Rapid Sequence Induction and Intubation (RSII) For Anesthesia

Rapid sequence induction and intubation (RSII) for anesthesia - UpToDate 17-01-21 13:11
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Rapid sequence induction and intubation (RSII) for anesthesia

Author: Lauren Berkow, MD
Section Editor: Carin A Hagberg, MD, FASA
Deputy Editor: Marianna Crowley, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Dec 2020. | This topic last updated: Jun 02, 2020.
AIRWAY MANAGEMENT FOR PATIENTS WITH COVID-19
In patients with novel coronavirus disease 2019 (COVID-19 or nCoV), there is a high risk of aerosol spread of the virus
during laryngoscopy and other airway management procedures. Techniques for improving patient care and
minimizing infectious risks to care providers and spread of the virus during emergency intubation are summarized in
the following table ( table 1) and discussed separately. (See "Coronavirus disease 2019 (COVID-19): Anesthetic
concerns, including airway management and infection control" and "Coronavirus disease 2019 (COVID-19): Critical
care and airway management issues", section on 'The decision to intubate'.)
INTRODUCTION
Rapid sequence induction and intubation (RSII) for anesthesia is a technique designed to minimize the chance of
pulmonary aspiration in patients who are at higher than normal risk. The usual, nonrapid sequence of induction and
intubation for anesthesia consists of administration of an induction agent, proof of the ability to mask ventilate,
administration of a neuromuscular blocking agent (NMBA), and endotracheal intubation once paralysis is achieved,
usually approximately three minutes after induction. Since induction of anesthesia results in loss of airway protective
reflexes, pulmonary aspiration is a risk during the interval between loss of consciousness and inflation of the cuff of
the endotracheal tube.
The components of RSII are designed to protect the airway with a cuffed endotracheal tube as quickly as possible after
induction, while reducing the chance of passive or active regurgitation. An essential goal of RSII is the achievement of
adequate depth of anesthesia, and, most often, paralysis, for laryngoscopy, to prevent coughing, straining, and active
vomiting with airway manipulation.
While RSII is a departure from the usual practice of induction of anesthesia, the equivalent method of rapid airway
control, often called "rapid sequence intubation" (RSI), is the most commonly used method of controlling the airway in
the emergency department.
This topic will discuss the components, techniques, and medications used for RSII for anesthesia. Preoperative fasting
guidelines, airway management for induction of anesthesia, rapid sequence intubation in the emergency department,
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and medications used for induction of anesthesia are discussed more fully separately. (See "Induction of general
anesthesia: Overview" and "Preoperative fasting guidelines" and "Airway management for induction of general
anesthesia" and "Rapid sequence intubation for adults outside the operating room".)
INDICATIONS
General indications — RSII should be considered for the patient who is at increased risk of aspiration with induction
of anesthesia. This includes the patient with a full stomach, gastrointestinal pathology, increased abdominal pressure,
or pregnancy after 20 weeks gestation ( table 2):
● Patients with a full stomach, which includes:

• Patients undergoing emergency surgery
• Patients who have sustained trauma, regardless of the interval since last oral intake
• Patients who have not fasted according to preoperative fasting guidelines (see "Preoperative fasting
guidelines")
● Patients with gastrointestinal pathology, which includes:

• Gastroparesis
• Small bowel obstruction
• Gastric outlet obstruction
• Esophageal stricture
• Gastroesophageal reflux disease (see 'Gastroesophageal reflux disease (GERD)' below)
● Patients with increased intraabdominal pressure, which includes those with:

• Morbid obesity
• Ascites
● Pregnancy after 20 weeks gestation; earlier if symptoms of gastroesophageal reflux (controversial) (see
"Anesthesia for nonobstetric surgery during pregnancy", section on 'Preoperative aspiration mitigation')
Gastroesophageal reflux disease (GERD) — GERD is a common condition that may put patients at risk for passive
regurgitation and subsequent aspiration during induction of anesthesia.
Patient selection — The decision to perform RSII for patients with GERD must be individualized based on the
degree of symptoms and the potential risk of RSII. Patients should be questioned about symptoms of reflux during
preoperative evaluation, including the presence of heartburn, regurgitation, dysphagia, reflux symptoms at night, and
the need to sleep with the head of the bed elevated to avoid reflux. We consider RSII for the following patients:
● Patients with current symptoms of active reflux (ie, regurgitation, heartburn, or the need to sleep with the head of
the bed elevated)
● Patients who had significant symptoms of active reflux prior to starting antacid medication, such as proton pump
inhibitor (PPI), histamine-2 receptor antagonist (H2RA), or calcium carbonate
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● Patients who believe that symptoms of reflux would recur if antacid therapy was discontinued
● Patients with hiatal hernia or endoscopic evidence of GERD
We do not routinely perform RSII for patients who report heartburn only with spicy or acidic foods.
Clinical manifestations, diagnosis, and management of GERD are discussed more fully separately. (See "Clinical
manifestations and diagnosis of gastroesophageal reflux disease in children and adolescents" and "Medical
management of gastroesophageal reflux disease in adults".)
Preoperative antacids — Patients presenting for elective surgery who take antacid medication, including PPIs and
H2RAs, on a regular or as-needed basis should be instructed to take their usual medication before surgery. PPIs are
more effective at reducing gastric volume and increasing pH if given in two doses, one the evening prior to surgery,
and another on the morning of surgery [1,2]. A single dose of oral ranitidine three hours prior to induction of
anesthesia has been shown to significantly reduce gastric volume and increase pH of stomach contents. Ranitidine is
no longer available in the United States. Alternatives include famotidine, cimetidine, or a PPI. When administered
orally, two doses of a PPI are required for maximum efficacy (one the evening before and one the morning of surgery).
A meta-analysis of randomized trials that compared efficacy of H2RAs with PPIs found that a single IV dose or two oral
doses of PPIs were as effective as H2RAs administered by either route [3].
PREPARATION FOR ANESTHESIA
In addition to the preparation for routine induction of anesthesia, an assistant should be present who understands
RSII and is capable of correctly applying cricoid pressure to assist in airway management.
Airway evaluation — Airway evaluation is an important step in making the decision to perform an RSII. If a difficult
airway is predicted, the risk of aspiration must be weighed against the risk of difficult or failed airway management.
This is because RSII usually includes the administration of a neuromuscular blocking agent (NMBA) without proof that
mask ventilation will be possible once the patient is paralyzed. In all but the most urgent situations, a quick airway
examination and query about previous airway problems should be possible. If difficult airway management is
expected, a modified RSII, awake intubation, or even an inhalation induction may be chosen as alternatives. (See
"Airway management for induction of general anesthesia", section on 'Prediction of the difficult airway' and 'Potential
complications of RSII' below.)
Equipment — Preparation of equipment for RSII should be similar to that for routine induction. An assortment of
standard and alternative airway devices should be immediately available, including small, medium, and large
facemasks; several sizes and types of laryngoscopes; oral and nasal airways; several sizes of supraglottic airway, and a
bougie. Alternative devices for laryngoscopy, including a video laryngoscope and flexible intubating scope, as well as
other emergency airway equipment, should be accessible quickly and present in the operating room or anesthetizing
location if difficult airway is suspected. Working suction must always be close by during induction of anesthesia; for
RSII, we usually place the suction directly under the headrest for immediate access.
Premedication — Premedication may be administered prior to RSII to relieve anxiety, to blunt or eliminate the
physiologic response to airway management, and to reduce the volume or increase the pH of stomach contents.
● Anxiolytics – For patients who are hemodynamically stable, a benzodiazepine (eg, midazolam up to 1 to 2 mg IV)
may be administered to reduce anxiety. This dose should be titrated cautiously in older adults and when given
simultaneously with narcotic premedication, to avoid hypotension and loss of protective airway reflexes [4].
● Atropine – The administration of succinylcholine and airway manipulation can trigger a vagal response, especially
in children and neonates. We therefore suggest the use of atropine with RSII for all children younger than one
year and for children less than five years of age who receive succinylcholine, though succinylcholine is rarely
administered to children in the operating room. (See "Rapid sequence intubation (RSI) outside the operating room
in children: Approach", section on 'Pretreatment'.)
A vagal response to straightforward endotracheal intubation is much less common in adults; as such, atropine is
not routinely administered as a premedication before RSII for adults. However, anticholinergic treatment may be
required if bradycardia occurs with difficult laryngoscopy and intubation, or as a result of intubation in patients
with preexisting bradycardia caused by medication or conduction system disease [5-7].
● Opioids – Opioids may be administered as part of premedication for analgesia and sedation. They should be
titrated to avoid respiratory depression and loss of protective airway reflexes in patients at risk for aspiration,
especially in older patients, and when administered with benzodiazepines.
● Antacids – We suggest premedication with antacids prior to induction of anesthesia for patients at high risk of
aspiration to increase the pH of gastric contents so that, if aspiration does occur, it will result in less pulmonary
damage. Several classes of antacid medication are routinely used:
• Clear, nonparticulate oral antacid (eg, sodium citrate-citric acid, 30 mL orally immediately prior to induction)
increases pH of stomach contents [8].
• Histamine-2 receptor antagonist (H2RA) (eg, famotidine 20 mg IV, given 40 to 60 minutes prior to induction)
reduces the volume and increases the pH of stomach contents.
For pregnant patients and for those at high risk of aspiration, we routinely administer clear, nonparticulate
antacid prior to induction. For nonpregnant patients at high risk of aspiration who have not received a proton
pump inhibitor (PPI) or H2RA on the morning of surgery, we also administer an H2RA 40 to 60 minutes prior to
induction.
● Prokinetic agent – Intravenous (IV) metoclopramide increases lower esophageal sphincter tone [9], induces
peristalsis, and enhances stomach emptying, thereby reducing gastric volume and the risk of regurgitation.
Metoclopramide is particularly useful in patients with gastroparesis undergoing general anesthesia. It is also
antiemetic and may help prevent postoperative nausea and vomiting. Rare adverse effects of metoclopramide
include extrapyramidal effects and tardive dyskinesia, which are more common if administered quickly. We
reserve metoclopramide for patients with uncontrolled reflux and pregnant patients who are symptomatic with
reflux. In this setting, we administer metoclopramide 10 mg IV over one to two minutes.
Positioning — The patient's head should be positioned in the sniffing position to facilitate intubation (atlanto-occipital
extension with head elevation of 3 to 7 cm). Obese patients may require a ramped position ( figure 1). (See "Airway
management for induction of general anesthesia", section on 'Patient positioning'.)
When RSII is planned, we prefer to position the operating table with the head up because passive regurgitation and
aspiration may be less likely if the larynx is above the level of the lower esophageal sphincter. We flex the hips to
elevate the back of the operating table, or tilt the table 20 degrees head up, making sure that once that is done, the
height of the patient's head is optimal for intubation. Should the patient regurgitate prior to or during induction, the
table should be quickly tipped head down, the patient's head turned to the side, and the mouth suctioned to avoid
aspiration.
Preoxygenation — All patients presenting for general anesthesia should be preoxygenated with 100 percent oxygen
to increase oxygen reserve and provide additional time to secure the airway. This is particularly important prior to
RSII, since with this technique, mask ventilation is not usually performed between induction and intubation.
Preoxygenation is administered for three minutes of normal tidal volume breathing, for eight deep breaths over one
minute, or until the fraction of expired oxygen is over 90 percent [10]. (See 'Mask ventilation' below.)
The use of nasal cannula for passive apneic oxygenation during laryngoscopy can prolong the time to desaturation in
high-risk patients during airway management [11-13]. We suggest the administration of oxygen by nasal cannula at 10
L in addition to facemask oxygen for those patients who are at high risk for rapid oxygen desaturation during the
apneic period between induction and intubation, and for those at higher risk of difficult intubation.
Methods for apneic oxygenation have become available that may be useful for preoxygenation as well as passive
oxygenation during RSII. The transnasal humidified rapid insufflation ventilatory exchange (THRIVE) technique uses a
device that provides humidified high-flow nasal oxygen with continuous positive airway pressure (CPAP). THRIVE may
maintain a blood gas profile equivalent to face mask preoxygenation in spite of longer apnea time [14,15]. (See
"Preoxygenation and apneic oxygenation for airway management for anesthesia".)
A number of studies have shown either more rapid or effective preoxygenation or increased time to desaturation after
apnea with the use of CPAP during preoxygenation [16-18]. CPAP can be provided using a tight-fitting anesthesia face
mask, and pressure support ventilation provided with positive end-expiratory pressure (PEEP). Morbidly obese
patients in particular may benefit from CPAP preoxygenation. Low levels of inspiratory pressure should be used to
avoid gastric insufflation.
CRICOID PRESSURE DURING RSII
Although controversial, we routinely apply cricoid pressure (also known as Sellick's maneuver) prior to and during RSII
until confirmation of correct endotracheal tube placement. Despite conflicting evidence regarding the effectiveness of
cricoid pressure for preventing regurgitation, clinical experience suggests that, in most situations, it is not harmful
and may be beneficial.
The most significant downside to the use of cricoid pressure is the possibility that it may make laryngoscopy,
supraglottic airway placement, or mask ventilation more difficult. We routinely have an assistant apply cricoid
pressure during RSII, but we communicate the need to shift or release the pressure as necessary to facilitate
endotracheal intubation. Cricoid pressure may have to be released if intubation proves difficult and/or mask
ventilation, supraglottic airway placement, or flexible fiberoptic bronchoscopy become necessary. Indeed, the 2015
Difficult Airway Society guidelines from the United Kingdom recommend that cricoid pressure be released if initial
attempts at laryngoscopy are difficult [19]. Should active vomiting occur, cricoid pressure should be released to avoid
esophageal rupture.
We do not routinely use cricoid pressure during RSII for patients with acute cervical spinal cord injury because it can
move unstable cervical spine fractures. In trauma patients with possible but unevaluated cervical spine injury, cricoid
pressure should only be used along with manual in line stabilization to stabilize the posterior cervical spine. (See
"Anesthesia for adults with acute spinal cord injury", section on 'Airway management strategy'.)
As originally described by Sellick in 1961, the cricoid cartilage ring is pressed backward by an assistant against the
underlying cervical vertebrae, occluding the lumen of the esophagus to prevent regurgitation of stomach contents
into the pharynx ( figure 2) [20]. Based on cadaver and patient studies, pressure should be applied at 10 Newtons
(approximately 2.5 lbs) while the patient is awake and increased to 30 Newtons after loss of consciousness. Despite
these recommendations, clinicians and assistants are not routinely trained to standardize application of pressure [21-
23].
While optimal external laryngeal manipulation (OELM) of the thyroid cartilage is often used to improve the view of the
vocal cords during laryngoscopy, cricoid pressure should not be applied in an attempt to improve laryngeal view, as it
may in fact make the view worse.
Cricoid pressure controversies — The need for, efficacy, anatomical basis, and optimal technique for application of
cricoid pressure have all been questioned, and literature is inconclusive [24]. Some guidelines, including the American
Heart Association Guidelines for Cardiopulmonary Resuscitation, no longer recommend the routine use of cricoid
pressure [25]. Only two randomized controlled trials have evaluated cricoid pressure for RSII with direct laryngoscopy
[26]. In one of these trials, the primary outcome was the pressor response to endotracheal intubation; there was no
