Colleagues in Respiratory Medicine

Rapid-Sequence Intubation in
Adults: Indications and
Concerns
Charles E. Smith, M.D., F.R.C.P.C.

Rapid-sequence induction and intubation (RSI) is a technique that is designed to niques and use of induction agents and
provide optimal tracheal intubating conditions and reduce the risk of pulmonary neuromuscular relaxants, and specific
aspiration. RSI has a higher success rate, fewer complications, and better out- contingency plans are immediately
come compared with orotracheal intubation without neuromuscular relaxants available should tracheal intubation
and blind nasotracheal intubation. Before considering performing RSI, the fail. The purpose of this review is to
clinician must ensure that intubation is predicted to be successful based on provide a concise, up-to-date review of
assessment of the airway. Failure to intubate and subsequent inability to venti-
these key principles of RSI with spe-
late can lead quickly to death or cerebral hypoxia and brain injury. Maximal
preoxygenation can be attained by providing 100% oxygen through a sealed cific reference to victims of trauma.
system for 3 to 5 minutes of normal tidal volume ventilation or by hyperventi-
lation with 8 deep breaths of 100% oxygen within 60 seconds. Cricoid pressure
INDICATIONS FOR
prevents passive regurgitation of stomach contents and reduces the risk of
gastric insufflation during bag-mask ventilation. Cricoid pressure can also dis- TRACHEAL INTUBATION
tort upper airway anatomy and make glottic visualization more difficult or Placement of a cuffed tracheal tube
impossible. Brief release of cricoid pressure or external laryngeal manipulation below the vocal cords minimizes the
and depression of the thyroid cartilage often improves the view at direct laryn- risk of aspiration of vomitus, blood, or
goscopy. The use of neuromuscular relaxants to facilitate intubation is associated secretions into the lungs and allows for
with side effects regardless of whether depolarizing (e.g., succinylcholine) or positive pressure ventilation and treat-
nondepolarizing (e.g., rocuronium or rapacuronium) agents are used. Avoidance
ment of respiratory failure (Table 1) (1).
of relaxants, however, results in inferior intubating conditions unless large doses
of induction agents and opioids are given. Tracheal intubation aids such as the Tracheal intubation ensures a patent
gum elastic bougie are useful whenever difficult glottic visualization occurs. The airway, facilitates tracheal suctioning,
bougie is relatively easy to insert through the glottic opening when only the and permits the maintenance of ad-
epiglottis (grade III view) or tip of the arytenoids (grade II view) can be verse operative positions and surgery
visualized. The tracheal tube is then threaded over the bougie and tracheal in and around the head and neck. Pre-
placement is confirmed using capnography. Special laryngoscopes, such as the hospital tracheal intubation is associ-
Bullard, WuScope, and McCoy, and lighted stylets are also valuable for facili- ated with improved survival in pa-
tating difficult intubation. The short learning curve with the McCoy hinged- tients with severe head injury after
blade tip is of obvious benefit. Contingency plans for failed intubation include blunt trauma (2). RSI has a higher suc-
use of the laryngeal mask airway (LMA), Combitube, and cricothyrotomy. cess rate, fewer complications, and bet-
Clin Pulm Med 2001;8(3):147–165 ter patient outcome compared with
Key words: Tracheal intubation, Induction agents, Opioids, Sedatives, Neuro-
muscular relaxants. 1068-0640/01/0803-147 $3.00
Clinical Pulmonary Medicine
Copyright © 2001 by Lippincott Williams & Wilkins,

R
apid-sequence induction and
intubation (RSI) is a technique
that is designed to provide op-
timal tracheal intubating conditions
while at the same time minimizing the
risk of pulmonary aspiration. The un-
derlying principles of RSI are as fol-
lows: the trachea needs to be intubated,
the patient is at risk of pulmonary as-
piration, tracheal intubation is pre-
dicted to be successful based on assess-
ment of the airway, cricoid pressure is
not contraindicated, the physician is
skilled at airway management tech-
Inc.
From the Department of Anesthesiology, Case
Western Reserve University, MetroHealth Med-
ical Center, Cleveland, OH.
Address correspondence to: Charles E. Smith,
M.D., F.R.C.P.C., Department of Anesthesia,
MetroHealth Medical Center, 2500 MetroHealth
Dr, Cleveland, OH 44109. Address e-mail to:
csmith@metrohealth.org

