failed Airway”?
Definitions may vary slightly between guidelines, but in the ED it usually means:
- Failed intubation attempts – typically ≥2 failed laryngoscopy attempts by an experienced operator.
- Failed oxygenation/ventilation – SpO₂ cannot be maintained despite bag-mask or supraglottic airway.
- Cannot intubate, cannot oxygenate (CICO) – the dreaded “can’t intubate, can’t oxygenate” situation.
The Big Picture of the Algorithm
Think of the failed airway algorithm in three escalating stages:
Stage 1: Recognize Early
- If two attempts fail, don’t keep repeating the same thing.
- Call it a “failed airway” and escalate to Plan B.
Stage 2: Rescue Oxygenation (Plan B)
- Insert a supraglottic airway device (i-gel, LMA).
- Optimize BVM with two-person technique, airway adjuncts, and PEEP.
- Confirm oxygenation with waveform capnography.
- If oxygenation stabilizes, pause and decide: continue with SGA, attempt intubation through SGA, or wake patient if possible.
Stage 3: Cannot Intubate, Cannot Oxygenate (Plan C)
- If BVM and SGA both fail: immediate surgical airway (cricothyrotomy).
- Do not waste time—once SpO₂ is falling and cannot be restored, cric is the only option.
- Preferred in ED: scalpel-bougie-tube technique (simple, fast, reliable).
Key Principles Rookies Must Remember
- Two failed attempts = change strategy. Don’t let ego kill your patient.
- Oxygenation is the priority. Securing an airway is not about “the tube”—it’s about maintaining oxygen delivery.
- Have the cric kit open. Even if you never need it, seeing it reminds the team that surgical airway is on the table.
- Communicate out loud. Announce: “This is a failed airway, we are moving to supraglottic.” This helps the team shift gears.
- Time is brain. Every desaturation increases hypoxic brain injury risk—don’t delay escalation.
A Simplified ED-Friendly Algorithm
Plan A: Intubation
- First attempt with best technique (VL preferred).
- Optimize: position, suction, preoxygenation, bougie.
Plan B: Oxygenation Rescue
- Supraglottic airway (i-gel or LMA).
- Optimize BVM with adjuncts.
Plan C: Surgical Airway
- Immediate cricothyrotomy if cannot intubate + cannot oxygenate.
Common Rookie Pitfalls
- Too many repeated attempts. Each failed laryngoscopy worsens trauma, bleeding, swelling, and hypoxia.
- Delaying the cric. Hesitation kills—better to cut early than too late.
- Not rehearsing the plan. If you’ve never verbalized or practiced it, stress will paralyze you.
- Neglecting oxygenation. Don’t focus only on the tube—oxygenation comes first, by any means.
The Mental Model: “A-B-C”
- A: Attempt intubation (Plan A).
- B: Backup oxygenation (SGA, BVM).
- C: Cricothyrotomy if all else fails.
Simple enough to recall in chaos.
Rookie Pearls
- Run simulations of failed airway scenarios—it’s the best way to prepare.
- Always prepare Plan B and C before RSI.
- Put the cric kit on the airway tray every time. Seeing it lowers the threshold for action.
- Remember: “The only failed airway is the one where you didn’t have a backup plan.”
Take-Home Message
A failed airway is one of the most stressful moments in emergency medicine. Rookies who understand the algorithm know that it’s not about panicking—it’s about switching strategies fast.
- Plan A: Try intubation with best shot.
- Plan B: Rescue oxygenation with SGA/BVM.
- Plan C: Cricothyrotomy if CICO.
Keep it simple, practice it often, and your patients (and your nerves) will thank you.
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