Can’t Intubate, Can’t Oxygenate


Can’t Intubate, Can’t Oxygenate/Ventilate (CICO) scenarios are rare but critical airway emergencies which can quickly progress to severe hypoxia and death if not managed effectively by the healthcare team. There are many different approaches to the difficult or failed airway, all ultimately culminating in a last-line attempt at an emergency surgical airway (ESA)/front of neck access (FONA)/surgical cricothyroidotomy, or a needle cricothyroidotomy.

  • Incidence of ~1:10,000 anaesthetics
  • Call for help early
  • Prepare for ESA/needle cricothyroidotomy, fibre-optic intubation (FOI), or blind nasal intubation
  • Use emergency O2 flush if there is access to ventilator circuit, or high-flow oxygen through face mask

NoteUltrasound can be used to assist with placement of surgical airway and quick assessment of successful intubation.


ANZCA in their Airway Management resources refer to a model devised by Dr Nick Chrimes called the ‘Vortex Approach’ for recognising and responding to a CICO scenario.

The Vortex Approach:

Note: The Vortex Approach advocates for a single phonetic pronunciation of ‘CICO’ as Ky-Koh to avoid misunderstanding.

  • Aimed at all members of the team involved in potential difficult airways (critical care doctors, nurses, surgeons, paramedics, etc.).
  • Applies to any clinical context which involves airway management.
  • Preparing (or ‘Priming’) for a CICO scenario and eventual CICO Rescue during any airway management should be done simultaneously throughout attempts at Lifelines.
  • As any airway difficulty progresses, CICO Status should be escalated. CICO Status should be escalated after an unsuccessful best effort at any lifeline, or earlier if anticipated possible difficult airway or deteriorating clinical picture.
  • Dropping oxygen saturation or prolonged time attempting to establish an airway should immediately trigger simultaneous preparation for CICO Rescue.

CICO Status – a way of recognising the potential need for CICO Rescue early. Chrimes N et al
  • 3 upper airway ‘Lifelines’ (ETT, LMA/SGA, Face Mask) followed by progression to CICO Rescue (also referred to as surgical airway).
    • There should be a ‘best attempt’ at each upper airway Lifeline (in any order), after which if still unsuccessful, progression to surgical airway should immediately follow
    • There should be no more than 3 attempts at each Lifeline, and something should be changed between each attempt to improve the chance of success
    • 5 changes that can be made for each Lifeline:
      • Manipulations
      • Adjuncts
        • Face mask: Guedel airway/Oropharyngeal airway (OPA), Nasopharyngeal airway (NPA)
        • ETT: Fibre-optic intubation (FOI), Shikani optical stylet, video laryngoscopy, different laryngoscope blades
      • Size/Type
      • Suction/Increased flow
      • Muscle tone  
  • After each ‘best attempt’ at an upper airway Lifeline, declare this out loud so that all members of the team are aware.
  • Once a best attempt has been made at all 3 Lifelines, proceed immediately to CICO Rescue (surgical airway).
    • Note: SpO2 is not a factor in the decision to proceed to CICO Rescue, as although SpO2 may demonstrate adequate oxygenation, it cannot evaluate safe apnoea time or physiological oxygen reserve which is likely fast depleting. Oxygen saturations are an important consideration, however, in making the context-specific decision as to when a ‘best effort’ at a Lifeline has been made. For example, if SpO2 is critically low, the airway team may make the decision to only have one ‘best attempt’ at each lifeline before moving to the next Lifeline or to CICO Rescue.
CICO - Vortex Approach diagram
The ‘Vortex Approach’ diagram demonstrating the ‘Green Zone’ (adequate alveolar oxygen delivery) at the outer edge of the vortex after supraglottic ‘Lifelines’ are successful at restoring ventilation, as well as in the centre after successful surgical or cannula infraglottic airway placement. Chrimes N et al

CCC Airway Series

Journal articles

  • Heard AM, Green RJ, Eakins P. The formulation and introduction of a ‘can’t intubate, can’t ventilate’ algorithm into clinical practice. Anaesthesia. 2009;64:(6)601-8. [pubmed] [full text]

FOAM and web resources

Critical Care


Dr Alex Duller LITFL Author

Critical Care Trainee and Surgical Research Assistant, BMed (UNE/UoN). Clinical Associate Lecturer with the University of Sydney School of Medicine. Born and raised in Sydney but contemplating an escape to the country. Passion for simulation-based teaching, peri-operative research, and FOAMed. Enjoys trail running, gardening (edible stuff), and cooking (with edible stuff from garden).

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

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