Clinical Pulmonary Medicine • Volume 8, Number 3 • May 2001 147

orotracheal intubation without neuro-
muscular relaxants and blind nasotra-
cheal intubation (3,4). The average suc-
cess rate for blind nasotracheal
intubation was 67% to 72% (5) com-
pared with 92% to 96% for paralytic-
assisted intubation (6 –9).
COMPLICATIONS OF RSI
Although RSI had a success rate of
99% in ⬎1200 patients (10), complica-
tions of RSI may be catastrophic (e.g.,
death, Table 2). Unanticipated difficult
intubation occurred in 1.1% to 3.8% of
48,730 general anesthetics, and failed
intubation occurred in 0.13% to 0.3% of
general anesthetics (11). Difficult intu-
bation occurs with a much higher fre-
quency outside the operating room en-
vironment. For example, 10.8% of
intubations were reported to be diffi-
cult in a prospective study of 691 intu-
bations in the French emergency pre-
TABLE 1. Indications for tracheal
intubation.
• Airway protection and risk
for aspiration
• Definitive maintenance of
airway patency
• Emergency surgery and
requirement for general
anesthesia
• Mechanical ventilation and
respiratory failure
• Maintenance of oxygenation
or positive end-expiratory
pressure
• Head trauma and Glasgow
Coma Scale ⱕ8
• Advanced cardiac life
support and drug
administration
• Pulmonary toilet
• Hypoxemia refractory to
oxygen therapy
• Uncontrolled seizure activity
requiring airway control
• Depressed level of
consciousness in trauma
patient
• Combative patient with
compromised airway
From Stene JK, Grande CM, Barton CR.
Airway management for the trauma pa-
tient. In: Stene JK, Grande CM, eds.
Trauma Anesthesia. Baltimore, MD: Wil-
liams & Wilkins; 1991:64 –99.
148
hospital medical system (12). Failed
intubation occurred in 4% of 84 pa-
tients undergoing RSI by an aeromed-
ical transport service (8). Similarly,
failed intubation occurred in 3% of 229
acutely injured patients in the emer-
gency department (13) and in 4.5% of
1657 prehospital intubations by para-
medics (6).
In 238 critically ill patients, emer-
gency intubation was associated with a
significant frequency of major compli-
cations such as esophageal intubation
(8%), aspiration (4%), mainstem intu-
bation (4%), death within 30 minutes of
the intubation (3%), and pneumotho-
rax (1%) (14). The mortality rate was
highest in patients who had systolic
blood pressure ⱕ90 mm Hg before in-
tubation (15%) (14). In a retrospective
study of 1657 prehospital patients un-
dergoing succinylcholine-assisted intu-
bation, aspiration occurred in 13%, car-
diac arrest in 1.3%, and unrecognized
esophageal intubation in 0.4% (6). In a
TABLE 2. Risks of rapid-sequence
intubation.
• Hypoxic brain damage
• Death
• Failed intubation
• Esophageal intubation
• Vomiting and pulmonary
aspiration
• Exacerbation of injuries
already present (e.g., cervical
spine, head, cricoid,
tracheobronchial)
• Specific complications of
induction agents and
relaxants (e.g., hypotension,
anaphylaxis, hyperkalemia,
bronchospasm)
• Pneumothorax
• Endobronchial intubation and
atelectasis
• Excessive cervical spine
movement
• Laryngotracheal disruption
• Airway trauma
• Awareness
From Smith CE, Peerless JR. Rational use
of neuromuscular blocking agents for
emergency airway management in the
trauma patient. In: Smith CE, Grande
CM, eds. The Use of Neuromuscular Block-
ing Agents in the Trauma Patient. ITACCS
monograph. New York, NY: McMahon
Group; 1996:3– 8.
prospective study on sedatives and he-
modynamics during RSI, the in-hospi-
tal mortality rate was 24% of 86 pa-
tients (15). In this study, substantial
decreases in systolic blood pressure (by
54 mm Hg) occurred in patients with
pulmonary edema after administration
of thiopental, fentanyl, or midazolam
as part of the RSI regimen (15).
Aspiration of gastric contents into
the airway remains an important cause
of morbidity and mortality (16). Predis-
posing factors for aspiration include
increased gastric volume or pressure
(e.g., full stomach, intestinal obstruc-
tion, morbid obesity, term pregnancy,
severe gastroesophageal reflux), gastric
pH ⬍ 2.5, depressed laryngeal reflex
(e.g., head injury, drugs), emergency
surgery, increased American Society of
Anesthesiology physical status, inade-
quate skeletal muscle relaxation during
intubation, difficult intubation, and de-
creased lower esophageal sphincter
tone (17,18).
The incidence of recognized clinical
aspiration, defined as presence of bil-
ious secretions or particulate matter in
the tracheobronchial tree or presence of
a new infiltrate on chest radiograph in
patients undergoing emergency sur-
gery, is 1 in 895 (18). In patients requir-
ing emergency intubation in the field,
90% of documented aspiration oc-
curred before administration of para-
lytic drugs (6). In survivors and non-
survivors of trauma, the incidence of
aspiration was 6% (19). Intubation
without paralysis (also known as intu-
bation minus paralysis or IMP) was
associated with a 15% incidence of pul-
monary aspiration in 67 patients re-
quiring emergency intubation (com-
pared with 0 in 166 patients having
RSI) (3).
ASSESSMENT OF THE
AIRWAY
The upper airway is a complex struc-
ture. Although there are many ana-
tomic factors or pathologic conditions
that can help predict the likelihood of
difficulty with airway management,
difficult intubations can still be unpre-
dictable based on patient examination.
Anatomic characteristics such as lim-
ited airway joint mobility, short mus-
cular neck with full set of teeth, large
tongue, receding mandible, protruding
maxillary incisor teeth, and a long,
high, arched palate with a long narrow
Smith • Rapid-Sequence Intubation in Adults
mouth impair alignment of the oral,
pharyngeal, and laryngeal axes and
make visualization of the laryngeal ap-
erture by direct laryngoscopy difficult
(Table 3, Figures 1 and 2) (21,22). Dis-
eases that distort the airway such as
tumor and infection may also make
direct laryngoscopy difficult or impos-
sible.
Trauma patients may have sustained
blunt or penetrating injuries to the air-
way (e.g., laryngeal fracture, cricoid
disruption, tracheobronchial tears), or
injuries to nearby tissue or vascular
structures that may distort airway
anatomy (23–25). Additionally, trauma
patients are often in respiratory dis-
tress as a result of flail chest, lung con-
tusion, and hemo- or pneumothoraces.
Trauma patients may be irritable and
uncooperative due to underlying hy-
poxemia, head injury, alcohol, or drug
intoxication (26).
Immobilization of the cervical spine
results in increased difficulty exposing
TABLE 3. Assessment for difficult direct laryngoscopy.
Reason for Difficulty
1. Disproportionately increased size
of base of tongue relative to
pharynx
2. Decreased mandibular space:
larynx relatively anterior to the
rest of the upper airway structures
3. Decreased head extension and
neck flexion
4. Decreased mouth opening
5. Various conditions and disease
states causing respiratory failure or
as in Table 5
6. Inadequate level of training and
experience
Modified from Mallampati SR. Recognition of the difficult airway. In: Benumof JL, ed. Airway
Management: Principles and Practice. St. Louis, MO: Mosby, 1996:126 –142.
Clinical Pulmonary Medicine • Volume 8, Number 3 • May 2001
FIGURE 1. Airway examination showing
anterior view and palpation of the neck.
From McIntyre JWR. The difficult tracheal
intubation. Can J Anaesth. 1987;34:204 –
213. With permission.
the laryngeal inlet during conventional
laryngoscopy (Table 4) (27–32). Mid-
face fractures permit posterior move-
ment of the hard palate creating airway
obstruction. Basal skull fractures may
be associated with central facial frac-
tures and can result in intracranial pen-
etration of nasally placed tubes (1).
Mandibular fractures can also result in
airway obstruction as well as inability
Objective Evaluation
Mallampati class III: only soft
palate visible when patient
opens mouth wide and
protrudes tongue (see Figure 2)
Thyromental distance ⬍6 cm (2.4
inches): measured from the
thyroid cartilage (Adam’s apple)
to the submentum (see Figure
1); receding chin
Head extension ⬍35 degrees
Neck flexion ⬍25 degrees
Short, thick neck
Cervical spine immobilization (see
Table 4)
Distance between upper and lower
incisors ⬍4 cm (1.6 inches)
Mandibular fractures, especially
condylar
Rigid cervical neck collar
Clinical examination of airway and
adjacent structures
Prominent maxillary teeth with
overbite
Long narrow mouth with high
arched palate
Difficult to objectively evaluate
to open the mouth. Obstruction of the
airway because of maxillofacial trauma
is aggravated by soft tissue injury, for-
eign body (e.g., avulsed teeth), and up-
per airway bleeding. Nasal injury may
be associated with severe epistaxis.
Anatomic characteristics that predis-
pose to difficulty with bag-mask venti-
lation include receding mandible, large
tongue, short neck, large facial fea-
tures, facial trauma, facial burns, obe-
sity, and large beards (Table 5) (21).
These characteristics assume even
greater significance should tracheal in-
tubation fail and the patients’ lungs
need to be ventilated to avoid death.
PREOXYGENATION
Preoxygenation extends the maxi-
mum amount of time that a patient can
be apneic without dying. Maximal
preoxygenation is attained when the
alveolar, arterial, tissue, and venous
compartments are all saturated with
oxygen (33). The traditional method of
preoxygenation is providing 100% ox-
ygen through a sealed system (i.e., no
entrained air) for 3 to 5 minutes of
normal tidal volume ventilation (33).
Alternatively, hyperventilation with 8
deep breaths of 100% oxygen within 60
seconds through a sealed system can
also be used as an alternative to the
traditional 3- to 5-minute technique
(34). Patients with decreased functional
residual capacity, hemoglobin concen-
tration, alveolar ventilation, and car-
diac output have a decreased capacity
for oxygen loading and will desaturate
during apnea more rapidly than
healthy patients (35). Patients with ab-
normal gas exchange due to shunt or
ventilation-perfusion mismatch may
not achieve the same Pao2 with 100%
oxygen and can have precipitous de-
creases in oxygenation during apnea.
FIGURE 2. Airway examination showing
view of the mouth, teeth, uvula, tongue,
faucial pillars, and interincisor distance.
From McIntyre JWR. The difficult tracheal
intubation. Can J Anaesth. 1987;34:204 –
213. With permission.
149
 the patients’ lungs with 100% oxygen is
TABLE 4. Cervical spine immobilization and grade view with conventional often done as soon as the patient stops
laryngoscopy during general anesthesia and complete neuromuscular blockade. breathing. Manual ventilation of the
patients’ lungs using inflation pres-
Incidence of Grades III sures ⬍20 cm H2O and cricoid pres-
Condition and IV Views (%) Reference sure is unlikely to allow to introduce
MIAS 14 Hastings, 1994 (27) any air into the stomach (36,37) and is
MIAS 22 Heath, 1994 (28) extremely important to prevent oxygen
MIAS 39 Smith, 1999 (29) desaturation and carbon dioxide accu-
Rigid collar 26 Gabbott, 1996 (30) mulation during RSI.
MIAS and cricoid pressure 22 Nolan, 1993 (31)
MIAS and cricoid pressure 34 Laurent, 1996 (32)
Rigid collar with tape and 66 Heath, 1994 (28) CRICOID PRESSURE
sandbags Cricoid pressure or Sellick’s maneu-
MIAS, manual in-line axial stabilization; grade III view, only epiglottis visible; glottis cannot be ver is the application of cricoid pres-
seen; grade IV view, only hard palate visualized; epiglottis and glottis cannot be seen (20). sure to displace the cricoid cartilage
posteriorly and occlude the esophagus
Similarly, patients with increased oxy- It should be noted that it may be during RSI to prevent passive regurgi-
gen extraction will also desaturate difficult to achieve maximal preoxy- tation of stomach contents and reduce
more rapidly. genation in the emergency situation be- the risk of pulmonary aspiration (36).
In a computer apnea model, the time cause of failure to breathe 100% oxygen Cricoid pressure also reduces the risk
to critical hemoglobin desaturation through a sealed system and because of of gastric insufflation during bag-mask
(Sao2 ⱕ80% and decreasing) was 8.7 insufficient time of preoxygenation. ventilation (36).
minutes in a healthy 70-kg adult, as- Clinical endpoints of a sealed system Single-handed cricoid pressure is
suming an initial alveolar oxygen frac- include movement of an anesthesia res- done by placing the thumb and middle
tion of 0.87 (i.e., maximal preoxygen- ervoir bag in and out with each inha- finger on either side of the cricoid car-
ation, Figure 3) (35). Corresponding lation and exhalation, presence of a tilage and the index finger above,
times to critical desaturation were 5.5, normal end-tidal CO2 waveform on the thereby preventing lateral movement
3.7, and 3.1 minutes in a moderately ill capnogram, and inspired and expired of the signet-shaped cricoid cartilage
70-kg adult, a healthy 10-kg child, and oxygen concentrations ⬎90%. (38). The cricoid force required to pre-
an obese 127-kg adult, respectively Because maximal preoxygenation is vent regurgitation is estimated at 30 to
(35). often difficult to attain in the emer- 44 N (9.81 N ⫽ 1 kg) (38). This corre-
gency setting, bag-mask ventilation of sponds approximately to a force that is
slightly painful when applied to the
TABLE 5. Conditions that bridge of one’s nose. Cricoid pressure
predispose to difficulties with mask is widely accepted as a standard of care
ventilation and conventional during RSI, and it is unlikely that ran-
laryngoscopy. domized controlled trials will be per-
• Micrognathia formed to evaluate its use during RSI
• Macroglossia because of ethical considerations.
• Cleft palate The most important limiting feature
• Mandibular hypoplasia of cricoid pressure is that it may inter-
• Airway tumors fere with placement of the laryngo-
• Rheumatoid arthritis scope blade and can cause anatomic
• Down syndrome distortion of the upper airway such
• Lingual tonsil hyperplasia that the glottic inlet is more difficult or
• Epiglottitis FIGURE 3. Time to hemoglobin desatura- impossible to visualize (38). In the au-
• Laryngeal edema tion assuming maximal preoxygenation. thor’s experience, the simple maneuver
• Oral and retropharyngeal Patients with decreased functional residual of having the assistant ease up or re-
abscess capacity, hemoglobin concentration, alveo- lease previously applied cricoid pres-
• Trismus lar ventilation, and cardiac output have a sure during RSI (under direct laryngo-
• Morbid obesity decreased capacity for oxygen loading and scope vision) may alleviate airway
• Ankylosing spondylitis will desaturate during apnea more rapidly distortion and permit prompt insertion
• Respiratory distress than healthy patients. Patients with in- of the tube through the vocal cords.
• Airway papillomas creased oxygen extraction will also desatu- The benefit of rapidly inserting the tra-
rate more rapidly. From Benumof JL, Dagg cheal tube and inflating the cuff out-
Modified from Mallampati SR. Recogni-
tion of the difficult airway. In: Benumof
R, Benumof R. Critical hemoglobin desatu- weighs the potential risk of aspiration
JL, ed. Airway Management: Principles and ration will occur before return to an un- during the brief time that the cricoid
Practice. St. Louis, MO: Mosby, paralyzed state after 1 mg/kg intravenous pressure is not being applied. Cricoid
1996:126 –142. succinylcholine. Anesthesiology. 1997; pressure may also interfere with laryn-
87:979 –982. With permission. geal mask airway (LMA) insertion (39)

