Skip to content

Can’t intubate, Can’t Oxygenate


Paediatric critical procedures are rare in the emergency department. Data from one Victorian network showed that 83% of emergency physicians had not performed one in a twelve-month period. We also know from audit data that we seem to have a lower first-pass success rate (around 78%) when it comes to paediatric intubation. We can put in a lot of strategies to increase the chance of first-pass success but what happens if you get into a ‘Can’t Intubate, Can’t Oxygenate” (CICO) scenario?

Those of us that look after adults, as well as children, have a standard response to the CICO scenario using an established algorithm whether it is the Vortex approach or the DAS guidelines.  They all end up with a puncture of the neck (be it via scalpel or needle). What approach should be undertaken in children?

[Editors note: At this point, it is worth remarking that children are not heterogeneous creatures and your approach to an unimmunized 2-year-old with nasty epiglottitis is very different from the 12-year-old who has tried to inhale a never-ending gobstopper.]

Stefano Sabato and Elliot Long, both from the Royal Children’s Hospital, Melbourne have reviewed the evidence and tried to answer the question in this article:

Sabato SC, Long E. An institutional approach to the management of the ‘Can’t Intubate, Can’t Oxygenate’ emergency in children. Pediatric Anesthesia. 2016 Jun 1.

How common is the scenario?

The true number of CICO scenarios that occur in a paediatric setting is unknown. There were 13 major complications reported in the NAP4 dataset, representing 7% of all reported cases. Only 5 of these required a surgical airway. This is likely to be an under-representation of true events. Regionalisation of paediatric care and lack of resident ENT staff in the UK may have led to intensivists/anaesthetists having little experience in managing sick children.

Some of the potential risks mentioned include:

Failure to use capnography to confirm tube placement

Failure to adequately secure the tube once in place

Management of airway compromise during patient transfer

The incidence of failed intubation (defined as more than three attempts to get the tube through the cords) in healthy kids is around 0.08% rising to 0.24% in infants less than a year old.

Predicting the difficult airway in the child

Anecdotally there has been little emphasis on formal airway assessment in children with the majority of standard tools not validated in the paediatric population. Even when performed in adults an airway assessment might not reduce the risk of the unanticipated difficult airway.

Common sense would suggest that if a child has a history of sleeping issues, perhaps due to adenotonsillar hypertrophy, they may be more likely to obstruct on induction. Looking at the child you might spot drooling or mouth breathing that occurs with enlarged tonsils or upper airway obstruction. Congenital abnormalities or dysmorphic features such as micrognathia in the Cri du Chat sequence or glossomegaly in trisomy 21 can also make intubation a challenge.

Formal airway assessment should include:

Mouth opening

Assessment of dentition for loose or protruding teeth

Tongue size

Presence of soft tissues mass in the mouth?

Mandible size

Neck mobility

Tempero-mandibular joint (TMJ) mobility

The Mallampati score is impractical in children as they have a tendency not to do what is required, especially when scared and Kopp et al LINK found it to be a poor predictor of glottic view.

Needle versus Knife?

Whilst a formal tracheostomy by a qualified ENT surgeon would be fabulous, most of us don’t have Dr Eric Levi on speed dial. The options seem to be split between the ‘knife‘ (a scalpel-based approach) or the ‘needle‘  (a narrow or wide bore cannula or formal needle cric set).

The Knife

If you look after adults as well as children you should be familiar with the scalpel-finger-bougie technique so I won’t go into the details. The 4th National Audit Project from the Royal College of Anaesthetists in the UK suggested that a scalpel technique was preferable to the alternatives unless practitioners were more experienced in alternative techniques. Failure to commit to a ‘surgical’ airway in a timely fashion was highlighted as a key issue.

So why can’t we do the same with children?

Sabato and Long remind us that we are dealing with extremely small targets.  The neonatal cricothyroid membrane is only about 2.6mm in length and 3.0mm in width. That is smaller than a grain of rice!

The CTM in a neonate is smaller than a grain of rice

Identifying the appropriate anatomy will become easier as we become more proficient with the use of bedside ultrasound to identify landmarks.

The Needles

The authors of the article recommend a needle-based approach using as shallow an angle of approach as possible (with extension of the neck to expose the cricothyroid membrane) to avoid transfixing the trachea by puncturing the posterior wall.  There are a number of commercial kits available but poverty of choice is important. Should a CICO situation arise the last thing you need to be worrying about is which kit to use. A 16g cannula based kit is their recommendation. Children die because of a lack of oxygenation not a lack of an airway. The goal is to provide adequate oxygenation until expert help arrives.

For more on the various devices available then read this excellent article.

So what should we do?

Call for help early and get your friendly ENT surgeon involved. If that is not an option then the authors recommend a needle-based approach for front of neck access. They give examples of the kit used at the Royal Children’s Hospital. You can see the kit here. Being aware of the principles is one thing but like all emergencies, we have to be prepared to perform when the time comes. Mental rehearsal of your preferred technique helps, as does using part-trainers or practice in the animal lab but they do little to help one overcome the fear of performing the procedure. When intubating adults I use a checklist and call out my failed intubation plan, ending with a check of my surgical equipment. I must admit to having been more blasé about doing the same for paediatric intubations. This will no longer be the case.

How should you do it?

The Difficult Airway Society suggest the following approach.

