Emergency cricothyrotomy in five in-hospital “cannot intubate, cannot oxygenate” cases: a case series

Abstract

Background:

Emergency cricothyrotomy (CTM) is a rare but life-saving procedure performed under “cannot intubate, cannot oxygenate” (CICO) conditions. This study describes five in-hospital CICO cases requiring CTM, including one improvised procedure performed in a psychiatric ward without a formal airway kit, to highlight the procedural challenges and institutional preparedness.

Methods:

This retrospective case series included five consecutive patients treated between April 2021 and April 2024. Data on patient demographics, causes of airway obstruction, procedural techniques, operator experience, and outcomes were also collected.

Results:

CTM was successful in all patients on the first attempt, and they all survived and were successfully discharged. However, one patient developed hypoxic encephalopathy.

Conclusions:

CTM remains a rare but essential life-saving intervention for in-hospital CICO cases. Institutional preparedness – including standardized kits, simulation-based training, and regular competency maintenance – is crucial for improving safety and outcomes across hospital departments.

Introduction

Cricothyrotomy (CTM) is a life-saving procedure reserved for critical situations where conventional airway management techniques are unfeasible, particularly severe airway obstruction or anatomical abnormalities. However, this procedure is extremely rare, occurring in approximately one per 10 000–50 000 anesthetic procedures[1]. Although “cannot intubate, cannot oxygenate” (CICO) situations frequently occur in emergency and intensive care unit (ICU) settings, CTM remains uncommon^[2,3^].

Because CTM is rare, experiential learning opportunities are limited. Three major challenges have been identified: (1) variable departmental preparedness across hospitals, particularly outside ICUs; (2) limited exposure to real CICO scenarios or simulation-based training; and (3) uncertainty regarding the effects of operator experience and procedural techniques on outcomes^[3,4^].

HIGHLIGHTS

• Improvised CTM was performed successfully in a psychiatric ward.

• All five CTM cases occurred under confirmed CICO conditions.

• 18G needle and scissors used in place of a scalpel and forceps.

• First-attempt airway success rate was 100%.

• CTM training and equipment must be standardized across departments.

Recent airway management guidelines emphasize the early recognition of CICO and preparedness for front-of-neck access, supported by national audit data such as the Fourth National Audit Project[1]. The 2022 ASA Difficult Airway Guidelines[5] are now the principal reference, incorporating early decision making and structured algorithms for surgical airway interventions. The 2013 ASA guideline[6] was retained solely as a historical comparator, illustrating the evolution of recommendations.

This single-center case series presents five in-hospital CICO cases requiring emergency CTM to highlight the contextual challenges, operator experience, and institutional preparedness. The objective is to provide insights into kit standardization, competency maintenance, and simulation-based training to improve readiness for airway emergencies across hospital departments.

Presentation of cases

This retrospective case series included consecutive in-hospital CICO cases requiring emergency CTM at a single tertiary care institution between April 2021 and April 2024. Data were obtained from electronic health records, nursing documents, and operative reports. All procedures were performed by an attending surgeon who is board-certified in general surgery, gastroenterological surgery, emergency medicine, and intensive care, with more than 20 years of post-graduate experience.

Each procedure was performed according to institutional airway protocols. Data on patient demographics, event location, causes of airway obstruction, procedural techniques, instruments used, operator background, outcomes, and complications were collected and summarized in Table 1.

Table 1.

Summary of the five cricothyrotomy cases

Case	Age	Location/dept	CICO trigger (cause)	Pre-CTM airway maneuvers	CTM technique/kit	Operator role	Sedation	Time to airway (min)	Lowest SpO₂ (%)	First-pass success	Complications	Neurologic outcome	Disposition	Follow-up findings (voice/swallowing/stenosis)
1	60s	Psychiatry ward	Food bolus obstruction	BVM, laryngoscopy	18-gauge needle + Stationery scissors	ICU Chief (Airway lead)	No	5	Not recorded	Yes	Hypoxic encephalopathy	Severe disability	Transfer	Not assessable (permanent tracheostomy)
2	70s	ICU	Oropharyngeal bleeding	Attempted reintubation	Scalpel + hemostat (Pean)	ICU Chief	Yes	3	80	Yes	None	Not assessable (pre-existing neurologic deficit)	Transfer	Not assessable (permanent tracheostomy)
3	50s	ICU	Acute epiglottitis	OTI initially, reintubation failed	Scalpel + hemostat (Pean)	ICU Chief	Yes	1	96	Yes	None	Normal	Discharged	Normal voice, no dysphagia, no stenosis
4	60s	ICU	Hematemesis (blood flooding the airway)	Attempted reintubation	Scalpel + hemostat (Pean)	ICU Chief	No (awake)	1	90	Yes	None	Normal	Discharged	Normal voice, normal swallowing
5	75s	ICU	Retropharyngeal hematoma	Failed fiberoptic	Scalpel + hemostat (Pean)	ICU Chief	Yes	2	79	Yes	None	Normal	Transfer	Mild dysphonia, no dysphagia, no stenosis

Neurologic outcomes were evaluated based on comparisons with the pre-CTM baseline. Case 2 had residual deficits from a previous intracranial hemorrhage, limiting new neurologic assessment.