150 Smith • Rapid-Sequence Intubation in Adults

should this airway be required in the
situation of failed intubation.
When applied before induction of
anesthesia, cricoid pressure can in-
crease patient discomfort, activate up-
per airway reflexes, and cause nausea
and retching. The majority of anesthe-
siologists in one survey apply cricoid
pressure while giving the induction
agent (78%) (40). Eleven percent apply
cricoid pressure before the induction
agent and 11% apply cricoid pressure
after the induction agent had been
given (40). It is important to note that
aspiration can still occur during RSI
despite cricoid pressure being applied
(16). Aspiration can also occur despite
the presence of a cuffed tube below the
vocal cords and after removal of the
tracheal tube (41– 43).
Rare complications of cricoid pres-
sure include esophageal rupture
should active vomiting occur (36) and
disruption of the cricoid cartilage or
larynx should these structures be in-
jured (43). Trauma to the cricoid carti-
lage and larynx should be suspected in
any patient with hoarseness, subcuta-
neous emphysema, or palpable frac-
ture (44). In these instances, a surgical
airway may be preferable. Flexible fi-
beroptic bronchoscopic intubation may
also be of value.
INDUCTION AGENTS
Thiopental is a fast-onset barbiturate
hypnotic with short duration (45). The
rapid onset of effect is due to high lipid
solubility and high cerebral perfusion.
The maximum effect of a bolus injec-
tion is seen within 60 seconds. This is
followed by a rapid redistribution to
other vessel-rich tissues, which ac-
counts for the rapid offset (46). With
higher doses or multiple repeat doses,
recovery is delayed because the redis-
tribution mechanism is overwhelmed.
Because thiopental may produce hypo-
tension due to myocardial depression
and vasodilation, it should be admin-
istered in reduced or divided doses to
hemodynamically unstable patients or
patients with hypovolemia. In an RSI
study, a subset of patients receiving
thiopental as part of their induction
regimen had an average 38 mm Hg de-
crease in systolic blood pressure (15)
(Tables 6 and 7).
Thiopental decreases cerebral meta-
bolic oxygen consumption, cerebral
blood flow, and intracranial pressure
(ICP). The rapid onset of thiopental
makes this drug useful for treatment of
seizures, although the benzodiazepines
provide a more specific anticonvulsant
activity.
Propofol is a nonbarbiturate seda-
tive-hypnotic that is formulated in soy-
bean oil, glycerol, and egg phos-
phatide, similar to parenteral lipid
formulations (47). The onset is rapid,
usually within 1 to 2 minutes. Propofol
is metabolized by the liver to glucuro-
nide and sulfate conjugates, which are
excreted in the urine. The short dura-
tion of this agent is due to its large
volume of distribution as well as its
high clearance. Patients typically
emerge rapidly after anesthesia with
propofol and have a low incidence of
emesis.
There is a risk of severe hypotension
in certain patient populations because
of myocardial depression and vasodi-
lation. Caution must be taken to ad-
dress cardiovascular and volume sta-
tus when using this agent in the
hypovolemic patient (48). Preinduction
volume loading can offset some of the
cardiovascular effects associated with
propofol (49).
In head-injured patients, propofol
tends to cause cerebral vasoconstric-
tion and a reduction in cerebral metab-
olism, cerebral blood flow, and ICP.
Propofol provided more protection
against tracheal intubation–induced
bronchoconstriction than thiopental or
etomidate (50,51). The combination of
propofol and alfentanil prevented the
increase in intraocular pressure from
succinylcholine as well as the increase
associated with intubation (52). Propo-
fol attenuated the increase of masseter
muscle tone after administration of
succinylcholine (53).
Ketamine is a phencyclidine hyp-
notic that produces intense analgesia
and dissociative anesthesia character-
ized by electroencephalographic disso-
ciation between the thalamus and lim-

TABLE 6. Pharmacokinetics of selected intravenous induction agents.

Dose if SBP
Standard Dose <100 mm Hg Half-Life
Agent (mg/kg) (mg/kg) (hours) Comments
Thiopental 3–5 0.5–2 11.6 Rapid-onset barbiturate; may cause myocardial depression
and hypotension; preferred agent for head-injured patient
with hypertension
Etomidate 0.2– 0.3 0.1– 0.2 2 –5 Imidazole agent with rapid onset; cardiovascular effects
unlikely; associated with myoclonus and adrenal
suppression; preferred agent for hypotensive patient with
head injury or coronary artery disease
Propofol 1.5–2.5 0.5–1 4 –7 Alkylphenol agent with antiemetic properties; may cause
cardiac depression, hypotension, and pain on injection
Ketamine 1–2 0.5–1 1 –2 Phencyclidine agent with potent analgesic properties; may
cause sympathetic stimulation, bronchodilation, vivid
dreams, nystagmus, and salivation; preferred agent for
hypotensive patient with asthma or cardiac tamponade
Modified from Kingsley CP. Perioperative use of etomidate for trauma patients. In: Smith CE, Grande CM, eds. Perioperative Use of Etomidate in Trauma.
ITACCS monograph. New York, NY: McMahon Group; 1996:1–7.
SBP, systolic blood pressure.

