What is the recommended step‑by‑step airway management and rapid sequence intubation protocol for an adult patient requiring definitive airway control (e.g., loss of protective reflexes, severe hypoxia, airway obstruction, or anticipated deterioration)?

Airway Management and Rapid Sequence Intubation Protocol

For an adult patient requiring definitive airway control, perform rapid sequence intubation (RSI) using a structured protocol that includes semi-Fowler positioning, aggressive preoxygenation, administration of a sedative-hypnotic agent immediately followed by a neuromuscular blocking agent, and direct laryngoscopy with immediate rescue plans if intubation fails. 1

Step 1: Pre-Intubation Preparation and Assessment

Position the patient in semi-Fowler (head and torso inclined 30-45 degrees) to reduce aspiration risk and improve first-pass success. 1 For obese patients (BMI >30), use ramped positioning combined with reverse Trendelenburg to extend safe apnea time. 1

Verify all equipment before induction: 1

• Functional IV access with backup line
• Continuous waveform capnography (failure to use capnography contributes to >70% of ICU airway deaths) 2
• Operative suction immediately available
• Ventilator set to appropriate settings
• Complete airway cart including supraglottic airways (SGA) and front-of-neck airway (FONA) equipment 3, 1

For obese patients with non-palpable cricothyroid membrane, locate it with ultrasound before induction. 1

Step 2: Preoxygenation (Critical for Preventing Hypoxemia)

Deliver 3-5 minutes of preoxygenation using a well-fitted mask in a closed-circuit system. 1 This is the single most important step to prevent catastrophic desaturation.

For patients with severe hypoxemia (PaO₂/FiO₂ <150), use noninvasive positive pressure ventilation (NIPPV) for preoxygenation. 1, 2 High-flow nasal oxygen (HFNO) should be used when difficult laryngoscopy is anticipated. 1

For agitated, delirious, or combative patients who cannot tolerate preoxygenation devices, use delayed sequence intubation (DSI): 1

• Administer ketamine 1-1.5 mg/kg IV to achieve dissociative state 1
• Allow 3 minutes of preoxygenation while patient is sedated but breathing spontaneously 1
• Then proceed with neuromuscular blocker and intubation 1

Step 3: Gastric Decompression (When Indicated)

Insert nasogastric tube for decompression in patients at high risk of regurgitation when benefit outweighs risk. 1 This includes patients with bowel obstruction, recent large meal, or significant gastric distension.

Step 4: Medication Administration

Sedative-Hypnotic Agent (Must Be Given First)

A sedative-hypnotic induction agent MUST be administered before any neuromuscular blocking agent to prevent awareness during paralysis. 1 This is a best practice statement with no exceptions.

Choose one of the following: 1

• Ketamine 1-2 mg/kg IV: Preferred for hemodynamically unstable patients; maintains sympathetic tone
• Etomidate 0.3 mg/kg IV: Hemodynamically neutral; no mortality difference compared to other agents 1
• Propofol 2 mg/kg IV: Suppresses airway reflexes effectively but causes vasodilation and hypotension 1

Neuromuscular Blocking Agent (Mandatory with Sedative)

An NMBA must be administered when a sedative-hypnotic is used for intubation (strong recommendation). 1 This dramatically improves intubation success and reduces complications.

Choose one of the following: 1

• Succinylcholine 1.5 mg/kg IV: First-line choice for rapid onset (45-60 seconds) and brief duration
  • Contraindications: >24 hours post-burn (risk of fatal hyperkalemia), hyperkalemia, malignant hyperthermia history, neuromuscular disease 1
• Rocuronium 1.0-1.2 mg/kg IV: When succinylcholine is contraindicated; onset 60-90 seconds, duration 45-60 minutes 1
  • Sugammadex must be immediately available for reversal if needed 1

Wait at least 60 seconds after NMBA administration to allow full paralysis before attempting laryngoscopy. 1

Step 5: Airway Management During Apnea

Traditional RSI avoids positive pressure ventilation between induction and intubation to minimize aspiration risk. 1 However, modified RSI permits gentle bag-mask ventilation or CPAP if a good mask seal is achieved and hypoxemia develops. 1

If mask ventilation is required: 1

• Use two-person VE-grip technique
• Insert Guedel (oropharyngeal) airway
• Use minimal oxygen flow and lowest airway pressure necessary
• Confirm ventilation with waveform capnography 3

