Recommended Approach for Rapid Sequence Intubation (RSI) in Respiratory Distress
For patients with respiratory distress, rapid sequence intubation (RSI) should include proper preoxygenation, administration of a sedative-hypnotic agent followed by a neuromuscular blocking agent (NMBA), with succinylcholine as first-line choice or rocuronium at doses of 1.0-1.2 mg/kg when succinylcholine is contraindicated. 1
Positioning and Preparation
- The head and torso inclined (semi-Fowler) position is suggested during RSI to reduce aspiration risk and potentially improve first-pass intubation success 1, 2
- Ensure appropriate equipment is immediately available, including intubation devices, suction equipment, and rescue devices 2
- A protocol for intubation including respiratory and cardiovascular components should be used to decrease complications 1
Preoxygenation Strategies
- For severely hypoxemic patients (PaO₂/FiO₂ < 150), noninvasive positive pressure ventilation (NIPPV) is recommended for preoxygenation 1
- High-flow nasal oxygen (HFNO) is suggested when laryngoscopy is expected to be challenging 1, 2
- For agitated, delirious, or uncooperative patients, medication-assisted preoxygenation (sometimes called delayed sequence intubation) is recommended to improve preoxygenation tolerance 1, 2
- A ketamine-based approach for medication-assisted preoxygenation can increase oxygen saturation by approximately 8.9% before NMBA administration 1
Medication Selection
Sedative-Hypnotic Agents
- A hypnotic agent should be used for RSI, with options including etomidate, ketamine, or propofol, selected based on the patient's clinical condition 1, 2
- There appears to be no significant mortality difference between etomidate and other induction agents with respect to mortality or incidence of hypotension 1
- Consider hemodynamic status when selecting the induction agent:
Neuromuscular Blocking Agents
- An NMBA should always be administered when a sedative-hypnotic induction agent is used for intubation (strong recommendation) 1, 2
- Succinylcholine (1-2 mg/kg IV) is recommended as the first-line agent for RSI in patients with respiratory distress 1
- When succinylcholine is contraindicated, rocuronium at doses of 1.0-1.2 mg/kg should be used 1, 4
- Sugammadex should be readily available when rocuronium is used 1
Post-Intubation Management
- A post-intubation recruitment maneuver should be used in hypoxemic patients 1
- Apply PEEP of at least 5 cmH₂O after intubation of hypoxemic patients 1
- A cardiovascular component should be included in the protocol, defining conditions for fluid challenge and early administration of catecholamines to decrease cardiovascular complications 1
Common Pitfalls and How to Avoid Them
- Inadequate preoxygenation: Ensure proper technique and consider medication-assisted preoxygenation for uncooperative patients 1, 2
- Hemodynamic instability: Include a cardiovascular component in the intubation protocol with defined parameters for fluid challenges and early vasopressor use 1
- Delayed neuromuscular blockade: When using rocuronium, higher doses (1.0-1.2 mg/kg) are needed to achieve comparable intubation conditions to succinylcholine 1, 4
- Lack of preparation for difficult airway: Have second-generation extraglottic airway devices available as rescue devices 5
- Delayed post-intubation analgosedation: When using rocuronium, be aware that its longer duration may delay provision of post-intubation analgosedation, potentially increasing risk of awareness 1
By following this structured approach to RSI in patients with respiratory distress, clinicians can maximize first-pass success while minimizing complications, ultimately improving patient outcomes in terms of morbidity, mortality, and quality of life.