Clinical Pulmonary Medicine • Volume 8, Number 3 • May 2001 151

bic system (45,47). Ketamine has a
rapid onset of action within 60 seconds
after intravenous dosages of 1 to 2
mg/kg and 5 minutes after intramus-
cular dosages of 4 to 6 mg/kg (54).
Rapid redistribution is responsible for
the termination of unconsciousness,
whereas the analgesic effects may per-
sist for hours afterward.
Ketamine produces sympathetic ner-
vous system stimulation with increases
in heart rate, blood pressure, cardiac
output, and myocardial oxygen de-
mand. However, in vitro, ketamine
produces direct myocardial depression
(55). Patients may therefore experience
hypotension and decreased cardiac
output if catecholamine stores are de-
pleted or if there is exhaustion of sym-
pathetic system compensatory mecha-
nisms (56).
Ketamine is a potent cerebral vaso-
dilator and leads to an increase in ICP.
These cerebral vasodilator effects are
particularly undesirable in patients
with space-occupying intracranial le-
sions or in patients with elevated ICP.
However, ketamine is a noncompeti-
tive NMDA (N-methyl-d-aspartate) re-
ceptor antagonist that could theoreti-
cally reduce excessive excitotoxic
stimuli and brain ischemia after head
injury (57,58).
Ketamine is a potent bronchodilator
in patients with reactive airways dis-
ease and has been shown to provide
better intubating conditions than thio-
pental after administration of rocuro-
nium (59,60). Ketamine is the recom-
mended induction agent in patients
with life-threatening asthma requiring
RSI (61). Postoperative reports of
dreaming are very high after RSI with
ketamine (55% incidence) (62), and hal-
lucinations may occur. The frequency
of these disturbing events can be re-
duced by benzodiazepine administra-
tion.
TABLE 7. Cardiovascular and central nervous system effects of induction agents.
Blood
Agent Pressure
Thiopental Decrease
Etomidate No change
Propofol Decrease
Ketamine Increase
Modified from Kingsley CP. Perioperative management of thoracic trauma. Anesth Clin North Am. 1999;17:183–195.
* Centrally mediated sympathetic response usually overrides direct depressant effects. CMRO2, cerebral metabolic oxygen requirements.
152
Etomidate is a rapid-onset carboxy-
lated imidazole hypnotic with short
duration (45). Unlike thiopental and
propofol, etomidate has minimal or ab-
sent cardiac depressant effects when
administered in standard induction
dosages. The lack of cardiovascular ef-
fects is most likely due to etomidate’s
lack of effect on the sympathetic ner-
vous system and autonomic reflexes
(63). Etomidate does not cause hemo-
dynamic instability either when the
myocardium is normal or when it is
acutely ischemic (64). In isolated
hearts, etomidate was not cardiode-
pressant (65). In chronically instru-
mented dogs with left ventricular dys-
function and dilated cardiomyopathy,
maintenance of anesthesia with etomi-
date resulted in stable arterial blood
pressure, increased left ventricular af-
terload, and diminished systolic and
diastolic performance of the left ventri-
cle (66). No inhibition of myocardial
contractility was found in isolated hu-
man atrial muscle in the clinical con-
centration range of etomidate (67).
As with thiopental, etomidate de-
creases cerebral metabolic oxygen con-
sumption, cerebral blood flow, and
ICP. Etomidate offers an excellent
safety profile in hemodynamically
compromised patients and is useful for
RSI in patients with shock or unstable
cardiopulmonary status and in patients
with head injury (56,68 –71).
Etomidate as part of an induction
regimen containing alfentanil and
rocuronium attenuated the reaction to
intubation to a greater extent than thio-
pental (72). Etomidate does not blunt
the hypertension and tachycardia re-
sponse to intubation. In patients with
severe coronary artery disease, phar-
macologic interventions were required
to treat new myocardial ischemia when
etomidate and succinylcholine were
Cardiac Cerebral Blood
Heart Rate Contractility Flow
Increase No change Decrease
or decrease
No change No change Decrease
No change Decrease Decrease
Increase Increase* Increase
used for RSI in the absence of opioids
(73).
An increased hypnotic effect of eto-
midate was observed during hypovo-
lemia in an animal model (74). The
dose required to reach an isoelectric
EEG was almost 40% lower in hypovo-
lemic animals compared with controls
(74). Etomidate is not associated with
histamine release and reduced hista-
mine-induced contraction in human
isolated airway smooth muscle (75).
Problems with etomidate include ir-
ritation and phlebitis in the injected
vein, myoclonic movements on induc-
tion, and a higher incidence of nausea
and vomiting after extubation (76). In-
voluntary muscle movements (myoclo-
nus) and pain on injection with etomi-
date can be minimized with lidocaine
and small doses of midazolam. Myoc-
lonus is abolished by the simultaneous
administration of neuromuscular re-
laxant during RSI. Etomidate-induced
myoclonus is not associated with epi-
leptiform activity and appears to be
related to disinhibition of subcortical
structures that normally suppress ex-
trapyramidal motor activity. These
muscle movements can mistakenly be
confused with seizures, especially in
patients who have sustained head
trauma. Hypotension can occur during
conditions of hypovolemia and hemor-
rhagic shock mandating reduction in
the dose of etomidate.
Etomidate inhibits adrenal cortisol
synthesis by a reversible and concen-
tration-dependent block of 11-␤-hy-
droxylase and to a lesser extent 17-␣-
hydroxylase (47,76). This adrenal
suppression appears to be related to
binding of cytochrome P450 by the free
imidazole radical of etomidate and has
been associated with an increased mor-
bidity and mortality rate after pro-
longed use of etomidate in intensive
care unit patients (77). Single doses of
Intracranial
CMRO2 Pressure
Decrease Decrease
Decrease Decrease
Decrease Decrease
Increase Increase
Smith • Rapid-Sequence Intubation in Adults
 TABLE 8. Selected neuromuscular relaxants for rapid-sequence intubation.
Intubating Intubating Clinical
Agent Dose (mg/kg) Time (minutes)* Duration (minutes)† Comments
Succinylcholine 0.6–1.1 1 4– 6 Associated with several side effects that
may contraindicate its use (see Tables 9
and 10)
Rocuronium 0.6–1.2 0.7–1.1 31– 67 Nondepolarizer of choice for rapid-sequence
intubation; mild vagolysis
Rapacuronium‡ 1.5–2.5 1–1.5 17–24 Short-acting nondepolarizer; clinical
duration decreased to 8 –12 minutes with
early neostigmine reversal (rescue
reversal); may cause histamine release
Mivacurium 0.15– 0.25 1.5–2.5 16–23 Short-acting; metabolized by plasma
cholinesterase; histamine release
Vecuronium 0.08– 0.10 2.5–3 25– 40 Onset time delayed unless high doses
(0.3– 0.4 mg/kg) used; cardiovascular
effects unlikely
Cisatracurium 0.15– 0.2 1.5–2 55– 65 Potent stereoisomer of atracurium with
organ-independent elimination;
cardiovascular effects unlikely
Atracurium 0.4– 0.5 2–2.5 35– 45 Organ-independent elimination; histamine
release
Pancuronium 0.06– 0.10 2–3 65–100 Long-acting agent associated with
tachycardia and activation of the
sympathetic nervous system
Modified from Smith CE, Grande CM, Wayne MA, ITACCS Consensus Panel, and International Review Committee. Rapid Sequence Intubation in
Trauma. Baltimore, MD: International Trauma Anaesthesia and Critical Care Society (ITACCS); 1998. Poster.
* Average time to good to excellent intubating conditions (ⱖ80% block).
† Average time to 25% first-twitch recovery.
‡ Withdrawn from market due to serious adverse bronchospasm events.

etomidate may interfere with cortisol Depolarizing Agents

synthesis for at least 24 hours in the
critically ill (78).
NEUROMUSCULAR
RELAXANTS
The use of neuromuscular relaxants
to facilitate intubation is associated
with side effects regardless of whether
depolarizing or nondepolarizing
agents are used (79,80). However,
avoidance of relaxants generally re-
sults in inferior intubating conditions
unless large doses of other agents such
as propofol and alfentanil are adminis-
tered (81– 84). In patients with compro-
mised circulation, high doses of induc-
tion agents and opioids can cause
profound hypotension and are inap-
propriate. Moreover, compared with
RSI, intubation without use of neuro-
muscular relaxants has been associated
with an increased frequency of compli-
cations such as aspiration (15%), air-
way trauma (28%), and death (3%) in a
prospective study of RSI in the emer-
gency setting (3) (Table 8).
Because succinylcholine produces
rapid skeletal muscle relaxation, within
TABLE 9. Side effects of
30 to 60 seconds after its administra-
succinylcholine.
tion, it remains widely used for RSI. At
the molecular level, succinylcholine • Massive hyperkalemia in
binds to the acetylcholine receptors at susceptible patients
the neuromuscular junction, causing • Cardiac arrhythmias
conformational change in the receptor. • Muscle fasciculations
The receptor is then refractory to ace- • Myalgias
tylcholine, and the perijunctional mus- • Rhabdomyolysis
cle membrane sodium channels remain • Increased intracranial
frozen in an inactivated state. This de- pressure
polarizing type block persists until suc- • Increased intragastric
cinylcholine diffuses away from the pressure
junction. In patients with atypical • Increased intraocular
forms of plasma cholinesterase, dura-
pressure
tion of action of succinylcholine may be
• Malignant hyperthermia
increased to 3 to 4 hours (85).
• Masseter muscle spasm or
The use of succinylcholine is associ-
jaw rigidity
ated with the potential occurrence of
• Prolonged apnea (1–4 hours),
life-threatening events such as cardiac
if atypical plasma
bradyarrhythmias, hyperkalemia, and
malignant hyperthermia (Table 9) (86 – cholinesterase
90). Dose-related increases in creatine From Bevan DR. Complications of mus-
kinase and myoglobin occur as well. cle relaxants. Semin Anesth. 1995;14:63.
Succinylcholine stimulated break

