What are the beneficial pre-intubation steps for an elderly woman with potential comorbidities and decreased respiratory reserve undergoing rapid sequence intubation?

Pre-Intubation Steps for Rapid Sequence Intubation in an Elderly Woman

Position the patient in semi-Fowler position (head and torso inclined), provide aggressive preoxygenation with high-flow nasal oxygen or noninvasive positive pressure ventilation if severely hypoxemic, consider nasogastric tube decompression if at high aspiration risk, and have vasopressors immediately available at the bedside given the high risk of peri-intubation hypotension in elderly patients. 1

Positioning

• Place the patient in semi-Fowler position (head and torso inclined at 20-30 degrees) rather than supine positioning. 1
• This positioning improves first-pass intubation success, enhances preoxygenation by increasing functional residual capacity, and reduces aspiration risk of passively regurgitated gastric contents. 1
• The semi-Fowler position is particularly beneficial in elderly patients who often have decreased respiratory reserve and increased aspiration risk. 1

Preoxygenation Strategy

• Provide preoxygenation with FiO2 of 1.0 for 3-5 minutes using a completely sealing respiratory mask with capnography, targeting FetO2 concentration >0.9 and oxygen flow >10 L/min. 2
• Use high-flow nasal oxygen (HFNO) when laryngoscopy is expected to be challenging (conditional recommendation, low quality evidence). 1
• Use noninvasive positive pressure ventilation (NIPPV) if the patient has severe hypoxemia (PaO2/FiO2 <150), which is common in elderly patients with comorbidities. 1, 3
• If the patient is agitated, delirious, or combative and cannot tolerate preoxygenation devices, consider medication-assisted preoxygenation with ketamine (1-1.5 mg/kg IV) to achieve a dissociative state, followed by 3 minutes of preoxygenation before administering the neuromuscular blocking agent. 1, 3

Gastric Decompression

• Insert a nasogastric tube for gastric decompression when the benefit outweighs the risk in patients at high risk of regurgitation (best practice statement). 1
• Elderly women are often at higher risk due to delayed gastric emptying, medications affecting gastric motility, and potential comorbidities. 1
• Point-of-care ultrasound can help determine the need for nasogastric tube placement by assessing gastric content volume (risk increases with >1.5 mL/kg total gastric fluid volume). 1
• If a nasogastric tube is already in place, leave it in position during intubation; it does not need to be removed. 4
• Weigh the risk of complications (nasal bleeding, gagging/vomiting, esophageal perforation) against aspiration risk. 1

Hemodynamic Preparation

• Have vasopressors immediately available at the bedside before induction, as elderly patients are at particularly high risk for peri-intubation hypotension. 1, 5
• While there is insufficient evidence to recommend routine prophylactic vasopressor administration, peri-intubation hypotension is associated with ICU mortality. 1
• Consider having phenylephrine (50-200 μg bolus doses) or a continuous infusion of norepinephrine prepared and ready. 1
• Optimize resuscitation before RSI if time permits, though fluid boluses alone have not been shown to prevent cardiovascular collapse. 1
• The PREPARE II trial demonstrated that crystalloid fluid bolus alone failed to prevent cardiovascular collapse in critically ill patients undergoing RSI. 1

Medication Selection Considerations

• Select an induction agent with favorable hemodynamic properties for elderly patients. 1, 6
• Etomidate (0.2-0.4 mg/kg) provides relatively stable hemodynamics and may be preferred in hemodynamically unstable elderly patients. 1, 6, 5
• Ketamine preserves respiratory drive and has sympathomimetic properties that help maintain hemodynamic stability, making it suitable for elderly patients. 6
• Always administer a sedative-hypnotic induction agent before the neuromuscular blocking agent to prevent awareness during paralysis (best practice statement). 1, 6
• Either rocuronium (0.9-1.2 mg/kg) or succinylcholine (1.5 mg/kg) is appropriate when no contraindications exist. 1

Equipment and Personnel Preparation

• Ensure a peripheral nerve stimulator is available to monitor neuromuscular blockade. 7
• Have a second-generation extraglottic airway device immediately available in case of unexpected difficult airway. 2
• Ensure capnography is connected and functioning before induction. 2
• Consider involving a clinical pharmacist to reduce medication errors, particularly with bolus-dose vasopressors which have high error rates. 1

Common Pitfalls to Avoid

• Inadequate preoxygenation: Elderly patients desaturate more rapidly due to decreased functional residual capacity and increased oxygen consumption. Ensure full 3-5 minutes of preoxygenation with proper technique. 3, 2
• Failure to anticipate hypotension: Elderly patients have decreased cardiovascular reserve and are at higher risk for severe hypotension with induction agents. Have vasopressors drawn up and ready before induction. 1, 5
• Administering neuromuscular blocker before sedative: This results in awareness during paralysis, which occurs in approximately 2.6% of emergency intubations. Always sedate first. 1, 6, 5
• Inadequate assessment of aspiration risk: Elderly patients often have multiple risk factors including delayed gastric emptying, medications, and comorbidities. Actively assess and address this risk. 1, 2