difference between patients who had cricoid pressure applied and those who did not [27]. The other trial, which
evaluated aspiration and intubating conditions with and without cricoid pressure, was a prospective, randomized,
multicenter study of 3472 patients who required RSII for increased risk of aspiration [28]. There was no difference in
the incidence of aspiration (0.6 percent with cricoid pressure versus 0.5 percent without). Median intubation time was
longer in patients who had cricoid pressure applied (27 versus 23 seconds), and there was higher incidence of
Cormack Lehane grade 3 or 4 laryngeal views with cricoid pressure (10 versus 5 percent) ( figure 3). (See "Direct
laryngoscopy and endotracheal intubation in adults", section on 'Glottic view scores'.)
● Evidence that cricoid pressure may reduce the incidence of aspiration of gastric contents is scant and consists
primarily of observational clinical studies and experimental data from cadaver studies [29], including the
following:
• Cadaver studies have shown that cricoid pressure prevents reflux of saline into the pharynx at esophageal
pressures up to 50 cmH2O [21,30-32].
• Several studies have shown that cricoid pressure prevents gastric insufflation during mask ventilation in
children and adults [33-35].
• An observational study performed in patients undergoing elective surgery reported that cricoid pressure
applied at 30 Newtons effectively occluded the upper esophagus, as determined by the inability to pass
gastric tubes of two different sizes [36].
• There are case reports of regurgitation when cricoid pressure was released [20,37].
● Lack of efficacy of cricoid pressure and possible harm are suggested by several studies and observations, as
follows:
• The anatomical basis for the use of cricoid pressure has been questioned by imaging studies. Both computed
tomography (CT) and magnetic resonance imaging (MRI) studies have shown that the esophagus is located
lateral to the midline in approximately 50 percent of patients [38,39]. The application of cricoid pressure
displaced the esophagus laterally in 90 percent of subjects [39], suggesting that the esophagus would not be
occluded by pressing the cartilage against cervical vertebrae. In contrast, an MRI study showed that
application of 2 to 4 kg of cricoid pressure moved the cricoid cartilage and the hypopharynx as one unit,
effectively obliterating the lumen of the alimentary tract, even with lateral displacement [40].
• Cricoid pressure at 20 Newtons has been shown to reduce lower esophageal pressure in awake, un-
anesthetized volunteers (presumably by reflex), with restoration to baseline after release of pressure [41]. If
applicable to anesthetized patients, this effect could theoretically increase the chance of gastroesophageal
reflux, though it isn't clear whether this would increase the chance of reflux into the pharynx. Another study
of awake volunteers reported that application of cricoid pressure did not promote gastroesophageal reflux
[42].
• Several studies have reported a worsened Cormack Lehane grade view during laryngoscopy, prolonged time
to intubation, and/or airway obstruction with the use of cricoid pressure [29,43-47].
NASOGASTRIC TUBE
For patients with bowel obstruction, ileus, and other gastrointestinal pathology, some clinicians place a nasogastric
tube to decompress the stomach prior to induction of anesthesia. Nasogastric drainage or suction does not guarantee
an empty stomach and may not remove particulate matter. Such patients often present for anesthesia and surgery
with a nasogastric tube already in place. We generally leave the nasogastric tube in place during RSII, connect it to
suction to drain the stomach prior to induction, and then leave it open to air as a vent for the stomach. The stomach is
suctioned again prior to emergence. While presence of a nasogastric tube may impair the function of the lower and
upper esophageal sphincters [48], two cadaver studies have shown that cricoid pressure effectively prevents
regurgitation of stomach contents with a nasogastric tube in place [22,30]. In addition, the nasogastric tube can help
identify the esophagus during laryngoscopy and therefore make esophageal intubation less likely.
CHOICE OF MEDICATIONS
Since the aim of RSII is to place an endotracheal tube as quickly as possible after loss of consciousness, all medications
used should be rapid in onset, without significant hemodynamic effects when given at the required doses, and should
achieve optimal intubating conditions. Depending on the planned surgical procedure, a short duration of action or
reversibility may be desirable as well. An important goal of RSII is the achievement of an adequate depth of anesthesia
and, in most cases, paralysis to prevent coughing, gagging, straining, or vomiting during airway manipulation.
Induction agents
Dose and timing of induction agent — We typically titrate the anesthesia induction agent to loss of consciousness
prior to the administration of neuromuscular blocking agent (NMBA). As RSII was originally described, a precalculated
dose of an induction drug was administered, immediately followed by an NMBA. This timing can result in either
underdosing, with the possibility of awareness or an undesirable sympathetic response to intubation, or to
overdosing, with the possibility of hypotension. An alternative method of administration is to titrate the induction
medication to loss of consciousness, recognizing that total induction time may be slightly longer with a titration
technique. There are no data comparing the risk of aspiration, awareness, or hemodynamic consequence of RSII using
the titration versus bolus technique.
Choice of agent — Propofol is the induction agent we use most commonly for RSII, but the choice, dose, and
speed of administration of the induction agent should be individualized. Patients presenting for emergency surgery
may be hypovolemic or have other comorbidities that increase the risk of hemodynamic instability with induction.
Ketamine and etomidate are alternatives to propofol for patients at increased risk of hypotension with induction.
Propofol — Propofol is the most commonly used medication for induction of anesthesia and for RSII. Advantages
for RSII include its rapid onset (30 to 45 seconds) and its ability to suppress airway reflexes and produce apnea [49].
Duration of action of propofol is short (5 to 10 minutes), which is an advantage if airway management is difficult and
the patient must be awakened. However, the short duration of action means that repeat doses of propofol may be
required if airway management is prolonged. (See "General anesthesia: Intravenous induction agents", section on
'Propofol'.)
Propofol can cause hypotension because of dose-dependent venodilation, arterial dilation, and decrease in cardiac
contractility [50]. The usual induction dose for RSII is 2 mg/kg, with reduced doses for patients at increased risk of
hypotension [49].
Etomidate — Etomidate is an imidazole drug that acts directly on the gamma-aminobutyric acidA (GABAA) receptor
complex, with a fast onset and short duration of action. Unlike propofol, etomidate does not cause vasodilation or
myocardial depression, an advantage for patients who are at increased risk for hypotension [51]. For RSII, the
induction dose of etomidate is 0.2 to 0.4 mg/kg IV, with rapid onset (30 to 45 seconds) and duration of action of 5 to 15
minutes [52]. (See "General anesthesia: Intravenous induction agents", section on 'Etomidate'.)
Etomidate has been associated with adrenal suppression in the first 12 hours after a single dose and may prevent a
rise in cortisol in response to a surgical stimulus [51]. However, a systematic review including six trials (772 patients)
reported that a single induction dose of etomidate for endotracheal intubation in critically ill patients was not
associated with increased mortality compared with other induction agents [53].
Ketamine — Ketamine is an NMDA receptor antagonist used for induction of anesthesia. It is a mild direct
myocardial depressant [54], but in patients with an intact autonomic nervous system, it increases sympathetic tone,
resulting in an increase in blood pressure, heart rate, and cardiac output [55]. Thus, ketamine is an alternative to
etomidate for patients at risk for hypotension. However, sympathetic stimulation with administration of ketamine is
dependent upon the presence of adequate sympathetic reserve. In the patient who has maximally activated the
sympathetic response and depleted all reserve (eg, patients with profound hypovolemic shock), ketamine
administration may result in hypotension as a result of myocardial depression. The RSII induction dose of ketamine is
1 to 2 mg/kg IV. (See "General anesthesia: Intravenous induction agents", section on 'Ketamine'.)
Induction with ketamine for patients with traumatic brain injury is controversial. The concern is that ketamine may
increase cerebral blood flow and intracranial pressure (ICP), thereby reducing cerebral perfusion. However, since it
increases cardiac output and maintains mean arterial pressure, cerebral perfusion may actually increase. We believe
that ketamine is an appropriate induction agent for RSII in patients with suspected ICP elevation and normal blood
pressure or hypotension. In patients with hypertension and suspected ICP elevation, ketamine should be avoided
because of its tendency to further elevate blood pressure.
Barbiturates — Prior to the introduction of propofol, thiopental was the most commonly used agent for both
routine induction of anesthesia and RSII. It is no longer available in the United States, though it is still used in other
parts of the world. Methohexital is another barbiturate used for induction, with limited availability in the United States.
With an induction dose of thiopental, 3 to 5 mg/kg IV, the time to effect is less than 30 seconds, and the duration of
action is approximately 5 to 10 minutes. The induction dose of methohexital is 1 to 3 mg/kg IV, with similar time to
effect and duration of action [56]. (See "General anesthesia: Intravenous induction agents", section on 'Methohexital'.)
Both barbiturates are myocardial depressants and venodilators, and can cause hypotension. Doses should be reduced
for older patients and for those at risk for hypotension. In addition, thiopental releases histamine and should be
avoided in patients with asthma or reactive airway disease [57].
Opioids — Short-acting opioids (eg, fentanyl 1 to 3 mcg/kg IV three minutes prior to induction) is usually administered
to reduce the sympathetic nervous system response to intubation. Remifentanil, an ultrashort-acting opioid, can be
administered to profoundly suppress airway reflexes for intubation when the administration of NMBA is undesirable
or contraindicated. (See 'Remifentanil intubation' below and "Induction of general anesthesia: Overview", section on
'Induction with endotracheal intubation'.)
Lidocaine — Lidocaine (eg, 1 to 1.5 mg/kg IV given two minutes prior to intubation) is administered to blunt the
sympathetic response to laryngoscopy and suppress the cough reflex [58-61]. Lidocaine pretreatment may prevent or
decrease the transient rise in intracranial pressure with laryngoscopy and intubation, though studies of this effect
have reached contradictory conclusions. Hypotension may occur with administration of higher doses of intravenous
lidocaine [62]. (See "Pretreatment medications for rapid sequence intubation in adults outside the operating room",
section on 'Lidocaine' and "Induction of general anesthesia: Overview", section on 'Induction with endotracheal
intubation'.)
Neuromuscular blocking agents (NMBAs) — NMBAs are administered for RSII to achieve optimal intubating
conditions and to prevent coughing, gagging, straining, and vomiting as a result of airway manipulation.
Succinylcholine — Unless contraindicated, for most cases we suggest the use of succinylcholine (1 to 1.5 mg/kg)
rather than nondepolarizing NMBAs for RSII because it provides excellent intubating conditions within 30 to 60
seconds [63]. Paralysis is achieved once fasciculations have stopped, at which point intubation can be performed. If a
defasciculating dose of a nondepolarizing NMBA is administered in addition, the dose of succinylcholine must be
increased to 1.5 to 2 mg/kg IV to overcome the antagonism between nondepolarizing and depolarizing NMBAs. (See
"Clinical use of neuromuscular blocking agents in anesthesia", section on 'Drug interactions'.)
Succinylcholine causes muscle fasciculations in most patients, which tend to be more severe in younger and more
muscular patients. Administration of succinylcholine can increase intragastric pressure, primarily as a result of
fasciculation of abdominal musculature, though this effect is variable [64]. A study of thiopental/succinylcholine
induction in young, unpremedicated male patients reported increases in intragastric pressure as high as 30 cmH2O
over baseline. The increase was prevented by administration of a defasciculating dose of nondepolarizing NMBA (eg,
vecuronium, rocuronium, cisatracurium). The potential increase in intragastric pressure may be of particular concern
in patients with reduced competence of the lower esophageal sphincter, such as those with abdominal distention,
hiatal hernia, pregnancy, and gastroesophageal reflux. (See 'Defasciculation' below.)
When masseter muscle spasm occurs after succinylcholine, administration of a nondepolarizing NMDA may or may
not successfully resolve the spasm [65]. If endotracheal intubation is not possible, mask ventilation should be
attempted, and preparations for a surgical airway should be made. Rarely, masseter muscle spasm progresses to
spasm in extremities and may herald malignant hyperthermia. Isolated masseter spasm usually resolves over
approximately 20 minutes [66]. Succinylcholine is discussed more fully separately. (See "Clinical use of neuromuscular
blocking agents in anesthesia", section on 'Succinylcholine'.)
Defasciculation — We do not routinely administer a defasciculating dose of nondepolarizing NMBA before

