Cannot intubate, cannot oxygenate: front-of-neck access

What it is

«Cannot intubate, cannot oxygenate» (CICO) is the rare, life-threatening point at which tracheal intubation, a supraglottic airway and face-mask ventilation have all failed and oxygen saturation keeps falling. Without oxygen, brain injury and cardiac arrest follow within minutes, so the response is emergency front-of-neck access through the cricothyroid membrane, the thin band between the thyroid cartilage above and the cricoid cartilage below. Current guidelines favour a scalpel technique: with the neck extended, the operator identifies the membrane, makes a transverse stab incision through it, rotates the blade, slides a bougie into the trachea and railroads a small cuffed tracheal tube over it, then confirms with capnography. If the membrane cannot be felt, a vertical midline skin incision and blunt finger dissection find it. Needle cricothyroidotomy with jet oxygenation is an alternative in some settings and is preferred in young children, whose small, soft larynx makes a surgical cricothyroidotomy hazardous. The procedure is simple; the hard part is deciding to do it in time.

How to recognise it

• Intubation has failed after a limited number of attempts.
• A supraglottic airway does not oxygenate, even after changing size or device.
• Face-mask ventilation with two hands, adjuncts and full paralysis does not oxygenate.
• Oxygen saturation keeps falling; bradycardia or arrhythmia appears late, as the heart becomes hypoxic.
• No capnography trace with any device.

Why it happens

• Upper-airway obstruction above the larynx (swelling, blood, tumour, laryngospasm) blocks every device that sits in the mouth or pharynx.
• Repeated attempts at intubation add oedema and bleeding.
• The cricothyroid membrane lies below the vocal cords, so access there bypasses the obstruction.
• Fear of the procedure and focusing on one more attempt delay the decision.

What to do at once

1. Declare «cannot intubate, cannot oxygenate» aloud — naming it ends further attempts and moves the team to the neck.
2. Make sure the patient is fully paralysed and keep trying oxygen from above — relaxation helps, and upper-airway oxygen may still add a little.
3. Extend the neck (pillow under the shoulders) — extension brings the larynx forward and stretches the membrane.
4. Find the membrane with the laryngeal handshake: thyroid cartilage, then the dip above the cricoid ring — accurate landmarks prevent wrong-level cuts.
5. Palpable membrane: transverse stab through skin and membrane, blade towards you, rotate it — this opens a path into the trachea.
6. Impalpable membrane: vertical midline skin incision, blunt finger dissection to the larynx, then the transverse stab — this finds the anatomy.
7. Slide a bougie along the blade into the trachea, railroad a small cuffed tube, inflate the cuff — the bougie guides the tube into the airway.
8. Ventilate and confirm with capnography — a sustained waveform proves tracheal placement; then secure the tube.

Costly mistakes

• Waiting too long: the decision, not the cut, is where most delay happens.
• Not ensuring full neuromuscular block before giving up on the mask and supraglottic airway.
• Cutting through the thyroid gland or at the wrong level because the landmarks were not felt first.
• Losing the track: removing the blade before the bougie is in the trachea.
• Assuming placement without capnography; a tube in the soft tissues of the neck causes surgical emphysema and no oxygenation.

Next step

• Once oxygenated, call the surgical or ear, nose and throat team to convert to a formal tracheostomy or secure airway.
• Look for bleeding, surgical emphysema, pneumothorax and tube misplacement; a chest radiograph helps.
• Admit to intensive care; decide with seniors whether the planned surgery proceeds.
• Document the event, tell the patient and family, and give a written difficult airway alert for future anaesthetics.
• Debrief the team, report the event and practise the scalpel technique regularly on simulators.

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Elsewhere in DurgiPedia

• Emergency front-of-neck access: cricothyroidotomy and tracheostomy
• Larynx: cartilages, glottis and laryngeal nerves
• Bag-mask ventilation
• Supraglottic airway devices

Connections

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Educational content; it does not replace supervised training, your institution's protocols or the anaesthetist's or intensivist's decision. It contains no doses and no ventilator or infusion settings.

Sources: Cricothyroidotomy (StatPearls (NCBI Bookshelf), 2025); Difficult Airway (StatPearls (NCBI Bookshelf), 2026).

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