Clinical Pulmonary Medicine • Volume 8, Number 3 • May 2001 153

down of intramuscular glycogen, par-
ticularly in fast-twitch muscles, and
caused accumulation of lactate in inter-
costal muscles (91). Masseter muscle
rigidity after succinylcholine may
make tracheal intubation difficult and
indicate the potential for malignant hy-
perthermia.
Succinylcholine-induced brady-
arrhythmias, including asystole, may
occur after repeat doses of this agent in
adults and with the initial dose in chil-
dren. In the author’s experience, car-
diac arrhythmias are more common
during conditions of hypoxia or hyper-
carbia. Pretreatment with atropine pre-
vents these bradyarrhythmias.
Hyperkalemic deaths can occur after
succinylcholine in patients with burns
or active neurologic disease or in chil-
dren with subclinical muscular dystro-
phy. The literature strongly suggests
that succinylcholine be avoided after
24 to 48 hours of injury in patients with
burns, massive trauma, crush and de-
gloving injuries, spinal cord injuries,
stroke, severe abdominal infections,
tetanus, and in patients with neuro-
muscular disease such as Duchenne’s
muscular dystrophy, because of the
risk of hyperkalemic cardiac arrest (Ta-
ble 10) (86).
The susceptibility to massive hyper-
kalemia is most likely a result of pro-
liferation of extrajunctional nicotinic
cholinergic receptors. The administra-
tion of small subparalyzing doses of
nondepolarizing relaxants before suc-
TABLE 10. Conditions associated
with exaggerated hyperkalemia
after succinylcholine.
• ⬎24 hours after major burns
and multiple trauma
• Crush injuries
• Metabolic acidosis
• Extensive denervation of
skeletal muscle
• Upper motor neuron injury
• Tetanus
• Chronic abdominal infection
• Subarachnoid hemorrhage
• Duchenne’s muscular
dystrophy
• Conditions causing
degeneration of central and
peripheral nervous systems
From Bevan DR. Complications of mus-
cle relaxants. Semin Anesth. 1995;14:63.
154
cinylcholine prevents fasciculations
but does not prevent the development
of life-threatening hyperkalemia (54).
Preexisting hyperkalemia from renal
failure or severe acidosis may also pre-
dispose to hyperkalemia after succinyl-
choline (92).
Succinylcholine is also associated
with other undesirable side effects
mostly related to its depolarizing
mechanism of action. Nonetheless, ad-
ministration of succinylcholine did not
result in loss of intraocular contents in
a cat model of ocular trauma (93). In
patients with head trauma and other
central nervous system pathologies,
Kovarik and colleagues (94) demon-
strated that succinylcholine did not ad-
versely affect cerebral perfusion pres-
sure, ICP, electroencephalogram, or
middle cerebral blood flow. In a
blinded randomized crossover trial in
patients with severe head injury, there
were no adverse effects of succinylcho-
line, 1.0 mg/kg, on ICP or cerebral per-
fusion pressure (95).
Administration of small doses of
nondepolarizing relaxants in an effort
to prevent fasciculations and other side
effects (pretreatment) has been advo-
cated (96 –98). However, pretreatment
may produce significant muscle weak-
ness before loss of consciousness and
can cause pulmonary aspiration
(99,100). In elderly patients, pretreat-
ment produced muscle weakness and
decreased oxygen saturation and pul-
monary function before intubation
(101). Pretreatment also delays onset of
succinylcholine neuromuscular block-
ade and may decrease the degree of
paralysis (102).
Nondepolarizing Neuromuscular
Relaxants
The need for a rapid-onset nondepo-
larizing agent to replace succinylcho-
line for RSI has been obvious for many
years (103). Nondepolarizing relaxants
bind to the ␣ subunits of the acetylcho-
line receptor at the neuromuscular
junction and competitively inhibit neu-
romuscular transmission. In contrast to
succinylcholine, nondepolarizers do
not cause conformational change in the
acetylcholine receptor. The receptor
channels remain closed, and no current
or ions flow. Unlike succinylcholine,
nondepolarizing relaxants do not cause
hyperkalemia, cardiac bradyarrhyth-
mias, or malignant hyperthermia, nor
do they increase intraocular, intracra-
nial, or intragastric pressure (79,80).
For these reasons, rapid-onset non-
depolarizing relaxants such as rocuro-
nium are good alternatives to succinyl-
choline whenever there is concern
about the potential for adverse effects
of succinylcholine. The most common
reason reported for use of rocuronium
in the emergency department was con-
cern for succinylcholine-induced hy-
perkalemia (104).
Rocuronium is a nondepolarizer al-
ternative for succinylcholine in terms
of onset but has an intermediate clini-
cal duration (30 to 60 minutes) (105).
Rocuronium has a small volume of dis-
tribution, is highly ionized at physio-
logic pH, and does not cross the blood-
brain barrier. Rapid initial decline in
blood levels is caused by redistribu-
tion. Elimination is chiefly by hepatic
metabolism followed by renal excre-
tion. Onset times similar to those of
succinylcholine can be obtained with
doses of rocuronium of 0.9 to 1.2
mg/kg (106).
There is an important dose-related
effect for rocuronium for both onset
and peak effect at the adductor pollicis
and airway musculature (107–110). For
example, it has been shown that the
dose-response curve for rocuronium at
the laryngeal adductor muscles and di-
aphragm is shifted to the right com-
pared with that of the adductor pollicis
(111,112). Thus, lower doses of rocuro-
nium may be inadequate for acceptable
intubation conditions after 60 seconds
(107,108,110). In a study by Andrews
and associates (113), rocuronium, 1
mg/kg, improved intubation condi-
tions compared with the 0.6 mg/kg
dose and was clinically equivalent to
intubation conditions after succinyl-
choline, 1.0 mg/kg, during RSI. The
incidence of clinically acceptable intu-
bating conditions with rocuronium, 1
mg/kg, succinylcholine, 1 mg/kg, and
rocuronium, 0.6 mg/kg, was 93%, 97%,
and 77%, respectively (113).
Excellent-grade intubating condi-
tions were observed more frequently
after succinylcholine, 1 mg/kg (80%),
compared with rocuronium, 1 mg/kg
(65%), in a randomized blinded trial
during RSI when laryngoscopy was
initiated 50 seconds after the relaxant
(114). However, there were no differ-
ences in clinically acceptable condi-
tions between the groups (96% and
97%, respectively) (114). After induc-
Smith • Rapid-Sequence Intubation in Adults
tion with fentanyl and propofol, rocu-
ronium, 1 mg/kg, gives a 95% proba-
bility of successful intubation at 60
seconds (115).
The rapid onset time of rocuronium is
thought to be due to its lower potency,
which allows more molecules of the drug
to access the neuromuscular junction dur-
ing the first few circulation times (109).
There is no histamine release, although
there is a potential for mild vagolysis with
this agent in lightly anesthetized patients.
The use of rocuronium, 0.9 mg/kg, did
not result in clinically significant change in
heart rate, blood pressure, or plasma cate-
cholamine concentration in elderly pa-
tients (116). In patients with coronary ar-
tery disease, rocuronium, 1.0 mg/kg, was
associated with stable heart rate, blood
pressure, cardiac index, and mixed venous
oxygen saturation and a lower require-
ment for vasopressors compared with ve-
curonium, 0.15 mg/kg (117). Rocuronium
was associated with greater decreases in
intraocular pressure than succinylcholine
(118). When using rocuronium for RSI af-
ter thiopental has been given, it is prudent
to flush the drugs through the intravenous
tubing to avoid precipitation, which can
potentially occlude the tubing.
Rapacuronium is a new aminos-
teroid, nondepolarizing neuromuscu-
lar relaxant with a structure analogous
to that of pancuronium, rocuronium,
and vecuronium and a clinical profile
analogous to that of succinylcholine
(i.e., rapid onset of action and short
duration of action). Time to maximal
block is 52 seconds after a dose of 1.5
mg/kg and duration of action is 16.2
minutes (119). Early administration of
neostigmine shortens the recovery time
to 8.0 to 9.5 minutes (119). Early rever-
sal may be beneficial in patients with
difficult airways or failed intubation.
Intubating conditions after rapacuro-
nium and succinylcholine were com-
pared in 818 patients in 3 prospective
randomized multicenter trials (120).
The Viby-Mogensen Scale, which con-
sists of 5 parameters of intubating con-
ditions: vocal cord position, vocal cord
movement, jaw relaxation, airway re-
action, and movement of limbs, was
used to objectively measure intubating
conditions. Laryngoscopy was initiated
at 50 seconds after giving rapacuro-
nium, 1.5 mg/kg, or succinylcholine,
1.0 mg/kg, to anesthetized patients. In
the studies, clinically acceptable intu-
bating conditions were somewhat bet-
ter after succinylcholine than after ra-
Clinical Pulmonary Medicine • Volume 8, Number 3 • May 2001
pacuronium and occurred in 80% to
87% of the patients receiving rapacuro-
nium and in 89% to 97% of the patients
receiving succinylcholine (120).
Clinically acceptable intubating condi-
tions were achieved less frequently after
rapacuronium, 1.5 mg/kg, than after suc-
cinylcholine in 335 patients when laryn-
goscopy was initiated 50 seconds after giv-
ing the relaxant (121). Increasing the dose
of rapacuronium to 2 or 2.5 mg/kg or
initiating laryngoscopy at 60 or 90 seconds
rather than at 50 seconds may allow for
better overall intubating conditions with
rapacuronium.
Unlike rocuronium, rapacuronium
may cause histamine release. The most
frequent adverse events seen with ra-
pacuronium in 1956 patients undergo-
ing clinical trials were hypotension
(5.2%), tachycardia (3.2%), bradycardia
(1.5%), and bronchospasm (3.2%) (120).
Corresponding frequency of these
events after succinylcholine in 572 pa-
tients were 6.5%, 0.5%, 1%, and 2.1%,
respectively (120). Pulmonary side ef-
fects such as bronchospasm and in-
creased airway pressure were observed
in 11% of patients given rapacuronium
during RSI with thiopental or propofol
and opioids (121).
Since the release of rapacuronium
into clinical practice, there have been
several reports of serious adverse bron-
chospasm events including a few un-
explained fatalities. As a result, the
manufacturer of rapacuronium has
withdrawn the drug from the market
(“Voluntary Market Withdrawal, Ad-
verse Drug Reaction,” Organon Inc,
West Orange, NJ, March 27, 2001).
Vecuronium is a monoquaternary
steroidal nondepolarizing muscle re-
laxant. In the usual recommended in-
tubating doses, 0.10 to 0.15 mg/kg, the
onset of action is delayed compared
with rocuronium or succinylcholine
(110,122). However, vecuronium does
have the advantage of being devoid of
cardiovascular effects even when large
doses are rapidly administered. There
is no histamine release (123). Vecuro-
nium is metabolized by the liver into 3
active metabolites and is excreted in
the bile and urine (124).
Before the availability of rocuro-
nium, the use of a high-dose vecuro-
nium technique, 0.3 to 0.4 mg/kg, to
achieve a rapid onset of neuromuscular
blockade was advocated (125). This re-
sulted in an accelerated onset of block
of 80 to 90 seconds but was associated
with a prolonged duration of clinical
effect (126).
OTHER DRUGS
Midazolam is a short-acting potent wa-
ter-soluble benzodiazepine with sedative,
anxiolytic, amnestic, and anticonvulsant
properties (127). Onset of action is within 1
to 2 minutes. Midazolam is metabolized in
the liver and excreted by the kidney, with
an elimination half-life of 1 to 4 hours
(128). Small incremental doses, 1 to 2 mg
IV, are very useful for retrograde and an-
tegrade amnesia and sedation. These
doses have minimal, if any, hemodynamic
effects. Midazolam is an effective agent for
providing sedation before and after RSI.
The effects of midazolam are rapidly re-
versed by the benzodiazepine antagonist
flumazenil. However, the elimination of
flumazenil is substantially more rapid
than that of midazolam, and resedation
may occur (129).
Opioid drugs are useful adjuncts to de-
crease pain and coughing associated with
direct laryngoscopy and tracheal intuba-
tion (130). The clinical effects of opioid
analgesics are exerted via stimulation of
the various opioid receptor subtypes at
different levels of the neuraxis. Central
nervous system effects included sedation
and hypnosis with reduction in cerebral
metabolism, pupillary constriction, and
stimulation of the chemoreceptor trigger
zone in the area postrema. The cough cen-
ters of the medulla are depressed after
administration of opioids. Respiratory ef-
fects include a dose-related depression of
the ventilatory response to carbon dioxide,
an elevated apneic threshold, and a
blunted ventilatory response to hypox-
emia.
Opioids also blunt the stress re-
sponse to pain and decrease sympa-
thetic tone leading to peripheral vaso-
dilation and venodilation. There is no
myocardial depression after clinically
relevant doses of fentanyl, alfentanil,
sufentanil, and remifentanil, although
centrally mediated bradycardia may
occur. Decreased pulmonary compli-
ance, chest wall rigidity, and laryngo-
spasm may occur leading to difficulty
with ventilation if the onset of action of
the opioid precedes that of the neuro-
muscular relaxant (117,131).
Fentanyl is a potent synthetic opioid
with minimal hemodynamic or cere-
brovascular effects (132). Onset is
within 6 minutes, with a duration of 45
to 60 minutes. Fentanyl is rapidly re-
155
distributed into a large volume of dis-
tribution, which largely determines its
duration of action when smaller doses
are given. Elimination is via hepatic
transformation and kidney excretion.
The sympathoadrenal response to intu-
bation is attenuated by adding fenta-
nyl, 2.5 ␮g/kg, to an induction regimen
of thiopental and neuromuscular
blockade (133).
Alfentanil has a smaller volume of
distribution and shorter elimination
time compared with fentanyl or sufen-
tanil (134). Rapid plasma-effect site
equilibration with alfentanil results in a
relatively larger peak effect site con-
centration. Sufentanil is 5 to 10 times
more potent than fentanyl and has
longer distribution and elimination
half-lives than alfentanil (134).
Remifentanil is a newer opioid agent
that is often administered by infusion
pump. The peak effect site concentra-
tion after remifentanil is ⬇1.5 minutes,
which is very similar to that seen with
alfentanil (135). The unique character-
istic of remifentanil is its rapid clear-
ance by plasma esterases into metabo-
lites with nearly no activity at the mu
receptor. Bolus doses of 1.0 and 1.25
␮g/kg were effective in controlling the
hemodynamic response to intubation
in patients receiving thiopental and
succinylcholine (136). However, the
1.25 ␮g/kg dose was associated with
hypotension in 35% of patients (136)
and is therefore not recommended. In
the author’s practice, bolus doses of 0.5
to 0.75 ␮g/kg have proved useful with-
out clinically significant hypotension.
A number of other drugs such as
lidocaine, labetalol, esmolol, clonidine,
verapamil, nicardipine, and diltiazem
can also be used in an effort to sup-
press the cardiovascular responses to
tracheal intubation (137–139). The com-
bination of low-dose fentanyl, 2 ␮g/kg,
and esmolol, 2 mg/kg, was effective in
blunting both the heart rate and blood
pressure response to laryngoscopy and
intubation during RSI (140). Lidocaine,
1.5 mg/kg IV, 2 minutes before laryn-
goscopy and intubation did not pre-
vent hemodynamic reactions evoked
by RSI (141) (Table 11).
TRACHEAL INTUBATION:
CONVENTIONAL DIRECT
LARYNGOSCOPY
Before starting the RSI procedure,
equipment needs to be prepared and
156
checked (Table 12). Contingency plans bilization (MIAS, Figure 4). With cervi-
for difficult intubation must be imme- cal spine precautions, the incidence of
diately available should intubation fail. difficulty with glottic visualization
A brief neurologic assessment should during conventional laryngoscopy is
be done including Glasgow Coma increased significantly (Table 4) (28).
Scale, pupillary equality and response If the patient is on an operating room
to light, and sensory and motor exam- table or bed, the height of the bed
ination. should be adjusted such that the pa-
The patient is placed supine. Elevat- tient’s face is at the level of the laryn-
ing the head 10 cm with pads under the goscopist’s xiphoid cartilage. If the pa-
occiput and shoulders remaining on tient is lying supine on the ground, the
the table together with head extension larynx is easier to visualize when the
at the atlanto-occipital joint serves to laryngoscopist assumes the left lateral
align the oral, pharyngeal, and laryn- decubitus position compared with the
geal axes such that the passageway kneeling position (Figure 5) (142).
from the mouth to glottis is most The mouth is opened and the laryn-
nearly a straight line. If the patient is goscope blade is inserted into the right-
suspected of having a cervical spine hand side of the mouth. Care is taken
injury, head extension is avoided and to avoid contacting incisor teeth and to
the trachea should be intubated while deflect the tongue away from the lu-
maintaining the neck in a neutral posi- men of the blade. With a curved blade
tion using in-manual in-line axial sta- (e.g., MacIntosh), the tip of the blade is
TABLE 11. Selected opioid agents, midazolam, and lidocaine for rapid sequence
intubation.
Dose in
Agent Standard Dose Hypotensive Patient Comments
Fentanyl 2–5 ␮g/kg 1–2 ␮g/kg Minimal hemodynamic or
cerebrovascular effects;
useful agent for blunting
noxious stimuli (e.g.,
direct laryngoscopy,
tracheal intubation)
Sufentanil 0.5–1.0 ␮g/kg 0.1– 0.5 ␮g/kg Similar to fentanyl but
more potent; faster offset
Alfentanil 20 – 80 ␮g/kg 5–20 ␮g/kg Similar to fentanyl but
faster onset and offset
Midazolam 2– 4 mg 0.5–2.0 mg Benzodiazepine agent with
minimal cardiovascular
effects when used in
small doses; useful for
sedation and amnesia;
increases seizure
threshold; can be
reversed with flumazenil
Lidocaine 1.5 mg/kg 1.0 mg/kg Useful adjuvant agent for
blunting airway reflexes;
also blunts BP and ICP
response to intubation,
myoclonus after
etomidate, and injection
site pain from propofol
and etomidate
Modified from Grande CM, Smith CE, Stene JK. Trauma anesthesia. In: Longnecker DE, Tinker
JH, Morgan GE, eds. Principles and Practice of Anesthesiology. 2nd ed. St. Louis, MO: Mosby; 1998:
2138 –2164.
BP, blood pressure; ICP, intracranial pressure.
Smith • Rapid-Sequence Intubation in Adults