succinylcholine, though other clinicians do. A small dose of nondepolarizing NMBA has been shown to reduce the
fasciculations, myalgias, and the increase in intragastric pressure that result from administration of succinylcholine
[64,67]. The defasciculating dose should be 10 percent of the ED95 for the chosen drug (ie, 2 mg rocuronium IV, 1.5 mg
cisatracurium IV, or 0.3 mg vecuronium IV) given two to three minutes prior to induction. (The ED95 is the median dose
of NMBA which results in 95 percent twitch depression, and is typically much lower than the intubating dose) (
table 3). (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Endotracheal intubation'.)
Higher doses may result in signs of paralysis, including diplopia and difficulty breathing or swallowing, and should be
avoided. If a defasciculating dose is administered, the dose of succinylcholine must be increased to 1.5 to 2 mg/kg IV
to overcome the antagonism between nondepolarizing and depolarizing NMBAs [68]. Without fasciculations as a
marker for paralysis, a peripheral nerve stimulator may be used to confirm adequate relaxation for intubation.
A number of other drugs have been studied as pretreatment to prevent fasciculations and myalgias, with variable
results. A meta-analysis of randomized trials concluded that succinylcholine-induced fasciculations are best prevented
with pretreatment with NMBAs, lidocaine, or magnesium [67].
Alternatives to succinylcholine
Nondepolarizing NMBAs — All nondepolarizing NMBAs have a slower time to onset and longer duration of
action than succinylcholine. When the use of succinylcholine is contraindicated, high doses of nondepolarizing NMBA
can be administered to speed the onset of paralysis. However, the clinical duration of paralysis will be much longer
with the use of these higher doses. This may be problematic when shorter surgery is planned or when nerve
monitoring will be used during surgery. In addition, if airway management proves difficult, prolonged paralysis
eliminates the option of awakening the patient to allow spontaneous ventilation. (See "Clinical use of neuromuscular
blocking agents in anesthesia", section on 'Nondepolarizing neuromuscular blocking agents'.)
● Rocuronium – When administered for RSII, rocuronium is the nondepolarizing NMBA that allows the fastest onset
of action and the best intubating conditions, with the least side effects. A relatively high dose of rocuronium is
required for RSII. In a meta-analysis of 50 trials that compared the use of succinylcholine with rocuronium for RSII,
succinylcholine >1m/kg IV provided superior intubating conditions compared with rocuronium 0.6 to 0.7 mg/kg IV,
but there was no difference in intubating conditions when rocuronium 0.9 to 1.0 mg/kg IV was administered [69].
The onset and duration of neuromuscular block depends on the dose. After induction of anesthesia with
thiopental, rocuronium 0.9 to 1.2 mg/kg IV achieves maximal neuromuscular block in 55 to 75 seconds, with
clinical duration (recovery of twitch to 25 percent of control) of 53 to 73 minutes [70]. In contrast, succinylcholine
1.5 mg IV achieves maximal block in 45 to 60 seconds, with a clinical duration of 6 to 10 minutes [71].
Sugammadex is a novel medication that can reverse the effects of rocuronium. Sugammadex functions as a
chelating agent for rocuronium and can rapidly reverse neuromuscular blockade even after the administration of
high doses of rocuronium [72]. Importantly, sugammadex may not reverse the effects of muscle relaxation quickly
enough to consider it a "rescue" medication in the cannot intubate, cannot ventilate scenario, especially in the
setting of other depressant medications [73]. Sugammadex is discussed more fully separately. (See "Clinical use of
neuromuscular blocking agents in anesthesia", section on 'Sugammadex'.)
While less desirable than rocuronium, cisatracurium and vecuronium are two other commonly used nondepolarizing
NMBAs that can be used for RSII. As compared with rocuronium, the onset of paralysis with each of these is slower.
Rapid onset of paralysis can be achieved by administration of a high dose, which results in prolonged duration of
action, or by using a priming dose, that is, a small dose (10 percent of the intubating dose), of NMBA two to four
minutes prior to the intubating dose of the drug.
Since the priming dose of NMBA may cause signs of paralysis, including diplopia, blurry vision, difficulty swallowing,
and risk of aspiration [74], we do not routinely administer a priming dose of NMBA. Recommended doses of
vecuronium and cisatracurium for RSII are as follows:
● Vecuronium – 0.1 mg/kg IV (approximately 2 x ED95) results in a time to maximum block of 2.4 minutes with a
clinical duration (recovery of twitch to 25 percent of control) of 44 minutes [75]. Like Rocuronium, Vecuronium can
be reversed with sugammadex.
● Cisatracurium – 0.4 mg/kg IV (approximately 8 x ED95) results in a time to maximum block of 1.9 minutes with a
clinical duration (recovery of twitch to 25 percent of control) of 91 minutes [76].
If a nondepolarizing NMBA is used (instead of succinylcholine or for defasciculation), fasciculations do not occur as a
marker of paralysis. A peripheral nerve stimulator can be used to confirm adequate paralysis and optimum intubating
conditions prior to laryngoscopy. (See 'Succinylcholine' above.)
Remifentanil intubation — Remifentanil, an ultrashort-acting narcotic, is particularly useful for intubation when
succinylcholine is contraindicated and when the prolonged duration of action of NMBAs is undesirable. For a high-
dose remifentanil intubation, the administration of propofol (2 to 2.5 mg/kg IV) followed by remifentanil (3 to 5
mcg/kg IV) provides good to excellent intubating conditions at 1 to 2.5 minutes after induction [77-79]. We give
ephedrine (10 mg IV) along with the propofol for this type of induction to avoid the profound bradycardia and
hypotension that may result from these doses of remifentanil and propofol. Propofol 2 mg/kg IV has been shown to
provide better intubating conditions than thiopental 6 mg/kg IV or etomidate 0.3 mg/kg IV when given for induction
with remifentanil 3 mcg/kg IV without NMBAs [80].
Doses of propofol and remifentanil should be reduced for the elderly and for other patients who are at risk for
hypotension with induction. (See "General anesthesia: Intravenous induction agents", section on 'Dosing
considerations'.)
MASK VENTILATION
Ventilation by mask is traditionally not performed prior to intubation during RSII, to avoid inflating the stomach and
thereby increasing the chance of regurgitation. Without the application of cricoid pressure, bag-mask ventilation with
inflation pressure over 20 cmH2O can result in inflation and, potentially, distention of the stomach [35]. However, a
number of studies have shown that cricoid pressure prevents gastric insufflation during mask ventilation in children
and adults without airway obstruction and, in adults, with airway pressures up to 60 cmH2O [33-35].
Patients without decreased oxygen reserve or increased oxygen consumption should not desaturate during RSII
without mask ventilation. For patients expected to desaturate rapidly with apnea (eg, those with decreased functional
residual capacity because of obesity or increased intraabdominal pressure; those with sepsis or fever), gentle, low-
pressure mask ventilation with cricoid pressure is not likely to inflate or distend the stomach.
Modified RSII — There is no standard definition of "modified RSII," but most commonly it refers to the combination of
cricoid pressure and mask ventilation during induction and intubation [81]. The modification of RSII may be either the
addition of mask ventilation to an otherwise traditional RSII, or the application of cricoid pressure to a routine
induction and intubation. Common scenarios in which modified RSII may be chosen include the following:
● When airway evaluation suggests that intubation may be difficult for a patient who is at high risk of aspiration,
gentle mask ventilation may be attempted prior to administration of a neuromuscular blocking agent (NMBA) to
prove that ventilation will be possible if intubation is difficult or prolonged. In this situation, one very low-pressure
breath may be all that is required.
● Mask ventilation may be performed for patients who are likely to desaturate with apnea, despite preoxygenation.
In this situation, several low-pressure breaths (<20 cmH2O) may be required while waiting for paralysis.
● For the patient who may be at unclear but potentially higher risk of regurgitation and aspiration, cricoid pressure
may be applied during routine induction. Examples include patients with asymptomatic hiatal hernia, morbid
obesity without symptoms of gastroesophageal reflux disease, and patients who have fasted appropriately but
who are receiving opioids.
CHOICE OF LARYNGOSCOPE
As the goal of RSII is to intubate as rapidly as possible, the anesthesia clinician should use the laryngoscope and blade
most likely to succeed on the first attempt. In most cases, this will be a standard laryngoscope used for direct
laryngoscopy with a Macintosh or miller blade. However, when a difficult airway is expected, a video laryngoscope
may be a better choice, assuming the clinician is facile with its use. (See "Airway management for induction of general
anesthesia", section on 'Prediction of the difficult airway'.)
A number of trials have compared videolaryngoscopy with direct laryngoscopy with regard to first-attempt success at
intubation and time to intubation, both particularly important for RSII, with variable results. Though studies
consistently find a better glottic view with video laryngoscopes, a meta-analysis of trials comparing one type of video
laryngoscope with direct laryngoscopy reported no difference in successful first-attempt intubation or time to
intubation [82]. In contrast, in another study, 200 patients with predicted difficult airways based on Mallampati
classification grade 3 or 4 ( figure 4) were randomly assigned to intubation with a video laryngoscope versus direct
laryngoscopy [83]. Videolaryngoscopy resulted in a higher first-attempt intubation rate, decreased time to intubation,
and a reduced number of optimizing maneuvers.
No matter which laryngoscope is chosen for RSII, a backup plan and the necessary equipment must be immediately
available and at the bedside if difficult airway management is expected. All anesthesia clinicians should be familiar
with a difficult airway algorithm ( algorithm 1). (See "Airway management for induction of general anesthesia",
section on 'Preparation for induction of anesthesia'.)
For RSII, we place a stylette in the endotracheal tube to add rigidity, to facilitate placement through the vocal cords,
and to increase the chance of success on the first attempt at laryngoscopy. It is important to recognize that increasing
the rigidity of the endotracheal tube can also potentially increase the risk of injury to the vocal cords or trachea. Once
the tip of the tube is placed through the vocal cords, the stylette should be removed to avoid trauma to the anterior
trachea and the tube advanced under direct vision.
POTENTIAL COMPLICATIONS OF RSII
The decision to perform RSII, to modify the induction sequence, or to perform a standard sequence induction must
take into account the individualized potential risks of each choice. Potential complications of RSII include difficulty with
intubation, hypoxia, hypotension, active regurgitation, and aspiration.
Difficult or failed airway — Difficult intubation is always a possibility during induction of anesthesia. If the
preoperative airway evaluation suggests potential difficulty with intubation, an awake or, if necessary, inhalation
induction may be chosen instead of RSII. Difficult intubation is not always predictable [84]. Thus, equipment,
personnel, and a backup plan for airway management must always be ready when RSII is performed. Anesthesia
clinicians should be familiar with a difficult airway algorithm ( algorithm 1). (See "Approach to the anatomically
difficult airway in adults outside the operating room".)
Hypoxia — The most common risk of RSII is hypoxia, a potential result of oxygen desaturation during the period of
apnea prior to intubation. Patients with poor oxygen reserves, such as obese patients, pregnant patients, and patients
with pulmonary disease, may be at higher risk for arterial desaturation, despite preoxygenation. Low-pressure mask
ventilation during RSII may prevent hypoxia and desaturation for such patients. (See 'Modified RSII' above.)
Passive apneic oxygenation using high-flow oxygen through a nasal cannula and continuous positive airway pressure
preoxygenation are strategies that may increase the time to apneic oxygen desaturation during RSII. (See
'Preoxygenation' above.)
Hypotension — Hypotension is common after RSII, especially for those patients who present for emergency surgery
with hemodynamic instability. Dysrhythmias and cardiac arrest can also occur in critically ill patients with poor
cardiovascular reserve. The selection of induction agent, rate of administration, and the dose administered should be
based on the patient's clinical condition and comorbidities. (See 'Induction agents' above.)
Regurgitation — Regurgitation may occur during RSII, despite the maneuvers designed to prevent it. If the patient
regurgitates, the head of the operating table should be quickly tipped down to allow material to drain away from the
larynx. The head should be turned to the side and the oropharynx suctioned prior to intubation. The trachea should
be suctioned prior to administration of a positive pressure breath. If active vomiting occurs, cricoid pressure should be
released to avoid esophageal rupture [85].
Aspiration — Regurgitation and aspiration can occur during RSII, even when protocols are followed as suggested. The
incidence of aspiration during emergency surgical procedures is approximately 0.15 percent [86].
The sequelae depend on the volume and type of material aspirated and the patient's comorbidities. Aspiration of
small amounts of oral secretions may result in minor complications, such as cough or tracheal irritation, while
aspiration of large-volume, particulate, or acidic material can result in infection, airway obstruction, acute respiratory
distress syndrome, and death. Evaluation and management of aspiration pneumonia is discussed more fully
separately. (See "Aspiration pneumonia in adults".)
EMERGENCE FROM ANESTHESIA
Patients at high risk of aspiration during induction of anesthesia are also at high risk of aspiration during emergence
from anesthesia. In most cases, an orogastric tube should be passed during the anesthetic and suctioned and
removed immediately prior to emergence. Patients should remain intubated with the endotracheal tube cuff inflated
until responding to commands and until airway reflexes return. Patients should be transported to the recovery area
with the head of the bed elevated to reduce the chance of reflux.
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around the world are
provided separately. (See "Society guideline links: Coronavirus disease 2019 (COVID-19) – Guidelines for specialty care"
and "Society guideline links: Coronavirus disease 2019 (COVID-19) – International public health and government
guidelines" and "Society guideline links: Coronavirus disease 2019 (COVID-19) – Resources for patients" and "Society
guideline links: Airway management in adults".)
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SUMMARY AND RECOMMENDATIONS
● Rapid sequence induction and intubation (RSII) is routinely performed for patients at high risk of aspiration during
the induction of general anesthesia. The risk of aspiration should be balanced against the risk of difficult
intubation, hypoxia during apnea, and hypotension with RSII. (See 'General indications' above.)
● An essential goal of RSII is the achievement of adequate depth of anesthesia and, most often, paralysis for
laryngoscopy, to prevent coughing, straining, and active vomiting with airway manipulation.
● For patients who are at high risk of aspiration, we suggest the administration of antacid medication before
induction to increase the pH of gastric contents (Grade 2C). For pregnant patients and for those at high risk of
aspiration, we routinely administer clear, nonparticulate antacid prior to induction (eg, sodium citrate-citric acid,
30 mL by mouth). For nonpregnant patients at high risk of aspiration who have not received a proton pump
inhibitor or histamine-2 receptor antagonist (H2RA) on the morning of surgery, we also administer an H2RA 40 to
60 minutes prior to induction (eg, famotidine 20 mg IV). (See 'Premedication' above.)
● Components of RSII are designed to protect the airway with a cuffed endotracheal tube as quickly as possible
after induction of anesthesia, while preventing passive or active regurgitation of stomach contents. They include:
• Preoxygenation (see 'Preoxygenation' above)

