Airway Attempt Limits

Why this matters

The oxygen saturation (sat) is 70%. Someone still wants one more look. The same look uses up the oxygen the patient has left.

That is how you reach cannot-intubate-cannot-oxygenate (CICO). You cannot pass a tube. You also cannot get oxygen in with a bag or a supraglottic airway (SGA).

In cardiac arrest, high-quality cardiopulmonary resuscitation (CPR) still comes first. A long look is not the first move. “I almost had it” is how crews repeat the same look.

Clinical sequence

1. Give oxygen first with a two-person BVM. If you already have an SGA that shows a waveform, use that. Do not start a look on a blue patient if the bag still moves the chest.
2. On the first look, use your best position and the blade you are trained on. Add a bougie, an intubating introducer, if that is your system’s first-pass plan.
3. Between looks, bag until you see the chest rise. Then change one thing. Change the position, the blade, the operator, or place an SGA. Do not repeat the same pass.
4. If you still cannot get oxygen in, say CICO out loud. Move to the rescue you trained. That is usually an SGA, then front-of-neck access if your protocol allows it.
5. In arrest, do not spend the pause in compressions on a long look. Compressions and defibrillation still lead. Airway work can happen at the same time. It does not replace CPR.

Teaching points

• Many systems stop at two or three attempts. Know your number. One more look with no change is the same attempt again.
• Name the change before you look. Use ear-to-sternal-notch position, video laryngoscopy, or direct laryngoscopy (a blade and your eye, with no screen). You can also switch to a bougie, a smaller tube, a different operator, or an SGA.
• Oxygen is the goal. A rising sat with an SGA beats a clear view you cannot pass a tube through.
• Say this before the last look your protocol allows, not after the sat is 40%: “I cannot intubate. I cannot oxygenate. I am moving to rescue.”
• Use the gear that is already open. Do not stop oxygen while someone hunts for a blade that is still in the bag.

Common errors

• Taking four identical direct-laryngoscopy attempts because you saw the arytenoids.
• Not bagging between looks while someone searches the airway bag for a different blade.
• Calling for front-of-neck access only after hypoxia has already caused pulseless electrical activity (PEA).

Practice

Related: Difficult Airway Anticipation, Front-of-Neck Access.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

• NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; follow your protocol
• Difficult Airway Society guidelines — limit attempts, change the plan, declare CICO
• AHA 2025 Part 7: Adult BLS — airway maneuvers support ventilation; a long look is not the first BLS move
• AHA 2025 Part 9: Adult ALS — airway in parallel with high-quality CPR, not instead of it