TABLE 12. Equipment for
rapid-sequence intubation.
• Masks, e.g., sizes 3 and 4
• Oxygen source
• Laryngoscope blades and
handle, e.g., MacIntosh 3 and 4
• Large-bore suction
• 14F stylet
• Tape to secure tube
• Oral and nasal airways
• Manual ventilation bag with
reservoir
• Extra laryngoscope bulbs and
batteries
• Endotracheal tubes and 10-mL
syringe, e.g., ID 7–8 mm
• Gum elastic bougie
• Equipment for failed intubation:
e.g., LMA, Combitube,
cricothyrotomy tray
Modified from Smith CE, Walls RM,
Lockey D, et al. Advanced airway man-
agement and use of anesthetic drugs. In:
Grande CM, Soreide E, eds. Prehospital
Trauma Care. New York, NY: Marcel Dek-
ker Inc; 2001:203–253.
LMA, laryngeal mask airway; ID, inter-
nal diameter.
advanced into the vallecula, and a for-
ward and upward movement of the
blade exerted along the axis of the han-
dle stretches the hypoepiglottic liga-
ment, thereby lifting the epiglottis and
exposing the vocal cords. With a
straight blade (e.g., Jackson-Wisconsin
or Miller), the tip of the blade is placed
beneath the laryngeal surface of the
epiglottis. Subsequent forward and up-
ward movement exposes the laryngeal
inlet. The choice of blade is usually
based on personal preference.
FIGURE 4. Manual in-line axial stabilization
to prevent movement of the cervical spine dur-
ing tracheal intubation. From Smith CE, Peer-
less JR. Rational use of neuromuscular block-
ing agents for emergency airway management
in the trauma patient. In: Smith CE, Grande
CM, eds. The Use of Neuromuscular Blocking
Agents in the Trauma Patient. ITACCS
monograph. New York, NY: McMahon
Group; 1996:3–8. With permission.
Clinical Pulmonary Medicine • Volume 8, Number 3 • May 2001
The tracheal tube, held in the right hand
like a pencil, is introduced on the right side
of the mouth and through the vocal cords
until the cuff disappears. The pilot balloon
is inflated, and ventilation is confirmed by
sustained presence of end-tidal carbon di-
oxide, presence of bilateral breath sounds
with absence of air over the epigastrium,
and chest increase. The tube is securely
taped or tied at the appropriate depth
(143). A distance of 20 to 24 cm is required,
on average, to place the distal end of the
tube at the midtracheal position. In the
author’s practice, a cuffed 7.0-mm internal
diameter tube is usually chosen for
women and a cuffed 8.0-mm tube for men,
although it is acknowledged that most
adult tracheas readily accept a cuffed 8.0-
to 9.0-mm internal diameter tube.
A summary of the various steps in-
volved in RSI is provided in Table 13.
Suggested drugs for RSI according to clin-
ical setting and hemodynamic stability are
presented in Table 14, and management of
specific complications such as hypoten-
sion or difficulty with bag-tube ventilation
is shown in Table 15.
CONFIRMATION OF
TRACHEAL INTUBATION:
END-TIDAL CARBON
DIOXIDE (CO2)
Direct visualization of the tracheal tube
passing through the vocal cords is the sim-
plest and most reliable method of confirm-
ing intratracheal placement. However,
with the introduction of capnography into
clinical practice, identification of CO2 in
the expired gas is now routinely per-
formed whenever an endotracheal is in-
serted. This method provides objective ev-
FIGURE 5. The larynx is easier to visual-
ize when the laryngoscopist assumes the
left lateral decubitus position compared
with the kneeling position. From Adnet F,
Cydulka RK, Lapandry C. Emergency tra-
cheal intubation of patients lying supine on
the ground: influence of operator body po-
sition. Can J Anaesth. 1998;45:266 –269.
With permission.
idence of tracheal rather than esophageal
intubation in patients with spontaneous
circulation. Although CO2 can be detected
initially with esophageal intubation if ex-
pired CO2 entered the stomach during
bag-mask ventilation, the concentration is
low and diminishes over three or four
breaths.
There are several pitfalls of using
capnography to confirm tracheal intu-
bation including transport delay when
using low-vacuum side-stream cap-
nometers, malfunctioning equipment,
and lighting conditions in the prehos-
pital setting (e.g., colorimetric detec-
tor). In addition, a kinked or obstructed
tracheal tube, severe bronchospasm,
and tension pneumothorax may pre-
vent exhalation and hence measure-
ment of expired CO2. Finally, during
circulatory arrest and cardiopulmo-
nary resuscitation, CO2 transport from
the tissues to the lung is markedly de-
creased or absent with correspond-
ingly low or absent end-tidal CO2.
Another technique to verify tracheal
tube placement consists of a collapsible
bulb attached to an endotracheal tube
adaptor. If the tip of the endotracheal
tube is in the trachea, the bulb rapidly
fills with air that is aspirated out of the
tracheal-bronchial tree. If the tube is in
the esophagus, the bulb remains col-
lapsed. The collapsible bulb technique
does not rely on detection of CO2 and
is therefore most useful in cardiac ar-
rest situations where the operator has
not been able to visualize the tube
passing through the vocal cords.
TRACHEAL INTUBATION
AIDS (STYLET, BURP
MANEUVER, GUM ELASTIC
BOUGIE)
Difficult visualization of the glottis may
be overcome by using a rigid stylet placed
inside the tube. With this technique, the
tracheal end of the tube resembles the
shape of a hockey stick, which facilitates
directing the tube anteriorly.
External laryngeal manipulation or
depression of the thyroid cartilage of-
ten improves the view at laryngoscopy
(144). The BURP maneuver may also
improve the laryngoscopic view (Fig-
ure 6) (145). This is accomplished by
displacing the larynx in 3 specific di-
rections: (a) backward against the cer-
vical vertebrae; (b) upward, as far su-
perior as possible; and (c) slightly
laterally to the right.
157
 The gum elastic bougie (Figure 7)
has been used to facilitate tracheal in-
tubation whenever a grade III view is
encountered (31,146). While perform-
ing direct laryngoscopy and maintain-
ing adequate laryngoscopic force to
keep the epiglottis in full view, the
bougie is introduced by the operator
and gently advanced anteriorly under
the epiglottis and into the trachea until
clicks or holdup is felt. With the oper-
ator still maintaining laryngoscopic
force, a second operator then threads a
tracheal tube over the bougie. Occa-
sionally, the bougie may need to be
rotated 90 degrees for the tube to pass.
It is relatively easy to insert a bougie
through the glottic opening when only
the epiglottis (grade III view) or tip of
the arytenoids (grade II view) can be
visualized. Tracheal placement is then
confirmed using capnography.
SPECIAL LARYNGOSCOPES,
INTUBATING LARYNGEAL
MASK AIRWAY (iLMA),
LIGHTED STYLET, AND
RETROGRADE INTUBATION
The Bullard laryngoscope is an ana-
tomically shaped rigid fiberoptic in-
strument designed for oral indirect vi-
sualization of the larynx (147). The
major advantage of the Bullard laryn-
goscope is that virtually no head and
neck movement is required to obtain a
clear view of the vocal cords (148,149).
The WuScope is another combina-
tion intubating device, which is com-
posed of a rigid blade portion and a
flexible fiberscope (Figure 8) (150). The
rigid blade is anatomically shaped to
match the pharyngeal contour of the
oral airway, thus allowing oral access
to the glottis without tongue displace-
ment or head extension (29). The tubu-
lar blade of the WuScope creates more
viewing and intubating space and per-
mits oral intubation in patients with
limited mouth opening. The WuScope
also has a separate channel for provid-
ing supplemental oxygen.
It has previously been shown that
fiberoptic laryngoscopy using the Wu-
Scope was associated with easy glottic
exposure and tracheal intubation, even
in patients with anatomic factors that
would normally prevent adequate vi-
sualization of the vocal cords such as
cervical spine instability, hypoplastic
mandible, and protruding maxillary
incisors (151). At least 20 mm of mouth
opening is necessary to insert and ma-
nipulate the rigid fiberoptic WuScope
blades.
The McCoy or Heine flexible-tip la-
ryngoscope blade has a hinged-blade
tip that is controlled by a lever attached
to the blade (Figure 9). This new laryn-
goscopic blade, which attaches to a
standard laryngoscope handle, allows
the epiglottis to be elevated without
requiring excessive lifting force. Use of
the McCoy laryngoscope is invaluable
for improving the laryngeal view and
facilitating intubation in patients re-
quiring cervical spine immobilization
(30,32,152). Of particular note is the
very short learning curve for using this
blade. In the author’s experience, any
anesthesia provider who was comfort-
able with the technique of conventional
laryngoscopy could easily become ac-
complished with this blade after only
one or two attempts.
Transillumination of the soft tissues
of the neck using a flexible lightwand
device may also be useful to facilitate
orotracheal intubation (153). This light-
guided technique minimizes upper cer-
vical spine movement and has been
used successfully to perform indirect
orotracheal intubation in patients with

