What is the recommended procedure for intubation (insertion of an endotracheal tube) in patients requiring mechanical ventilation?

Rapid Sequence Intubation for Mechanical Ventilation

For critically ill adults requiring emergency intubation, rapid sequence intubation (RSI) is the recommended procedure, defined as the administration of a sedative-hypnotic agent and a neuromuscular-blocking agent in rapid succession with immediate endotracheal tube placement before assisted ventilation. 1

Pre-Intubation Preparation

Preoxygenation

• Administer 100% FiO2 for 5 minutes using face mask, bag-valve mask, high-flow nasal oxygen, or non-invasive ventilation prior to intubation attempt 1
• Mask ventilation during preoxygenation may reduce critical hypoxemia risk and should not be routinely avoided despite historical concerns about aspiration 1

Equipment and Personnel

• Ensure immediate availability (<5 minutes) for endotracheal intubation equipment and personnel capable of managing mechanical ventilation 1
• Have vasopressors immediately available, as hypotension occurs in approximately 28.6% of emergency intubations, particularly in patients with hypercarbic COPD 2
• Confirm intravenous access is established 1

Patient Assessment for Intubation Indications

• Intubate immediately for: airway obstruction, Glasgow Coma Score <8, respiratory rate >30 breaths/min with acute distress unresponsive to high-flow oxygen, refractory hypoxemia (PaO2/FiO2 <150 mmHg), progressive hypercapnia with acidosis (pH <7.25), or inability to protect airway 3
• Airway protection takes priority over obtaining complete vital signs including blood pressure 4

Medication Selection

Induction Agents

Etomidate (0.3 mg/kg) or ketamine (2 mg/kg) are the preferred induction agents due to favorable hemodynamic profiles 5, 6

• Etomidate produces less hypotension than ketamine in patients with shock or sepsis based on retrospective evidence 5
• Ketamine at 2 mg/kg IV is particularly advantageous in trauma settings and avoids complications of other agents 6
• Propofol and sevoflurane are alternatives when rapid reversibility is needed, but carry higher hypotension risk 1

Neuromuscular Blocking Agents

Rocuronium (0.6-1.2 mg/kg) or succinylcholine (1.5 mg/kg) are the preferred paralytics, with minimal differences in first-pass success rates 1, 5, 6

• For rapid sequence intubation, rocuronium 0.6-1.2 mg/kg provides excellent intubating conditions in <2 minutes 7
• Rocuronium 0.6 mg/kg achieves intubation-ready conditions (≥80% block) in median 1 minute, with maximum blockade in <3 minutes 7
• Succinylcholine 1 mg/kg (real weight) offers short duration with rapid return of spontaneous ventilation if intubation fails 1
• Use of neuromuscular blocking agents improves both mask ventilation and intubation conditions, and should not be withheld in anticipated difficult airways 1

Pretreatment Medications

• Pretreatment with atropine, lidocaine, or fentanyl has fallen out of favor due to limited evidence outside select scenarios 5
• Consider fentanyl only in specific high-risk situations, as it increases apnea risk 1

Intubation Technique

Laryngoscopy Approach

• Videolaryngoscopy reduces Cormack-Lehane grade III/IV views and should be used as first-line for unanticipated difficult intubation 1
• Limit attempts to 1-2 by an expert practitioner, using optimization techniques (head repositioning, gum elastic bougie, BURP maneuver) 1
• Use largest endotracheal tube available (8-9 mm) to minimize airway resistance 8

Medication Administration

• Administer sedative-hypnotic and neuromuscular blocker in rapid succession without waiting for loss of consciousness 1
• Place endotracheal tube immediately before initiating assisted ventilation 1

Post-Intubation Management

Immediate Confirmation and Monitoring

• Use waveform capnography for all intubations—failure to do so contributes to >70% of ICU airway-related deaths 4
• Avoid hyperventilation post-intubation (maintain 10 breaths/minute) to prevent compromised venous return and cerebral blood flow 3

Ventilator Settings

• Initiate low tidal volumes (6-8 mL/kg predicted body weight) with target plateau pressure <30 cmH2O 1
• Titrate PEEP guided by FiO2 requirements to achieve SpO2 >90% 1
• Monitor for auto-PEEP by decreasing respiratory rate, shortening inspiratory time, and prolonging expiratory time 8

Hemodynamic Management

• Initiate fluid resuscitation if hypotension develops, but do not delay intubation for fluid administration when airway is compromised 4
• Avoid excessive positive pressure ventilation immediately post-intubation to prevent further hemodynamic compromise 4

Critical Pitfalls to Avoid

• Never delay intubation while waiting for arterial blood gas or radiography when clinical signs of respiratory failure are present 3
• Do not withhold neuromuscular blockers in anticipated difficult airways—they improve success rates 1
• Avoid setting external PEEP exceeding measured intrinsic PEEP, as this worsens hyperinflation 8
• Store rocuronium with cap and ferrule intact to prevent fatal medication errors from accidental administration 7
• In tension pneumothorax, perform needle decompression before intubation if hemodynamic compromise is present 4