Extend the neck (making the target as big as possible)

Stabilize the larynx with the non-dominant hand

Access the cricothyroid membrane with a dedicated 14/16g cannula

Aim in a caudal direction

Confirm position with aspiration of air into a syringe containing saline

Connect to an oxygen source
– adjustable, pressure limiting device
– 4bar O2 source – matching l/min with age

Slowly increase inflation pressure/flow rate to achieve maximal chest rise

Maintain upper airway patency to aid expiration

DAS recommend following adult guidelines once the child is over the age of 8. Needle cricothyroidotomy is not without risk and though it may be successful on the first go in up to 70% of cases there is a high risk of perforation of the posterior wall of the trachea. Trans-tracheal cannulation is not a failure of the technique if oxygenation is maintained.

Perhaps the easiest way to connect to an oxygen source is to attach a 3mm ETT tube connecter.  You then have a universal 22mm connector to attach to your circuit.

How do we train for it?

Cliff Reid has written in the past about using the greatest piece of virtual reality hardware there is – the brain – to prepare for such a rare event. There are part-task trainers for adult practice but I challenge the readers to find one for use in paediatric practice.

The first key step is reducing the risk of it happening in the first place through proper training and preparation. More than two attempts at tracheal intubation are associated with an increased risk of complications and each further attempt incrementally increases the risk. Techniques such as the use of video laryngoscopes and optimum pre-oxygenation and apnoeic oxygenation may modify some of the risks but sometimes there is no accounting for anatomical variation.

Of course, this article could have been called The Needle and the Damage Done after this song, from the amazing Neil Young about a very different type of needle.

With thanks to @NicholasChrimes, @DrEricLevi, @airwaycam, @DitchDoc14, and especially @kovacsgj

Selected references

Sabato SC, Long E. An institutional approach to the management of the ‘Can’t Intubate, Can’t Oxygenate’ emergency in children. Pediatric Anesthesia. 2016 Jun 1.

Nguyen LD, Craig S. Paediatric critical procedures in the emergency department: Incidence, trends and the physician experience. Emergency Medicine Australasia. 2016 Feb 1;28(1):78-83.

Long E, Sabato S, Babl FE. Endotracheal intubation in the pediatric emergency department. Pediatric Anesthesia. 2014 Dec 1;24(12):1204-11.

Cook TM, Woodall N, Frerk CO. 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 1: anaesthesia. British journal of anaesthesia. 2011 May 1;106(5):617-31.

Radia T, Bernard S, Rainsley V, Florman K, Chen Q, Jaffer M. G73 Paediatric difficult airway equipment in emergency departments: a regional audit. Archives of Disease in Childhood. 2015 Apr 1;100(Suppl 3):A30-1.

Adewale L. Anatomy and assessment of the pediatric airway. Pediatric Anesthesia. 2009 Jul 1;19(s1):1-8.

Dickison AE. The normal and abnormal pediatric upper airway. Recognition and management of obstruction. Clinics in chest medicine. 1987 Dec;8(4):583.

Walker RW. Management of the difficult airway in children. Journal of the royal society of medicine. 2001 Jul 1;94(7):341-4.

Weiss M, Engelhardt T. Proposal for the management of the unexpected difficult pediatric airway. Pediatric Anesthesia. 2010 May 1;20(5):454-64.

Black AE, Flynn PE, Smith HL, Thomas ML, Wilkinson KA. Development of a guideline for the management of the unanticipated difficult airway in pediatric practice. Pediatric Anesthesia. 2015 Apr 1;25(4):346-62.

Schaefer JJ. Simulators and difficult airway management skills. Pediatric Anesthesia. 2004 Jan 1;14(1):28-37.

Kopp VJ, Bailey A, Valley RD et al. Utility of the Mallampati classification for predicting difficult intubation in paediatric patients. Anesthesiology 1995 83: A1146.

Jagannathan N, Sohn L, Fiadjoe JE. Paediatric difficult airway management: what every anaesthetist should know!. British journal of anaesthesia. 2016 Apr 19:aew054.

Smith KA, Gothard MD, Schwartz HP, Giuliano Jr JS, Forbes M, Bigham MT. Risk factors for failed tracheal intubation in pediatric and neonatal critical care specialty transport. Prehospital Emergency Care. 2015 Jan 2;19(1):17-22.

Santoro AS, Cooper MG, Cheng A. Failed intubation and failed oxygenation in a child. Anaesthesia and intensive care. 2012 Nov;40(6):1056-8.

Dalesio NM, Kattail D, Ishman SL, Greenberg RS. Ultrasound use in the pediatric airway: the time has come. A&A Case Reports. 2014 Feb 1;2(3):23-6.

Stafrace S, Engelhardt T, Teoh WH, Kristensen MS. Essential ultrasound techniques of the pediatric airway. Pediatric Anesthesia. 2016 Feb 1;26(2):122-31.

Cote CJ, Hartnick CJ. Pediatric transtracheal and cricothyrotomy airway devices for emergency use: which are appropriate for infants and children?. Pediatric Anesthesia. 2009 Jul 1;19(s1):66-76.



No data was found

Leave a Reply

Your email address will not be published. Required fields are marked *

1 thought on “Can’t intubate, Can’t Oxygenate”

  1. Dr Anna Kirby-Bailey

    Ive had this experience alone with a surgeon – baby run into dept by parents -13 month old baby choked on a bottle top – chubby neck and landmarks impossible to feel – we used Trachy as anaesthetists arrived and it actually flicked the bottle top to within reach