Cricoid pressure (Sellick maneuver) should only be applied if a trained assistant is present and must be removed immediately if it hinders intubation. 1

Step 6: Laryngoscopy and Intubation

The most experienced available operator should perform the intubation. 2 Use videolaryngoscopy when available, as it improves first-pass success rates. 1

For cervical spine injury: 1, 2

• Perform early RSI with manual inline stabilization
• Remove anterior portion of cervical collar to improve mouth opening
• Use bougie during direct laryngoscopy
• Maintain low threshold for switching to videolaryngoscopy

Confirm tube placement immediately with waveform capnography—this is the definitive monitor. 3 Clinical signs alone are unreliable. 3

Step 7: Failed Intubation Algorithm (Cannot Intubate)

If first intubation attempt fails, immediately call for help and prepare rescue equipment. 3

Plan B: Supraglottic Airway (SGA)

Insert an SGA (i-gel or LMA) to restore oxygenation. 3 A maximum of three attempts at SGA insertion are permitted with changes to size, type, and operator. 3

If SGA ventilation is successful (confirmed by waveform capnography and stable SpO₂): 3

• Consider single attempt at fiberoptic-guided intubation through the SGA (requires training) 3
• If oxygenation is marginal, aspiration occurred, or ventilation is difficult, proceed directly to FONA 3
• Awaiting an expert is only reasonable if oxygenation is adequate and expert arrival is prompt 3

Plan C: Facemask Ventilation

If SGA fails or is unavailable, attempt facemask ventilation with: 3

• Optimal head/mandible positioning
• Two-person technique
• Oral or nasal airway adjuncts
• CPAP during facemask ventilation (advantageous in critically ill) 3

Maximum three facemask ventilation attempts are permitted. 3 Open the FONA set after the first failed SGA or facemask attempt. 3

Step 8: Cannot Intubate, Cannot Oxygenate (CICO) → Emergency FONA

Do not wait for life-threatening hypoxemia before transitioning to FONA. 3 Delayed transition due to procedural reluctance is a greater cause of morbidity than complications of the procedure itself. 3

Declare CICO explicitly to the team: "This is a can't intubate, can't oxygenate situation. We need to perform an emergency front of neck airway." 3

Emergency Surgical Cricothyroidotomy (Preferred FONA Technique)

Four-step technique: 3

1. Identify cricothyroid membrane (use ultrasound pre-induction in obese patients) 1
2. Stab incision through skin and membrane with scalpel (blade 20 or Minitrach scalpel); enlarge with blunt dissection 3
3. Apply caudal traction on cricoid cartilage with tracheal hook 3
4. Insert small cuffed tracheal tube (6-7 mm) and inflate cuff 3

For obese patients with non-palpable cricothyroid membrane, use vertical incision and proceed promptly to surgical airway—avoid repeated intubation attempts or prolonged SGA use. 1

Verify tube position with waveform capnography and ventilate with low-pressure source. 3

Step 9: Post-Intubation Management

Apply recruitment maneuver and PEEP ≥5 cmH₂O in hypoxemic patients. 1

Include cardiovascular protocol: 1

• Define conditions for fluid challenge
• Early administration of vasopressors for hypotension
• All sedatives and analgesics can cause vasodilation and hypotension by abolishing sympathetic tone 1

Obtain post-intubation chest X-ray to confirm tube depth and identify complications (pneumothorax, aspiration). 2

Critical Pitfalls to Avoid

Inadequate preoxygenation is the most common preventable cause of desaturation. 1 Ensure full 3-5 minutes or use medication-assisted preoxygenation for uncooperative patients. 1

Never administer an NMBA without first giving a sedative-hypnotic agent—this causes awareness during paralysis. 1

Do not perform multiple intubation attempts without restoring oxygenation between attempts. 3 Limit to 2-3 attempts maximum before moving to rescue plan.

Failure to use waveform capnography contributes to >70% of ICU airway deaths. 2 Clinical assessment alone is unreliable. 3

Delayed transition to FONA is a greater cause of morbidity than the procedure itself. 3 Transition should occur within 60 seconds of recognizing failed ventilation. 3

In obese patients (BMI >40), avoid repeated intubation attempts, prolonged SGA use, or mask ventilation—proceed promptly to FONA. 1 These patients have twice the risk of complications (fourfold if BMI >40) due to rapid desaturation. 1