CICO in recovery: when the crisis happens after the airway

airway cico recovery Jan 22, 2026

Can’t Intubate Can’t Oxygenate (CICO) isn’t just a theatre problem. It can occur after extubation or airway management in recovery — a moment where vigilance may fade but the physiological risk remains. CICO is defined as failure to oxygenate due to persistent upper-airway obstruction despite all reasonable supraglottic rescue attempts, signalling the need for transition to infraglottic rescue.  

Post-anaesthesia care units (PACU) present unique challenges for airway crises. Airway emergencies here are often complex, influenced by residual anaesthetic effects, sedation, surgical factors, and co-morbidities such as obstructive sleep apnoea and pulmonary disease. Systems, team readiness, and equipment availability vary widely between facilities.  

In the recovery setting, early identification of evolving airway obstruction is critical. Prevention strategies — including careful extubation criteria, risk assessment, and monitoring — reduce the likelihood of deterioration to CICO.  

Key Teaching Points
• Deploy structured airway risk assessments and PACU-specific emergency planning.  
• Recognise that residual sedation, muscle weakness, and airway swelling can evolve rapidly after the airway is secured.  
• Think “transition to CICO” early when supraglottic oxygenation fails despite optimisation efforts.  
• Crew resource management and clear communication improve team performance in crisis.  

Respiratory collapse in recovery can evolve quietly. Continuous monitoring of oxygenation, vigilance for subtle airway obstruction signs, and readiness to activate emergency airway protocols can make the difference between a manageable event and a CICO crisis.  

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References
Australian and New Zealand College of Anaesthetists (2017). Guideline for the management of evolving airway obstruction: transition to the Can’t Intubate Can’t Oxygenate airway emergency (PG61(A)). ANZCA.
Spruijt, B. & Huitink, J.M. (2024). Emergency airway management in the post anesthesia care unit. Current Opinion in Critical Care.

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