THE CHIEF
COMPLAINT
Back To Contents

Dyspnea / Respiratory · Adult Airway

Rapid Sequence Intubation (RSI)

Adult RSI; see the separate Pediatric Airway Note below

01Intubation Needed?

Indications

  • Oxygenation fails despite oxygen / noninvasive ventilation (NIV).
  • Ventilation fails: progressive respiratory acidosis, exhaustion, or declining effort.
  • The patient cannot maintain or protect the airway.
  • Anticipated deterioration requires airway control. Mosier 2015.

Support / Reassess

  • Treat reversible causes while supporting oxygenation / ventilation.
  • Do not delay necessary intubation for ineffective support.
  • Shock or respiratory distress alone does not mandate RSI. Resuscitate and reassess. See Physiologic Difficulty. Mosier 2015.

02Preparation

Anatomic Difficulty

LEMON — Anatomic Airway Assessment
LEMONAssessment
LLook externally
EEvaluate 3-3-2
MMallampati when assessable
OObstruction
NNeck mobility
  • Assess laryngoscopy, mask ventilation, supraglottic rescue, and front-of-neck access.
  • Use LEMON.
  • Anticipated major difficulty → consider awake intubation with appropriate expertise, especially if rescue oxygenation may be difficult. DAS 2025.

Physiologic Difficulty

  • Hypoxemia reduces apnea tolerance.
  • Shock may worsen with induction / positive-pressure ventilation.
  • Severe metabolic acidosis requires compensatory ventilation; apnea may precipitate collapse.
  • Right ventricular (RV) failure may worsen with positive-pressure ventilation. Mosier 2015.

Position / Equipment / Plan

  • Elevate the head / torso or ramp before preoxygenation. Adjust for anatomy, hemodynamics, and cervical-spine precautions. SCCM recommendation: conditional, very-low-certainty evidence. SCCM 2023.
  • Establish IV access; prepare ECG, SpO₂, BP, and waveform capnography monitoring.
  • Check oxygen, bag-mask equipment, airway adjuncts, and suction.
  • Prepare the ETT, cuff, laryngoscope, stylet / bougie, and backup devices, including supraglottic and front-of-neck airway equipment.
  • Prepare induction, paralysis, hemodynamic support, and ongoing analgesia / sedation.
  • Agree on the first attempt, backup operator / device, and rescue plan. DAS 2025 · PUMA 2022.

03Preoxygenation + Hemodynamic Support

Preoxygenation

  • Use high-concentration oxygen to build an oxygen reservoir before apnea.
  • Use NIV over conventional oxygen when feasible, especially with significant hypoxemia. Assess mask tolerance and aspiration risk. ACEP Level B. ACEP 2025.
  • NIV unsuitable → consider high-flow nasal cannula (HFNC). Consider nasal oxygen during laryngoscopy; both have weaker ACEP recommendations than NIV. ACEP 2025.
  • Agitation prevents preoxygenation → consider medication-assisted preoxygenation with the airway team ready. Do not delay a necessary airway. SCCM recommendation: conditional, very-low-certainty evidence. SCCM 2023.

Evidence — PREOXI

  • In 1,301 critically ill ED / ICU adults, NIV reduced SpO₂ <85% from 18.5% with an oxygen mask to 9.1%.
  • Aspiration did not significantly increase; patients with important contraindications were excluded. Safety during active vomiting was not established. PREOXI 2024.

Hemodynamic Support

  • Correct hypotension / poor perfusion during preparation; do not delay an immediately necessary airway.
  • Treat hypovolemia with fluids and hemorrhage with blood / hemorrhage control. Use cause-directed support, including vasopressors when indicated. Mosier 2015.

Evidence — PREPARE II

  • In 1,067 ICU adults, a routine 500-mL bolus did not significantly reduce cardiovascular collapse: 21.0% with fluid vs 18.2% without. No routine prophylactic bolus. PREPARE II 2022.
  • Evidence does not establish a superior peri-intubation vasopressor-versus-fluid strategy. SCCM 2023.

04Induction + Paralysis

  • Give an induction agent followed promptly by a neuromuscular blocker. Paralysis provides neither sedation nor analgesia. SCCM 2023.

Pretreatment

  • Use adjuncts selectively; no routine lidocaine or fentanyl pretreatment.
  • Lidocaine has inconsistent ICP effects and no established functional-outcome benefit. Lidocaine Review.
  • Avoid fentanyl, propofol, or midazolam for induction / coinduction in patients at increased risk for postintubation hypotension. ACEP 2025.

Induction Agents

  • Etomidate and ketamine are useful options; neither is reliably BP-neutral. Individualize adult induction doses to physiology. ACEP 2025.

Etomidate

  • Give 0.3 mg/kg IV; adverse effects include myoclonus and adrenal suppression.
  • Do not give steroids solely for etomidate-associated adrenal suppression. SCCM 2023.

Ketamine

  • Give 2 mg/kg IV; consider when bronchospasm is present.
  • Airway protection and cardiovascular stability are not guaranteed. ACEP 2025 · RSI Trial.

Evidence — Ketamine Vs Etomidate

  • The RSI trial randomized 2,365 critically ill ED / ICU adults to ketamine or etomidate.
  • Day-28 in-hospital mortality was 28.1% vs 29.1%; no significant difference.
  • Cardiovascular collapse occurred in 22.1% vs 17.0%, respectively: severe hypotension, new / increased vasopressors, or arrest. Do not assume ketamine protects against hypotension. RSI Trial.