TABLE 13. Summary of technique for rapid-sequence intubation.

1. Evaluate the airway. If, after evaluation of the airway, there is sufficient doubt about the ability to successfully
intubate, neuromuscular relaxants should not be administered and consideration should be given to securing the
airway in another fashion.
2. Assemble necessary equipment (e.g., laryngoscope, suction, gum elastic bougie, equipment for failed intubation)
and ensure that a neurologic assessment with Glasgow Coma Scale has been done.
3. Preoxygenate with 100% O2 using a sealed system or ventilate with bag-mask-valve device.
4. If suspected cervical spine injury, apply manual in-line axial stabilization of the head and neck and remove
anterior portion of the rigid cervical spine collar. Otherwise, use optimal sniff position.
5. Give appropriate medications intravenously, as indicated by the clinical setting and hemodynamic status. Flush
intravenous line with 10 mL of crystalloid solution after each drug to ensure delivery to central circulation and to
prevent precipitation within the intravenous line.
Induction agents: etomidate, thiopental, or ketamine
Neuromuscular relaxants: succinylcholine, or rocuronium
Adjunct drugs: fentanyl, lidocaine, midazolam
6. Apply cricoid pressure.
7. Ventilate the lungs with 100% O2 using inflation pressures ⬍20 cm H2O to prevent or treat hypoxemia and
hypercarbia before intubation.
8. Intubate the trachea 1 minute after the relaxant has been flushed in.
9. Release cricoid pressure after intratracheal placement is confirmed by visualizing the tube passing through cords
and sustained presence of end-tidal CO2 on the capnograph.
10. Auscultate the lungs to confirm bilateral breath sounds.
11. Secure the tube at a proper depth.
12. Be prepared to manage complications.
Modified from Smith CE, Grande CM, Wayne MA, ITACCS Consensus Panel, and International Review Committee. Rapid Sequence Intubation in
Trauma. Baltimore, MD: International Trauma Anaesthesia and Critical Care Society (ITACCS); 1998. Poster.

