An Anatomical Can’t Intubate, Can’t Oxygenate Scenario in the Intensive Care Unit: Lessons on Timing of CICO Declaration

ABSTRACT Airway management in critically ill patients carries a high risk of rapid hypoxemia and cardiac arrest. Contemporary airway algorithms, including the Vortex approach, prioritize oxygenation and assume the presence of a rescue oxygenation window after failed intubation attempts. We report a rapidly evolving, anatomically evident can’t intubate, can’t oxygenate (CICO) scenario in a 92-year-old ICU patient in whom effective oxygenation could not be achieved despite airway management fully consistent with current algorithms. Marked upper airway collapse was observed during the first intubation attempt, and bag-mask ventilation was ineffective throughout. Although CICO was declared and emergency tracheotomy initiated, cardiac arrest occurred before definitive oxygenation could be established. This case demonstrates that in critically ill patients with complete airway collapse and minimal physiological reserve, the assumption of a rescue oxygenation window may be invalid. Repeated attempts at non-surgical oxygenation may consume, rather than preserve, the remaining physiological reserve. We propose an Early CICO Declaration Trigger based on anatomical feasibility, physiological tolerance, and predicted futility of further non-surgical airway maneuvers to facilitate earlier progression to front-of-neck airway in selected ICU patients.