Neuromuscular Blockade

  • Use rocuronium or succinylcholine when relevant contraindications are absent. SCCM 2023.

Rocuronium

Succinylcholine

  • Dose: 1.5 mg/kg IV for adult RSI.
  • Avoid with hyperkalemia, skeletal muscle myopathy, or malignant-hyperthermia susceptibility.
  • Contraindicated after the acute phase of major burns, multiple trauma, extensive denervation, or upper motor neuron injury.
  • Hyperkalemic risk often peaks at 7–10 days; onset and duration are uncertain. Do not assume safety before day seven. Succinylcholine.

Ventilation During Induction

  • Provide gentle assisted ventilation when needed to prevent hypoxemia; balance aspiration risk. Do not wait for substantial desaturation.

Evidence — PreVent

  • 401 ICU adults, bag-mask ventilation between induction and laryngoscopy reduced SpO₂ <80% from 22.8% to 10.9%.
  • Aspiration did not significantly increase, but very-high-risk patients were excluded. Safety was not established for every airway. PreVent 2019.

05Intubation / Failed-Airway Rescue

First Attempt

  • Favor video laryngoscopy when available and the operator is trained; retain direct laryngoscopy as a backup.
  • Optimize position, suction, device, and tube-delivery adjuncts. Use external laryngeal manipulation to improve the view when needed. DAS 2025.
  • ACEP recommends considering video laryngoscopy; UK DAS recommends it whenever possible. ACEP 2025 · DAS 2025.

Evidence — DEVICE

  • In 1,417 ED / ICU adults, first-attempt success was 85.1% with video vs 70.8% with direct laryngoscopy. Severe complications were not significantly reduced. DEVICE 2023.

Failed-Airway Rescue

  • Failed attempt → stop, reoxygenate, and call for help. Use mask ventilation / a supraglottic airway for rescue oxygenation.
  • Oxygenation restored → maintain it. Change the position, suction, operator, device, or technique before another attempt.
  • Cannot intubate, cannot oxygenate → declare the emergency and perform front-of-neck access / cricothyrotomy. Do not delay rescue with repeated laryngoscopy. DAS 2025.

06Waveform Confirmation

Confirm Placement

  • Confirm sustained exhaled CO₂ with waveform capnography; continue monitoring.
  • Chest rise, breath sounds, absent gastric sounds, fogging, and SpO₂ do not replace capnography.

Absent / Inadequate Waveform

  • Immediately exclude esophageal placement or failure of ventilation.
  • Absent sustained CO₂ → remove the tube and ventilate by mask / supraglottic airway (PUMA default).
  • If removal would be dangerous, urgently confirm tracheal placement by a valid alternative technique while investigating other causes. Remove the tube if placement remains unconfirmed or sustained CO₂ cannot be restored. PUMA 2022.

Tube Depth

  • A CO₂ waveform does not exclude mainstem intubation. Check depth and bilateral ventilation. PUMA 2022.

07Immediate Postintubation Care

Analgesia / Sedation

  • Start promptly; titrate to hemodynamics and clinical needs.
  • Do not wait for movement after rocuronium. Induction may wear off while paralysis persists. Rocuronium.

Ventilation

  • Match settings to physiology and reassess gas exchange.
  • Allow adequate expiratory time in obstructive disease to avoid breath stacking / dynamic hyperinflation.
  • Maintain compensatory ventilation in severe metabolic acidosis; routine settings may be inadequate.
  • Obtain an early blood gas when needed. Mosier 2015.

Secure / Reassess

  • Secure the ETT and document depth. Recheck BP, perfusion, SpO₂, capnography, and ventilation.
  • Obtain a CXR for depth / complications—not initial tracheal confirmation.
  • Deterioration → immediately reassess tube position, ventilation, and hemodynamics. Consider induction and positive-pressure effects. PUMA 2022 · Mosier 2015.

In The Pit

  • Preoxygenate with NIV (BiPAP / CPAP)
    • When feasible, especially if hypoxemic
  • Consider HFNC
    • NIV not feasible, particularly with hypoxemia
  • Consider nasal O₂ during laryngoscopy
    • For apneic oxygenation
  • Gentle BVM ventilation after induction
    • Hypoxemic + low aspiration risk
  • Optimize hemodynamics before induction
    • Fluids / blood / pressors based on the cause
  • Etomidate or ketamine for induction
    • Both are reasonable agents; neither is reliably BP-neutral
  • Rocuronium or succinylcholine for paralysis
    • Paralysis ≠ sedation
  • Video laryngoscopy preferred
    • When available / operator trained → improves first-pass success
  • Reoxygenate and change something after a failed attempt
    • Do not repeatedly perform the same attempt
  • Front-of-neck airway
    • Cannot intubate / cannot oxygenate
  • Confirm with sustained waveform capnography
  • Sedation / analgesia immediately after intubation
    • Ventilator settings matched to physiology

Pediatric Airway Note

  • Use pediatric references for tube sizing, equipment, weights, and doses.
  • Atropine is optional for emergency-intubation premedication: 0.02 mg/kg, no minimum dose.
  • The 0.1-mg minimum does not apply to intubation premedication. Bradycardia dosing is separate. AHA / AAP 2025.

Must-Read References

View Full References

Additional Cited Guidance

Table Of Contents

Privacy & analytics choices