What are the differences between rapid sequence intubation (RSI) and modified rapid sequence intubation (modified RSI)?

Difference Between Rapid Sequence Intubation and Modified Rapid Sequence Intubation

Modified RSI differs from traditional RSI by incorporating gentle bag-mask ventilation or CPAP after induction and before intubation, whereas traditional RSI strictly avoids any positive pressure ventilation between induction and securing the airway. 1

Core Definitions

Traditional Rapid Sequence Intubation (RSI)

• RSI is defined as the administration of a sedative-hypnotic agent and a neuromuscular-blocking agent (NMBA) in rapid succession with immediate placement of an endotracheal tube before assisted ventilation. 1
• The technique was historically designed to minimize aspiration risk by avoiding any positive pressure ventilation between loss of consciousness and securing the airway. 1
• Cricoid pressure was traditionally applied throughout the procedure to prevent passive regurgitation. 1

Modified Rapid Sequence Intubation (Modified RSI)

• Modified RSI includes three defining features: (1) oxygen administration before induction, (2) application of cricoid pressure, and (3) an attempt to ventilate the patient's lungs via bag-mask before securing the airway. 2
• The modification allows for gentle continuous positive airway pressure (CPAP) or bag-mask ventilation after reliable loss of consciousness if a good seal is achieved. 3, 4
• This approach prioritizes preventing critical hypoxemia over the theoretical increased aspiration risk. 3, 4

Key Pharmacologic Differences

Both techniques require the same medication sequence—a sedative-hypnotic agent followed by an NMBA—but the timing of airway interventions differs. 1, 5

• Traditional RSI: No ventilation occurs between medication administration and intubation. 1
• Modified RSI: Gentle ventilation is permitted if needed to prevent desaturation. 2, 4
• The Society of Critical Care Medicine strongly recommends administering an NMBA when a sedative-hypnotic induction agent is used for intubation in both approaches. 1

Clinical Decision Algorithm: When to Use Each Approach

Use Traditional RSI When:

• Patient is cooperative and can tolerate adequate preoxygenation (3-5 minutes with well-fitted mask). 3
• Patient has normal oxygen saturation and no anticipated difficult airway. 3
• Risk of aspiration is high but oxygenation is adequate. 1

Use Modified RSI When:

• Patient has severe hypoxemia (PaO₂/FiO₂ < 150) despite preoxygenation. 1, 4
• Difficult or prolonged laryngoscopy is anticipated. 3, 4
• Patient is morbidly obese (BMI > 30 kg/m²) with rapid desaturation risk. 3
• The immediate risk of critical hypoxemia outweighs the theoretical increased aspiration risk from brief bag-mask ventilation. 4

Technical Specifications for Modified RSI Ventilation

If bag-mask ventilation is required during modified RSI, specific techniques minimize aspiration risk: 4

• Use the 2-handed, 2-person VE-grip technique (not single-handed C-grip). 3, 4
• Insert a Guedel (oropharyngeal) airway to maintain patency. 3, 4
• Apply minimal oxygen flows and airway pressures consistent with preventing hypoxia only. 3, 4
• Wait at least 1 minute after NMBA administration to ensure complete neuromuscular blockade before ventilation attempts. 3
• Apply gentle CPAP rather than positive pressure breaths when possible. 3, 4

Evolution of Practice and Current Controversies

Modern guidelines have shifted away from strict "no ventilation" dogma because preventing critical hypoxemia has become the priority over theoretical aspiration risk. 1, 4

• Mask ventilation has historically been avoided with RSI to reduce regurgitation and aspiration risk, but mask ventilation may reduce the risk of critical hypoxemia. 1
• The 2023 Society of Critical Care Medicine guidelines acknowledge this controversy but do not make a definitive recommendation for or against bag-mask ventilation during RSI due to insufficient evidence. 1
• A 2012 survey found that 93% of U.S. academic anesthesia programs use modified RSI, with 71% reporting they would attempt bag-mask ventilation before securing the airway. 2

Special Populations Requiring Modified Approach

Severely Hypoxemic Patients

• Use noninvasive positive pressure ventilation (NIPPV) for preoxygenation in patients with PaO₂/FiO₂ < 150. 1, 4
• Consider high-flow nasal oxygen (HFNO) when laryngoscopy is expected to be challenging. 1, 4

Obese Patients (BMI > 30 kg/m²)

• These patients have twice the risk of intubation-related complications (fourfold if BMI > 40 kg/m²) due to rapid and severe desaturation. 3
• Place patient in ramped position combined with reverse Trendelenburg. 3
• Modified RSI with planned gentle ventilation is often necessary. 2

Agitated/Uncooperative Patients

• Use medication-assisted preoxygenation (sometimes called delayed sequence intubation) with ketamine 1-1.5 mg/kg IV to achieve dissociative state, followed by 3 minutes of preoxygenation, then NMBA administration. 3, 5
• This represents a distinct variation where sedation precedes preoxygenation rather than occurring simultaneously. 3, 5

Common Pitfalls and How to Avoid Them

Pitfall: Rigid Adherence to "No Ventilation" Rule

• Modern evidence prioritizes preventing hypoxia over theoretical aspiration risk. 4
• If patient is desaturating after induction, gentle bag-mask ventilation with proper technique is safer than allowing profound hypoxemia. 4

Pitfall: Inadequate Preoxygenation

• Ensure meticulous preoxygenation for 3-5 minutes before induction to maximize safe apnea time. 3, 4
• In uncooperative patients, use medication-assisted preoxygenation rather than proceeding with inadequate preparation. 3, 5

Pitfall: Attempting Ventilation Before Complete Paralysis

• Wait at least 1 minute after NMBA administration or use peripheral nerve stimulator to confirm complete neuromuscular blockade before ventilation attempts. 3, 4
• Premature ventilation attempts risk coughing, laryngospasm, and increased aspiration risk. 3, 4

Pitfall: Poor Bag-Mask Technique

• Single-handed C-grip technique should be avoided; always use 2-person, 2-handed VE-grip for optimal seal. 3, 4
• Excessive airway pressures increase gastric insufflation and aspiration risk. 3, 4

Positioning Considerations for Both Approaches

The Society of Critical Care Medicine suggests using the head and torso inclined (semi-Fowler) position during both traditional and modified RSI. 1

• This positioning may reduce aspiration risk and potentially improve first-pass intubation success. 1
• However, one RCT showed decreased first-pass success with semi-Fowler position (76.2% vs 85.4%), so evidence remains mixed. 1