Recommended Approach for Rapid Sequence Intubation in Respiratory Distress
For patients with respiratory distress, rapid sequence intubation (RSI) should include proper preoxygenation, head and torso inclined positioning, administration of a sedative-hypnotic agent followed by a neuromuscular blocking agent, with either succinylcholine or rocuronium as the preferred paralytic agent. 1
Positioning and Preparation
- The head and torso inclined (semi-Fowler) position is recommended during RSI to reduce aspiration risk and potentially improve first-pass intubation success 1
- Nasogastric tube decompression should be performed when the benefit outweighs the risk in patients at high risk of regurgitation of gastric contents 1
- Ensure all necessary equipment for intubation, oxygenation, and ventilation is immediately available before administering medications 2
Preoxygenation Strategies
- Standard preoxygenation with an FIO2 of 1.0 using a completely sealing respiratory mask with capnography should take 3-5 minutes 3
- For severely hypoxemic patients, use noninvasive positive pressure ventilation (NIPPV) for preoxygenation 1
- High-flow nasal oxygen (HFNO) is recommended when laryngoscopy is expected to be challenging 1
- For agitated, delirious, or uncooperative patients, use medication-assisted preoxygenation (sometimes called delayed sequence intubation) to improve preoxygenation tolerance 1
Medication Selection
Sedative-Hypnotic Agents
- A sedative-hypnotic induction agent must be administered when a neuromuscular-blocking agent is used for intubation 1
- Options include:
- Etomidate (0.2-0.4 mg/kg IV): Minimal hemodynamic effects, good for patients with head injury, multisystem trauma, or hypotension 2
- Ketamine (1-2 mg/kg IV): Provides dissociative sedation/anesthesia and analgesia with relatively stable hemodynamic profile 2
- Propofol (2-6 mg/kg IV): Causes vasodilation and decreased cardiac output; may need dose reduction if other sedatives or narcotics have been administered 2
- There appears to be no significant difference between etomidate and other induction agents with respect to mortality or hypotension 1
Neuromuscular Blocking Agents
- The American College of Critical Care Medicine strongly recommends administering a neuromuscular blocking agent when a sedative-hypnotic induction agent is used for intubation 1
- Either rocuronium or succinylcholine is recommended for RSI when there are no contraindications to succinylcholine 1
- Succinylcholine: 1-2 mg/kg IV (higher dose of 2 mg/kg for infants less than 6 months old), onset within 30-45 seconds 2
- Rocuronium: 0.6-1.2 mg/kg IV, with higher doses (1.0-1.2 mg/kg) recommended for RSI to provide satisfactory intubating conditions in 60-90 seconds 2, 4
- When using rocuronium, sugammadex should be readily available as a reversal agent 3
Post-Intubation Management
- Apply PEEP of at least 5 cmH₂O after intubation of hypoxemic patients 1
- Consider a post-intubation recruitment maneuver in hypoxemic patients 1
- Include a cardiovascular component in the protocol, defining conditions for fluid challenge and early administration of catecholamines to decrease cardiovascular complications 1
Special Considerations
Medication-Assisted Preoxygenation (Delayed Sequence Intubation)
- Recommended for agitated, delirious, or uncooperative patients who cannot tolerate standard preoxygenation methods 1
- Involves administering a sedative-hypnotic agent (commonly ketamine) to facilitate preoxygenation before administering the NMBA 1
- This approach can increase oxygen saturation by approximately 8.9% before NMBA administration 1
Rapid Sequence vs. Delayed Sequence Intubation
- Standard RSI is recommended if the patient is cooperative 1
- Delayed sequence intubation should be considered if the patient is agitated, delirious, or combative 1
- DSI with NIPPV for preoxygenation is particularly beneficial in cases of severe hypoxemia 1
Common Pitfalls and How to Avoid Them
- Inadequate preoxygenation: Ensure proper technique and consider medication-assisted preoxygenation for uncooperative patients 1
- Hemodynamic instability: Include a cardiovascular component in the intubation protocol with defined parameters for fluid challenges and early vasopressor use 1
- 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
- Inappropriate medication selection: Consider patient-specific factors when selecting medications, such as using etomidate for patients with head injury or hemodynamic instability, and ketamine for patients with bronchospasm 2
- Failure to have rescue devices ready: Always have second-generation extraglottic airway devices available for unexpected difficult airways 3