What is the recommended regimen for smooth intubation?

Recommended Regimen for Smooth Intubation

For smooth intubation, the recommended regimen includes maintaining a deep level of anesthesia with rapidly reversible agents, administering a muscle relaxant (preferably rocuronium 0.6 mg/kg or succinylcholine 1 mg/kg), and using videolaryngoscopy when available to maximize first-pass success. 1

Preparation Phase

• Ensure availability of oxygenation techniques before induction
• Position patient optimally (ramped position for obese patients)
• Preoxygenation:
  • Use tight-fitting facemask with circuit capable of delivering CPAP
  • Apply nasal oxygen (5 L/min while awake, increased to 15 L/min after loss of consciousness)
  • Consider 5-10 cm H₂O CPAP if oxygenation is impaired
  • High-flow nasal oxygen (HFNO) may be used if already in place 1

Induction Phase

1. Anesthetic Depth:

   • Maintain deep level of anesthesia using rapidly reversible agents 1
   • Propofol or sevoflurane are preferred hypnotics 1
   • Consider adding short-acting opioid to improve intubation conditions (noting this may prolong apnea) 1
   • For hemodynamically unstable patients, ketamine is preferred 1

2. Neuromuscular Blockade:

   • First choice: Rocuronium 0.6 mg/kg (standard dose) or 1.2 mg/kg (high dose for rapid sequence) 2
   • Alternative: Succinylcholine 1 mg/kg (real weight) 1
   • Use quantitative neuromuscular blockade monitoring 1

3. Modified Rapid Sequence Approach:

   • Apply cricoid force (1 kg/10 N while awake, increasing to 3 kg/30 N after loss of consciousness) 1
   • Reduce or remove cricoid force if difficulty with laryngoscopy, tube passage, or mask ventilation 1

Intubation Phase

1. Laryngoscopy Technique:

   • Videolaryngoscopy is recommended to reduce incidence of difficult views and increase first-pass success 1
   • For direct laryngoscopy, use gum elastic bougie as part of first-line optimization 1
   • Limit attempts to maximum of three by experienced practitioners 1

2. Peroxygenation During Attempts:

   • Maintain nasal oxygen at 15 L/min during intubation attempts 1
   • Consider facemask ventilation with CPAP between attempts if hypoxia occurs 1

Special Considerations

• Anticipated Difficult Airway:

  • Consider awake intubation with minimal sedation and adequate topical anesthesia 1
  • For topical anesthesia, use lidocaine (maximum 9 mg/kg lean body weight) 1
  • Consider nasal vasoconstrictors if nasotracheal route planned 1

• Obesity:

  • Use ramped position
  • More aggressive pre- and peroxygenation
  • Consider early transition to surgical airway if difficulties encountered 1

Common Pitfalls to Avoid

1. Inadequate depth of anesthesia leading to coughing, bucking, or hemodynamic instability
2. Delayed administration of muscle relaxant resulting in suboptimal intubating conditions
3. Multiple intubation attempts without optimizing position or technique
4. Failure to maintain oxygenation between attempts
5. Inappropriate cricoid force application causing laryngeal distortion

Drug Selection Nuances

The choice between rocuronium and succinylcholine should consider:

• Rocuronium advantages: No hyperkalemia risk, no malignant hyperthermia risk 3
• Succinylcholine advantages: Faster onset, shorter duration 3
• For anticipated difficult airway, rocuronium with sugammadex availability offers comparable onset to succinylcholine with reversibility option 1

The evidence strongly supports that using appropriate muscle relaxation improves both mask ventilation conditions and intubation success rates 1, contradicting older practices of avoiding paralytics in anticipated difficult airways.