• Application of cricoid pressure ( figure 2) (see 'Cricoid pressure during RSII' above)
• Administration of an anesthesia induction agent, followed immediately by administration of succinylcholine
(see 'Choice of medications' above)
• Avoidance of mask ventilation prior to endotracheal intubation (see 'Mask ventilation' above)
• Endotracheal intubation with inflation of the endotracheal tube cuff as quickly as possible (see 'Choice of
laryngoscope' above)
Not all of these components will be appropriate for every patient.
● An assistant who is familiar with correct application of cricoid pressure and with assistance with airway
management should be present for RSII. A back-up plan for airway management should be determined prior to
induction, and the anesthesia clinician should be familiar with a difficult airway management algorithm (
algorithm 1). (See 'Cricoid pressure during RSII' above.)
● We suggest the application of cricoid pressure during RSII (Grade 2C). Despite conflicting evidence regarding the
effectiveness of cricoid pressure for preventing regurgitation, clinical experience suggests that, in most situations,
it is not harmful and may be beneficial. We shift or release pressure if laryngoscopy proves difficult, and release
cricoid pressure if active vomiting occurs. We avoid cricoid pressure in patients with acute cervical spinal cord
injury. (See 'Cricoid pressure during RSII' above.)
● We typically titrate the anesthesia induction agent to loss of consciousness prior to the administration of a
neuromuscular blocking agent (NMBA). We prefer propofol for hemodynamically stable patients. Ketamine and
etomidate are alternatives for hemodynamically unstable patients. (See 'Induction agents' above.)
● For most cases, we suggest the use of succinylcholine (1 to 1.5 mg/kg) rather than nondepolarizing NMBAs for
RSII (Grade 2C). If a defasciculating dose of a nondepolarizing NMBA is administered in addition, the dose of
succinylcholine must be increased to 1.5 to 2 mg/kg IV to overcome the antagonism between nondepolarizing
and depolarizing NMBAs. (See 'Succinylcholine' above.)
● If succinylcholine is contraindicated, rocuronium can provide rapid onset of paralysis but results in prolonged
duration of action, which may be undesirable. High-dose remifentanil induction is an alternative to RSII with an
NMBA. (See 'Alternatives to succinylcholine' above.)
● RSII may be modified to include low-pressure mask ventilation to prove the ability to ventilate prior to paralysis or
to prevent hypoxia for patients with reduced oxygen reserve. (See 'Modified RSII' above.)
● Patients at high risk of aspiration during induction of anesthesia are also at high risk of aspiration during
emergence from anesthesia. Prior to emergence, the stomach should be emptied using an orogastric or
nasogastric tube. (See 'Emergence from anesthesia' above.)
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derivative, in anaesthetized patients. A pilot study. Br J Anaesth 1980; 52 Suppl 1:53S.
76. Belmont MR, Lien CA, Quessy S, et al. The clinical neuromuscular pharmacology of 51W89 in patients receiving
nitrous oxide/opioid/barbiturate anesthesia. Anesthesiology 1995; 82:1139.
77. Bouvet L, Stoian A, Rimmelé T, et al. Optimal remifentanil dosage for providing excellent intubating conditions
when co-administered with a single standard dose of propofol. Anaesthesia 2009; 64:719.
78. Trabold F, Casetta M, Duranteau J, et al. Propofol and remifentanil for intubation without muscle relaxant: the
effect of the order of injection. Acta Anaesthesiol Scand 2004; 48:35.
79. Klemola UM, Mennander S, Saarnivaara L. Tracheal intubation without the use of muscle relaxants: remifentanil
or alfentanil in combination with propofol. Acta Anaesthesiol Scand 2000; 44:465.
80. Erhan E, Ugur G, Gunusen I, et al. Propofol - not thiopental or etomidate - with remifentanil provides adequate
intubating conditions in the absence of neuromuscular blockade. Can J Anaesth 2003; 50:108.
81. Ehrenfeld JM, Cassedy EA, Forbes VE, et al. Modified rapid sequence induction and intubation: a survey of United
States current practice. Anesth Analg 2012; 115:95.
82. Griesdale DE, Liu D, McKinney J, Choi PT. Glidescope® video-laryngoscopy versus direct laryngoscopy for
endotracheal intubation: a systematic review and meta-analysis. Can J Anaesth 2012; 59:41.
83. Jungbauer A, Schumann M, Brunkhorst V, et al. Expected difficult tracheal intubation: a prospective comparison
of direct laryngoscopy and video laryngoscopy in 200 patients. Br J Anaesth 2009; 102:546.
84. Cook TM, MacDougall-Davis SR. Complications and failure of airway management. Br J Anaesth 2012; 109 Suppl
1:i68.
85. Ralph SJ, Wareham CA. Rupture of the oesophagus during cricoid pressure. Anaesthesia 1991; 46:40.
86. Neilipovitz DT, Crosby ET. No evidence for decreased incidence of aspiration after rapid sequence induction. Can J
Anaesth 2007; 54:748.
Topic 94214 Version 29.0
GRAPHICS
Tracheal intubation of COVID-19 patients outside the OR: Guidelines and modifications
Key principles
Maximize first-attempt success while keeping patients and providers safe.