CTM, cricothyrotomy; CICO, cannot intubate, cannot oxygenate; ICU, intensive care unit; BVM, bag-valve-mask; OTI, orotracheal intubation; SpO₂, peripheral oxygen saturation; min, minutes.

The operational definition of “CICO” referred to the inability to maintain oxygenation despite optimized head positioning, airway adjuncts, and repeated mask ventilation attempts, as judged by the treating physician. Supraglottic airway use and muscle relaxant administration varied by case and were not uniformly applied.

Ethical approval was obtained from the institutional review board (Approval No. 25-0508, 3 June 2025). The study was registered in the Research Registry (researchregistry11269). This report adhered to the PROCESS 2023 guideline for transparent reporting of surgical case series[7]. All patients or their legal guardians provided written informed consent.

Case 1

A man in his 60s experienced choking and cardiopulmonary arrest in a psychiatric ward when a paste-like food bolus obstructed his airway. The ward nurse initiated cardiopulmonary resuscitation, while the ICU team arrived within 10 minutes. Orotracheal intubation was attempted; however, it failed because of the obstructing food mass. As no standard airway set was immediately available, the operator disinfected the skin with alcohol and used an 18-gauge needle as an improvised scalpel to incise the skin and cricothyroid membrane. Stationery scissors were used to widen the incision instead of Pean forceps. Despite being performed under non-sterile conditions, aseptic conditions were maintained using alcohol, and a single dose of prophylactic antibiotics was administered post-procedure.

Airway access was achieved successfully, and the patient was transferred to the ICU, where oral intubation was established. The wound was cleansed and sutured on day 2, with no evidence of infection. Tracheostomy was performed on day 10. The patient’s circulation recovered; however, he developed hypoxic encephalopathy and was transferred for long-term care 4 months later.

Case 2

A man in his 70s, who had been extubated after cerebral hemorrhage management in the ICU, developed upper airway obstruction due to tongue-base collapse and airway bleeding. A reintubation attempt by a neurosurgeon failed because of the profuse oral bleeding and poor visualization. Upon the emergency team’s arrival, oxygen saturation was 80%. Recognizing the CICO situation, the ICU chief immediately performed an emergency CTM, restoring airway patency on the first attempt. The patient was stabilized; he underwent tracheostomy on day 4 and was transferred for rehabilitation 2 months later.

Case 3

A man in his 50s was admitted with acute epiglottitis; he was initially managed with orotracheal intubation in the ICU. Ventilatory insufficiency developed soon after because of a tube size mismatch with the airway anatomy. Anticipating reintubation difficulty and progressive desaturation, the ICU chief proceeded with an emergency CTM using standard surgical instruments. Ventilation was restored immediately. The patient underwent tracheostomy later the same day, which was closed 4 days afterward following epiglottitis resolution. He was discharged 14 days later without complications. He remained well at 1 year post-discharge.

Case 4

A man in his 60s was admitted to the ICU after developing massive upper gastrointestinal bleeding that flooded the oral and pharyngeal cavities, rendering visualization and reintubation impossible. The patient maintained spontaneous breathing but rapidly developed hypoxemia.

To prevent respiratory or circulatory arrest, the ICU chief performed an awake CTM without sedation or muscle relaxants, using local topical anesthesia only around the incision site. Ventilation was promptly re-established, followed by successful endoscopic hemostasis. The patient was reintubated for airway protection, and he was extubated on day 7. He was stable 9 months later without airway complications.

Case 5

A 75-year-old woman admitted for a cervical vertebral fracture developed progressive neck hematoma, causing compressive airway obstruction. Fiberoptic intubation failed due to poor visualization from swelling and bleeding. The ICU chief immediately performed a CTM, successfully securing the airway on the first attempt.

She underwent elective tracheostomy 5 days later and remained on mechanical ventilation in the ICU for 30 days. Although transient concern for vocal cord dysfunction arose, the tracheostomy was closed 8 months later following successful rehabilitation, and the patient was discharged without residual airway symptoms.

Discussion

All five CTM cases were performed under in-hospital CICO conditions where conventional airway management had failed. In all cases, airway access was achieved on the first attempt without immediate life-threatening complications, supporting CTM as an essential life-saving intervention in hospital-based emergencies.