Prevent contamination and spread of virus. There is a high risk of aerosolization of virus during airway management.
Tracheal intubation should be performed by the clinician with the most airway management experience whenever possible.
RSI steps (seven P's) Important actions and modifications
Preparation Use checklist adapted for COVID-19 patients. Placing required airway equipment and medications in prepackaged bundles
may be helpful.
Review airway plan as a team before entering room. RSI preferred whenever possible. Avoid awake intubation (cough during
awake intubation increases viral spread).
Prepare all required equipment and draw up and label all medications (including induction agent, NMBA, vasopressor [eg,
norepinephrine infusion], isotonic IVF) before entering intubation room.
Keep all nonessential equipment just outside room.
Have available all standard airway equipment plus:

Bag-mask with HEPA filter
Video laryngoscope with clear, disposable cover for the device
Ventilator and tubing with in-line adaptors (for suctioning and bronchoscopy) and HEPA filters
Waveform capnography if available
Smooth clamp for ETT
Use negative-pressure room for intubation whenever possible. Keep door closed; may hang a sign prohibiting entrance
during procedure.
Limit intubation team in room to 3 members: intubator; nurse or other clinician; respiratory therapist.
If possible, second intubator wearing PPE should remain outside room to assist with anticipated difficult airway or as
necessary.
Before entering room:

Perform hand hygiene.
Don PPE with proper technique and supervision. PPE should include:
N95 respirator or PAPR
Eye protection (goggles, face shield that covers front and sides of face, or full face PAPR)
Double gloves
Gown and cap (some recommend shoe covers, such as disposable booties)
Prepare marked bags for proper disposal/removal of clothing and equipment.
The precautions against infection listed immediately above should be taken by all clinicians directly involved in any pediatric
intubation or airway management. Asymptomatic infection in children is common and poses a risk for disease transmission.
Avoid pretreatment with nebulizers if possible; use MDI instead.
Preoxygenation Preoxygenate patient for 3 to 5 minutes with 100% O 2 using low or moderate flow rates (10 to 15 L/minute) and NRB mask.
Avoid BMV if at all possible. 5 minutes of preoxygenation preferred if circumstances permit.
If needed, can preoxygenate with modified NIV by using tightly fitting, non-vented mask connected to closed-circuit, dual-
limb ventilator with HEPA filter. Use a full-face mask if available (reduces aerosolization). Mask must fit standard ventilator
tubing. Continue NIV until patient apneic. Suspend ventilator before removing mask for intubation.
If patient remains hypoxic (SpO 2 <93%) using NRB mask, and NIV with closed circuit not available, can use BMV with HEPA
filter and PEEP valve. Hold mask tightly on patient's face using 2-hand thenar technique, increase oxygen flow rate as
needed, and have patient breathe passively. Perform synchronized bag-assist ventilation only if required.
In the hypoxic, agitated patient who cannot cooperate with preoxygenation efforts, a reasonable approach is to sedate the
patient with a smaller dose of ketamine (eg, 0.5 mg/kg IV) than would be used for RSI. This dose generally preserves
spontaneous ventilation and enables the patient to tolerate a tight mask seal, which may improve oxygenation and reduce
viral shedding. Once preoxygenation is complete, RSI may be performed using the remaining dose of ketamine or another
induction agent and a NMBA.
Avoid high-flow oxygenation methods (eg, flush rate) unless clinically required.
Avoid nasal cannula for oxygenation, including apneic oxygenation.
Upright posture or reverse Trendelenburg positioning improves preoxygenation.
Avoid BMV if at all possible; use HEPA filter if BMV must be performed.
If BMV necessary, 2-person thenar technique gives better seal and reduces aerosolization/contamination risk (provided
entry of additional provider can be avoided). Provide BMV using low volumes and relatively high rates.
Pre-intubation May give IV fluid bolus prior to giving RSI medications to patients who are volume depleted.
optimization
Avoid high-volume fluid resuscitation in COVID-19 patients at risk for ARDS.
Push-dose pressor may be needed for patients at high risk for hemodynamic decompensation (options include
phenylephrine 100 micrograms IV or epinephrine 10 micrograms IV).*
Vasopressor (eg, norepinephrine) infusion may be needed for patients with hypotension or hemodynamic instability before
or following administration of RSI medications.
Paralysis with induction Use high-dose NMBA: rocuronium 1.5 mg/kg IV or succinylcholine 2 mg/kg IV. Goal is rapid-onset apnea and elimination of
cough.
Protection of patient and Refer to "Preparation" above and "Post-intubation management" below.
staff
Placement (intubation) Use video laryngoscopy whenever possible.
Performed by experienced intubator.
Supraglottic airway preferred for rescue oxygenation and ventilation if needed (eg, intubation difficulty).
Ensure ETT is inserted 19 to 22 cm (measured at teeth); may reduce need for confirmation by chest radiograph.
Post-intubation Inflate cuff immediately following ETT placement and prior to initiating PPV.
management ¶
Confirm placement of the ETT. If a colorimeter or other removable EtCO 2 detector is used, clamp the ETT before removing
the device.
After confirming ETT placement, clamp the ETT, connect the ventilator tubing, and then remove the clamp. HEPA filter
between ETT and ventilator should be in place. Start mechanical ventilation. Secure the ETT.
Ventilator settings suitable for patient with ARDS are likely to be needed (assuming COVID-19-related respiratory illness is
reason for intubation). Δ
Procedure bundles can reduce exposure. May choose to perform intubation and central venous catheter placement
together and then obtain portable chest radiograph to assess both.
Limit ventilator disconnections. When disconnection required, clamp ETT first and disconnect at end-expiration.
Ideally, use ETT and ventilator with in-line adaptors for suctioning and bronchoscopy.
Ensure adequate sedation for patient care and safety and to avoid accidental extubation or disconnection of tubing.
Bag, transport, and clean all equipment as required.
Use proper PPE doffing, supervised by coach or other team member. Once PPE is removed, thoroughly clean your hands and
any exposed skin on the neck and face.
OR: operating room; RSI: rapid sequence intubation; NMBA: neuromuscular blocking agent (paralytic medication); IVF: intravenous fluid; HEPA: high-efficiency
particulate air; ETT: endotracheal tube; PPE: personal protective equipment; PAPR: powered air-purifying respirator; MDI: metered dose inhaler; O 2 : oxygen; NRB:
nonrebreather; BMV: bag-mask ventilation; NIV: noninvasive ventilation; SpO 2 : oxygen saturation; PEEP: positive end-expiratory pressure; DSI: delayed sequence
intubation; IV: intravenous; ARDS: acute respiratory distress syndrome; PPV: positive-pressure ventilation; EtCO 2 : end-tidal carbon dioxide; SBP: systolic blood
pressure; FiO 2 : fraction of inspired oxygen.
* The use of a push-dose pressor is based on clinical judgement. It is most appropriate for patients with overt shock (eg, SBP <90 mmHg, SI >1) but may be useful in
any hemodynamically unstable patient being intubated. For adults, options include phenylephrine 100 micrograms (50 to 200 micrograms) IV or epinephrine 10
micrograms (5 to 20 micrograms) IV, depending upon whether vasoconstriction alone or vasoconstriction and inotropic support is desired. Appropriate measures to
improve hemodynamics as much as possible should be taken prior to intubation and push-dose pressor use.
¶ The objective identification of patients whose intubation was difficult can help clinicians in the event that reintubation is necessary (eg, safety bracelet, red sticker on
ETT).
Δ Initial ventilator management for adults with ARDS includes low tidal volume (6 mL/kg predicted body weight), volume-limited assist control mode, PEEP (10 to 15 cm
H 2 O), and high FiO 2 (1.0). These settings are modified based on patient response. Refer to UpToDate topics discussing ventilator management in ARDS for details. For
initial settings in children, please refer to UpToDate topics on initiating mechanical ventilation in children.
References:
1. Wax RS, Christian MD. Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients. Can J Anaesth 2020.
2. Cook TM, El-Boghdadly K, McGuire B, et al. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the
Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia 2020.
3. Mason J, Herbert M. Novel Coronavirus 2019 (COVID-19). Available at: www.emrap.org/corependium/chapter/rec906m1mD6SRH9np/Novel-Coronavirus-2019-COVID-19?
MainSearch=%22covid%22&SearchType=%22text%22 (Accessed on March 28, 2020).
4. Weingart S. COVID Airway Management Thoughts. Available at: https://emcrit.org/emcrit/covid-airway-management/ (Accessed on March 28, 2020).
Graphic 127516 Version 23.0
Conditions that increase risk of aspiration during induction of anesthesia
Full stomach – nonfasted, emergency surgery or trauma
Pregnancy after 12 to 20 weeks gestation (gestational age for increased risk is controversial)
Symptomatic gastroesophageal reflux
Diabetic or other gastroparesis
Hiatal hernia
Gastric outlet obstruction
Esophageal pathology
Bowel obstruction
Increased intra-abdominal pressure – ascites, abdominal mass
Ramp position illustration
In the ramp position, the patient's head and torso are elevated such that the external
auditory meatus and the sternal notch are horizontally aligned (black line). This position
allows for a better view of the glottis in obese patients and should be used unless there are
contraindications (eg, possible cervical spine injury).
Cricoid pressure (Sellick maneuver)
Cricoid pressure (Sellick maneuver). Posterior displacement of the airway cartilages occludes the
compliant esophagus. In infants and young children, the tracheal cartilage is also very
compliant, and excessive force while applying cricoid pressure may impair airway patency.
Reproduced with permission from: King C, Rappaport LD. Emergent endotracheal intubation. In: Textbook of
Pediatric Emergency Procedures, 2nd ed, King C, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia
2008. Copyright © 2008 Lippincott Williams & Wilkins. www.lww.com.
Cormack-Lehane grading scheme for laryngoscopy
Difficulty of direct laryngoscopy correlates with the best view of the glottis, as defined by the
Cormack-Lehane scale. With this scale, a grade I view connotes a full view of the entire glottic
aperture, grade II represents a partial glottic view, grade III represents visualization of the
epiglottis only, and grade IV represents inability to visualize even the epiglottis.
Properties of neuromuscular blocking agents
Agent* Vecuronium Rocuronium Pancuronium Mivacurium Atracurium Cisatracurium Succinylcholine
Type (structure) Non- Non- Non-depolarizing Non-depolarizing Non- Non-depolarizing Depolarizing

depolarizing depolarizing depolarizing
Type (duration) Intermediate Intermediate Long Short Intermediate Intermediate Ultrashort
Potency - ED 95 0.04 0.30 0.07 0.08 0.21 0.04 to 0.05 0.25 to 0.30
(mg/kg)
Intubating dose 0.10 to 0.20 0.60 to 1.00 0.08 to 0.12 0.20 0.50 to 0.60 0.15 to 0.20 0.60 to 1.50
(mg/kg) (1.20 with RSII
dose)
Onset time (min) 3 to 4 1 to 2 2 to 3 3 to 4 3 to 5 4 to 6 1
Time to 25% 20 to 35 30 to 50 (60 to 60 to 120 15 to 20 20 to 35 30 to 60 5 to 10

recovery (min) 80 with RSII
dose)
Elimination half-life (min)
Normal organ 50 to 60 60 to 100 100 to 130 2 to 2.5 21 23 to 30 <1