We conducted a focused literature review using PubMed and Google Scholar with the keywords “cricothyrotomy,” “cricothyroidotomy,” “CICO,” and “in-hospital airway.” Adult case series, guidelines, systematic reviews, and observational studies were prioritized. In-hospital data were distinguished from prehospital or helicopter emergency cohorts. Prior guidelines, including DAS 2015[8] and the ASA Difficult Airway Guidelines^[5,6^], emphasize preparation, early recognition of CICO, and immediate readiness for front-of-neck access. The 2022 ASA guideline highlights structured algorithms, team communication, and escalation planning as outcome determinants[5].

Operator proficiency and structured training are major determinants of CTM success. Experienced clinicians are essential for safe airway management in critically ill patients[2], and composure, anticipation, and teamwork are key nontechnical factors^[9–11^]. Greenland et al highlighted the complexity of airway management and the central role of human factors in error reduction[9], while Flin et al[10] and Chrimes [11] emphasized that simulation-based training and human factor awareness are integral to minimizing errors during high-stress airway crises.

A review of two decades of emergency CTM cases confirmed the rarity and high success rate of the procedure when performed by trained clinicians, underscoring that despite its infrequency, CTM is vital and demands sustained institutional readiness.

Case 1 occurred in a psychiatric ward without a formal airway set, requiring improvised instruments such as the 18-gauge needle and scissors. Despite these constraints, airway access was achieved on the first attempt. This aligns with reports demonstrating the feasibility of improvised CTM in controlled simulations[12] and successful field use during mountain rescues[13]. These observations reinforce the importance of standardized kits and regular training, ensuring readiness across all hospital departments – not only ICUs.

Cases 2–5 involved CTMs conducted in the ICU in response to acute airway obstruction, using standard instruments and performed by trained personnel. Although the mechanisms of obstruction varied, all cases involved prompt decision making and procedural execution. Case 2 highlighted the importance of timely recognition and decisive intervention in post-extubation airway emergencies, particularly in patients at risk of oropharyngeal collapse. Case 3 demonstrated the potential of CTM as a bridging measure even in patients who were initially intubated but subsequently experienced airway compromise. Case 4 involved performing CTM while the patient was awake and spontaneously breathing without sedation, a decision made to avoid respiratory or circulatory collapse. This underscores the need for individualized judgment in critical airway scenarios. Case 5 illustrated the dynamic nature of airway risk in trauma patients and the necessity of rapid escalation to CTM when deterioration is imminent.

The contrast between the psychiatric ward and ICU preparedness in this series underscores institutional variability. Equipment unavailability and limited airway training outside critical-care areas can delay intervention. Multiple failed intubation attempts increase complications[3], while first-pass success reduces morbidity. Nontechnical skills – including situational awareness, leadership, and communication – are equally critical in airway management^[9-11^].

Improvised CTM is not recommended for training purposes because of the risk of self-injury. However, the operator’s extensive procedural experience – over 200 percutaneous biliary drainages – contributed to success. Notably, suction devices were unavailable, emphasizing the need for adaptability in resource-limited conditions. This case highlights the importance of preparedness, skill retention, and ward-level accessibility to standardized CTM kits containing a scalpel, tracheal hook, dilator, and tracheostomy tube. Simulation-based training should be conducted every 6–12 months to maintain procedural competency, as supported by institutional preparedness and training studies^[4,10,11^].

Limitations

This single-center, retrospective case series included a small sample size and heterogeneous follow-up duration. Time metrics, such as decision-to-incision intervals, were not consistently recorded. Although all CTMs were performed by a single experienced operator, these results may not be generalizable to all clinical environments. Future studies should employ multi-center prospective registries with standardized reporting parameters, as recommended by the PROCESS 2023 criteria[7].

Conclusions

In conclusion, emergency CTM remains a rare yet indispensable life-saving intervention for CICO situations. The success of all five in-hospital cases – including one improvised procedure – demonstrates that outcome depends on both technical expertise and institutional preparedness.

Hospital-wide standardization of CTM kits, routine simulation-based training every 6–12 months, and continuous competency assessment are essential to sustain readiness. Future multicenter registry studies should further define the relationships among technique, experience, and outcome in real-world CICO management.

Ethical approval

Ethical approval for this study (Protocol No. 25-0508) was provided by the Ethics Committee of St. Mary’s Hospital, Kurume, Fukuoka, Japan, on 3 June 2025.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Sources of funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Author contributions

M.Y.: Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Writing –original draft; Writing – review & editing. S.S., Y.T., T.I., Y.K., N.T., T.M., A.I., S.H., N.C., M.Y., and H.M.: Data curation; Formal analysis; Investigation; Methodology; Project administration. R.M. and H.K.: Conceptualization; Data curation; Formal analysis; Supervision; Investigation; Methodology; Project administration.

Conflicts of interest disclosure

The authors declare that there are no conflicts of interest regarding the publication of this paper.

Guarantor

Munehiro Yoshitomi.

Research registration unique identifying number (UIN)

This case report has been registered with the Research Registry: researchregistry11269.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Data availability statement

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.