function
Renal Mild increase 100 to 300 Increased x2 3 to 4 21 Mild increase <1

impairment
Hepatic Significant 120 to 400 Increased x2 3 to 6 21 23 to 30 <1

impairment increase
Maintenance 0.01 0.10 0.02 0.10 0.10 0.01 N/A

dose (mg/kg)
Infusion dose 1 to 2 5 to 12 Not 5 to 8 10 to 20 1 to 3

(mcg/kg/min) recommended
Elimination Renal 10 to Renal 30%; Renal 40 to 70%; Plasma Renal 10%; Hoffman 30%; Butyrylcholinesterase
route/metabolism 50%; hepatic 70% hepatic 20% cholinesterase (70% Hoffman 30%; ester hydrolysis (plasma
hepatic 30 to of succinylcholine ester hydrolysis 60% cholinesterase,
50% rate) 60% pseudocholinesterase)
Active 3-desacetyl- 17-desacetyl- 3-OH- No active metabolites No active No active No active metabolites
metabolites vecuronium rocuronium pancuronium; metabolites metabolites
(minimal) 17-OH-
pancuronium
Side effects Vagal blockade Minimal Vagal block Histamine release Histamine None; histamine Myalgia; bradycardia/
with large (tachycardia), release; release at high asystole in children or
doses catecholamine laudanosine and doses with repeated dosing;
release acrylates dual (phase II,
production competitive) block;
anaphylaxis
Contraindications None None Short surgical Pseudocholinesterase Hemodynamically None High K +; MH;
(other than procedures (<60 deficiency unstable patients muscular dystrophy;
specific allergy) min); not due to histamine children; receptor up-
recommended release regulation settings;
for continuous pseudocholinesterase
infusion deficiency
Comments Not for Pain on Significant Reversal by Organ- Trivial histamine Fastest onset, most
prolonged ICU injection; easily accumulation, cholinesterase independent release; minimal reliable NMBA for
administration reversible by prone to residual inhibitors; mixture of elimination plasma rapid tracheal
(myopathy); sugammadex; block (3-OH 3 isomers (cis-cis laudanosine and intubation
reversible by elimination metabolite has minimal); acrylate levels
sugammadex; half-life 50% activity of edrophonium for
elimination prolonged in pancuronium) antagonism more
half-life halved ICU patient; 17- effective during deep
in late desacetyl block
pregnancy; 3- metabolite has
desacetyl 20% activity
metabolite has
60% of the
parent
compound
potency
NA: data not available; ED 95 : effective dose to achieve 95% depression of baseline muscle contraction; NMBA: neuromuscular blocking agents; RSII: rapid sequence
induction and intubation; K +: potassium; MH: malignant hyperthermia; ST: single twitch; ICU: intensive care unit.
* The data are averages obtained from published literature and do not account for other influences such as volatile anesthetics, muscle temperature, etc.
Adapted from: Brull SJ. Neuromuscular blocking agents. In: Clinical Anesthesia, 8th ed, Barash PG, Cullen BF, Stoelting RK, et al (Eds), Wolters Kluwer, Philadelphia 2017.
The modified Mallampati classification for difficult laryngoscopy and intubation
The modified Mallampati classification [1] is a simple scoring system that relates the amount of mouth
opening to the size of the tongue, and provides an estimate of space available for oral intubation by
direct laryngoscopy. According to the Mallampati scale, class I is present when the soft palate, uvula,
and pillars are visible; class II when the soft palate and the uvula are visible; class III when only the soft
palate and base of the uvula are visible; and class IV when only the hard palate is visible.
Reference:
1. Samsoon GL, Young JR. Difficult tracheal intubation: a retrospective study. Anaesthesia 1987; 42:487.
American Society of Anesthesiologists difficult airway algorithm
SGA: supraglottic airway; LMA: laryngeal mask airway; ILMA: intubating laryngeal mask airway.
* Confirm ventilation, tracheal intubation, or SGA placement with exhaled CO 2 .
¶ Invasive airway access includes surgical or percutaneous airway, jet ventilation, and retrograde intubation.
Δ Other options include (but are not limited to): surgery utilizing face mask or supraglottic airway (SGA) anesthesia (eg, LMA, ILMA, laryngeal tube), local
anesthesia infiltration, or regional nerve blockade. Pursuit of these options usually implies that mask ventilation will not be problematic. Therefore, these options
may be of limited value if this step in the algorithm has been reached via the Emergency Pathway.
◊ Alternative difficult intubation approaches include (but are not limited to): video-assisted laryngoscopy, alternative laryngoscope blades, SGA (eg, LMA or ILMA)
as an intubation conduit (with or without fiberoptic guidance), fiberoptic intubation, intubating stylet or tube changer, light wand, and blind oral or nasal
intubation.
§ Emergency noninvasive airway ventilation consists of a SGA.
¥ Consider re-preparation of the patient for awake intubation or canceling surgery.
Reproduced with permission from: Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the difficult airway: an updated report by the
American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013; 118:251. DOI: 10.1097/ALN.0b013e31827773b2. Copyright ©
2013 by the American Society of Anesthesiologists, Inc. Unauthorized reproduction of this material is prohibited.
Contributor Disclosures
Lauren Berkow, MD Consultant/Advisory Boards: Teleflex [Airway management (Laryngeal mask airways)]; Masimo [Monitoring
(Masimo pulse oximetry)]. Carin A Hagberg, MD, FASA Grant/Research/Clinical Trial Support: Ambu [Airway management (Ambu
aScope 3, Ambu AuraFlex, Ambu AuraGain, Ambu Aura-I, Ambu AuraOnce, Ambu AuraStraight, Ambu Aura40, King Vision Video
Laryngoscope, King Vision Video Laryngoscope aBlade System, King LT, King LT-D, King LTS, King LTS-D)]; Karl Storz Endoscopy [Airway
management (Bonfils Retromolar Intubation Endoscope, Brambrink Intubation Endoscope, Berci-Kaplan DCI Video Laryngoscope, C-
MAC Video Laryngoscope, C-MAC Pocket Monitor)]; Vyaire Medical [Airway Management, respiratory diagnostics, ventilation and
operative care consumables (Vital Signs Head Positioner, VSD Laryngoscope systems Greenlight and Vital View, Vital Signs
humidification and filtration, oral airways, endotracheal tube, stylets and Laryngeal Mask Airways, Vyaire Anaesthesia breathing
circuits, face masks [SuperNova], nasal cannulas, Medisorb CO2 absorbent, enFlow fluid warming system and temperature probes and
cables)]. Marianna Crowley, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting
through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately
referenced content is required of all authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

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AIRWAY MANAGEMENT FOR PATIENTS WITH COVID-19

● Patients with a full stomach, which includes:

● Patients with gastrointestinal pathology, which includes:

● Patients with increased intraabdominal pressure, which includes those with:

● Patients with hiatal hernia or endoscopic evidence of GERD

PREPARATION FOR ANESTHESIA

CRICOID PRESSURE DURING RSII

Defasciculation — We do not routinely administer a defasciculating dose of nondepolarizing NMBA before

POTENTIAL COMPLICATIONS OF RSII

EMERGENCE FROM ANESTHESIA

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

• Preoxygenation (see 'Preoxygenation' above)

Not all of these components will be appropriate for every patient.

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 94214 Version 29.0

Maximize first-attempt success while keeping patients and providers safe.

RSI steps (seven P's) Important actions and modifications

Keep all nonessential equipment just outside room.

Have available all standard airway equipment plus:

Before entering room:

Avoid pretreatment with nebulizers if possible; use MDI instead.

Avoid nasal cannula for oxygenation, including apneic oxygenation.

Upright posture or reverse Trendelenburg positioning improves preoxygenation.

Placement (intubation) Use video laryngoscopy whenever possible.

Performed by experienced intubator.

Bag, transport, and clean all equipment as required.

Graphic 127516 Version 23.0

Conditions that increase risk of aspiration during induction of anesthesia

Full stomach – nonfasted, emergency surgery or trauma

Symptomatic gastroesophageal reflux

Diabetic or other gastroparesis

Gastric outlet obstruction

Increased intra-abdominal pressure – ascites, abdominal mass

Graphic 98506 Version 8.0

Ramp position illustration

Graphic 95285 Version 4.0

Cricoid pressure (Sellick maneuver)

Graphic 71800 Version 13.0

Cormack-Lehane grading scheme for laryngoscopy

Graphic 55034 Version 6.0

Properties of neuromuscular blocking agents

Agent* Vecuronium Rocuronium Pancuronium Mivacurium Atracurium Cisatracurium Succinylcholine

Type (structure) Non- Non- Non-depolarizing Non-depolarizing Non- Non-depolarizing Depolarizing

Type (duration) Intermediate Intermediate Long Short Intermediate Intermediate Ultrashort

Onset time (min) 3 to 4 1 to 2 2 to 3 3 to 4 3 to 5 4 to 6 1

Time to 25% 20 to 35 30 to 50 (60 to 60 to 120 15 to 20 20 to 35 30 to 60 5 to 10

Elimination half-life (min)

Normal organ 50 to 60 60 to 100 100 to 130 2 to 2.5 21 23 to 30 <1

Renal Mild increase 100 to 300 Increased x2 3 to 4 21 Mild increase <1

Hepatic Significant 120 to 400 Increased x2 3 to 6 21 23 to 30 <1

Maintenance 0.01 0.10 0.02 0.10 0.10 0.01 N/A

Infusion dose 1 to 2 5 to 12 Not 5 to 8 10 to 20 1 to 3

Graphic 114271 Version 3.0

The modified Mallampati classification for difficult laryngoscopy and intubation

Graphic 75229 Version 9.0

American Society of Anesthesiologists difficult airway algorithm

Graphic 94447 Version 8.0

Conflict of interest policy

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