158 Smith • Rapid-Sequence Intubation in Adults

difficult airways (e.g., cervical spine
trauma, micrognathia, jaw immobility,
glossomegaly) and in the prehospital
environment (154,155).
Current lightwands are largely fiberop-
tic in design and many can accommodate
both adult and pediatric tracheal tube
sizes (156). A darkened room is helpful for
observing the bright well-circumscribed
circle of light just below the hyoid and
above the thyroid cartilage in the midline
(156). The glow of light will remain con-
tinuously bright with successful tracheal
intubation, whereas briefly losing the light
and then recovering a glow in the midline
generally indicates esophageal intubation
(156). A lower glow above the supraster-
nal notch usually indicates a midtracheal
position. Relative contraindications for use
of the lighted stylet include glottic lesions,
morbid obesity, and bright sunlight (155).
Rare complications include separation of
the bulb and arytenoid cartilage disloca-
tion (156).
The iLMA was introduced in 1997 as
a modification of the standard LMA
(157). It can be used as an emergency
ventilating device or as an aid for blind
placement of an endotracheal tube of
up to 8.0 mm in internal diameter.
Compared with a standard LMA, the
iLMA has a wider diameter and
shorter length. Complications of the
iLMA include pharyngeal edema and
esophageal perforation (157,158).
Transillumination may enhance the
ability to advance the silicone tracheal
tube through the iLMA and into the
trachea. Transillumination is done us-
ing a flexible catheter with a bulb at-
tached to its distal end. The catheter is
inserted through the tracheal tube such
that the bulb protrudes from the distal
end. A glow in the neck is observed as
the tube is advanced. In a randomized
crossover trial of blind versus light-
guided intubation, the success rate was
higher (100% versus 91%) and the du-
ration of intubation shorter (31 versus
43 seconds) with the light-guided tech-
nique (159).
Retrograde intubation is another
method for securing the airway in cer-
tain situations. This technique requires
retrograde placement of a guidewire or
catheter via the cricothyroid membrane
into the trachea and between the cords
into the oropharynx (11). An orally or
nasally placed endotracheal tube is
then threaded over the guidewire and
into the trachea.
CONTINGENCY PLANS FOR
FAILED INTUBATION
Preoxygenation is of utmost impor-
tance because it provides a margin of
safety should contingency plans be-
come necessary. Only a few minutes of
critical oxygen deprivation are neces-
sary to permanently injure the brain.
Simple techniques such as clearing
the upper airway of any possible for-
eign-body obstruction should be done
first. Adjustment of head position or
removal/adjustment of cricoid pres-
sure may be all that is required to allow
intubation. Backward pressure over
the laryngeal cartilage may help im-
prove the view at laryngoscopy. Use of

TABLE 14. Suggested drugs for rapid-sequence intubation according to clinical setting.
Clinical Setting Induction Drug Neuromuscular Relaxant Adjunct Drugs
Cardiac or traumatic None None None
arrest, GCS 3
Shock, SBP ⬍80 mm Hg None Succinylcholine or Midazolam 1–2 mg, fentanyl 0.5–1.0
rocuronium ␮g/kg
Hypotension, SBP 80 –100 Etomidate 0.1– 0.2 mg/kg Rocuronium or Fentanyl 1.0 ␮g/kg
mm Hg, head injury succinylcholine
Hypotension SBP 80 –100 Ketamine 1 mg/kg Rocuronium or
mm Hg, cardiac succinylcholine
tamponade
Hypotension, SBP 80 –100 Etomidate 0.1– 0.2 mg/kg Rocuronium or Fentanyl 1.0 ␮g/kg, esmolol 10 mg
mm Hg, coronary succinylcholine (titrated)
artery disease
Normotension, head Etomidate 0.3 mg/kg or Rocuronium or Fentanyl 2.0 –3.0 ␮g/kg
injury thiopental 2–3 mg/kg succinylcholine
Normotension, coronary Etomidate 0.3 mg/kg Rocuronium or Fentanyl 2.0 – 4.0 ␮g/kg, esmolol
artery disease succinylcholine 10 –20 mg titrated
Hypertensive, head injury Etomidate 0.3 mg/kg or Rocuronium or Fentanyl 2.0 – 4.0 ␮g/kg
thiopental 3– 4 mg/kg succinylcholine
Hypertension, coronary Etomidate 0.3 mg/kg Rocuronium or Fentanyl 3.0 –5.0 ␮g/kg, esmolol
artery disease succinylcholine 10 –20 mg titrated or labetalol
7.5–10 mg titrated
Asthma Ketamine Rocuronium or Fentanyl, lidocaine
succinylcholine
Modified from Tryfus SJ, Abrams KJ, Grande CM. Airway management in neurological injuries. In: Abrams KJ, Grande CM, eds. Trauma Anesthesia and
Critical Care of Neurological Injury. Armonk, NY: Futura Publishing; 1997:121–151.
GCS, Glasgow Coma Scale score; BP, blood pressure; succinylcholine dose: 1.0 –1.5 mg/kg; rocuronium dose: 1.0 mg/kg. When using rocuronium and
thiopental in the same intravenous line, ensure that thiopental is flushed in before giving rocuronium to avoid precipitation. Lidocaine 50 –100 mg may
be used to blunt injection site pain from etomidate.

Clinical Pulmonary Medicine • Volume 8, Number 3 • May 2001 159

 TABLE 15. Management of selected complications during and after rapid-sequence intubation.
Complication Diagnosis Treatment
Manual ventilation device Difficult to manually ventilate Replace manual ventilation device
malfunction
Endobronchial intubation Difficult to manually ventilate, decreased Withdraw tube to mid trachea
or absent breath sounds unilaterally
Endotracheal tube Difficult to manually ventilate Pass 14F or 18F suction catheter; if still blocked,
blockage/kink replace tube
Tension pneumothorax Difficult to manually ventilate, decreased Needle thoracostomy/chest drain
or absent breath sounds unilaterally
with hyperresonance, hypotension
Increased pulmonary Difficult to manually ventilate, wheezing Smaller tidal volume, more rapid inspiration,
resistance (COPD, increased expiratory time, bronchodilators
asthma, bronchospasm)
Enlarged abdominal Difficult to manually ventilate Reverse Trendelenberg position
cavity (morbid obesity,
term pregnancy)
Decreased venous return Hypotension Fluid bolus, treat other causes of hypotension
(e.g., spinal shock, anaphylaxis), treat causes of
increased airway resistance
Myocardial depression Hypotension Fluid bolus, inotropes
(induction drugs,
cardiogenic shock)
Cardiac arrhythmias from Bradycardia, asystole, massive Atropine for bradycardia or asystole, then ACLS;
succinylcholine hyperkalemia (ventricular fibrillation) calcium for hyperkalemia, then ACLS
Modified from Smith CE, Walls RM, Lockey D, et al. Advanced airway management and use of anesthetic drugs. In: Grande CM, Soreide E, eds. New
York, NY: Marcel Dekker Inc; 2001:203–253.
COPD, chronic obstructive pulmonary disease; ACLS, advanced cardiac life support.

a stylet, bougie, or special laryngo- head and neck should be repositioned

scope blade is extremely helpful. to permit optimal bag-mask ventila-
If oxygenation cannot be maintained tion. A tight seal should be obtained
and the trachea cannot be intubated, an with the mask. It is extremely impor-
oral and/or nasal airway should be tant to appreciate that after every force-
inserted and the patient’s lungs venti-
lated with 100% oxygen using a two-
person technique. Extra help, if avail-
able, should be called for. The patient’s

FIGURE 8. The WuScope is composed of a

FIGURE 6. The view at laryngoscopy can
often be improved by exerting backward,
upward, and slightly rightward pressure
on the thyroid cartilage. The components of
this maneuver can be remembered by the
acronym BURP. The arrows indicate direc-
tion of pressure application. From Knill
RL. Difficult laryngoscopy made easy with
a “BURP.” Can J Anaesth. 1993;40:279 –
282. With permission.
FIGURE 7. The gum elastic bougie is a
60-cm-long tracheal tube introducer com-
posed of a braided polyester base with an
outer resin coating. The bougie has an ex-
ternal diameter of 5 mm and can accommo-
date tracheal tubes with an inner diameter
ⱖ6 mm. There is a 35-degree angle 2.5 cm
from the distal end.
handle, a tubular rigid blade, and a flexible
fiberscope. The blade portion forms a tubu-
lar exoskeleton that provides a built-in pas-
sageway through which the tracheal tube
can be advanced through the glottic open-
ing without the need for an intubating
stylet or head extension. Note the anatom-
ically shaped blades that match the pharyn-
geal contour of the oral airway. Twenty
millimeters of mouth opening is necessary
to insert and manipulate the blades.

160 Smith • Rapid-Sequence Intubation in Adults

ful intubation attempt, the amount of
airway edema and bleeding can in-
crease, leading to a progressive de-
creased ability to successfully bag-
mask ventilate and change in situation
from cannot intubate to cannot venti-
late.
Using the two-person bag-mask ven-
tilation technique, the most experi-
enced operator applies the mask to the
face and positions the upper airway
using a bilateral jaw thrust and chin lift
maneuver while a second individual
squeezes the bag to provide ventila-
tion. Cricoid pressure should be con-
tinuously maintained unless it inter-
feres with ventilation.
The LMA can provide a rapid clear
airway after failed RSI (11). It is com-
paratively easy to use and has a low
incidence of adverse reactions (160).
The LMA can also provide temporary
airway support as an alternative to
face-mask ventilation. Its use is clearly
established in the American Society of
Anesthesiologists’ difficult airway al-
gorithm and the European Resuscita-
tion Council guidelines as an alterna-
tive to intubation (161,162).
Advantages of the LMA include in-
creased speed and ease of placement
and a satisfactory airway in terms of
oxygen saturation (Table 16) (163). A
prospective study in Australia showed
that paramedics have high success
rates for LMA insertion during prehos-
pital emergency care (164). Cricoid
pressure may need to be briefly re-
leased to allow placement of the LMA
(39).
The double-lumen Combitube com-
bines the function of a tracheal tube
and an esophageal obturator airway
(165). The esophageal lumen has a
blocked distal end and perforations at
the pharyngeal level. The tracheal lu-
men has a distal open end. Proximal to
FIGURE 9. (A) Heine flexible-tip version of the McCoy laryngoscope blade. (B) Hinged-
blade tip is activated by depressing a lever attached to the blade. The hinged blade permits
the epiglottis to be lifted without requiring excessive force.
Clinical Pulmonary Medicine • Volume 8, Number 3 • May 2001
TABLE 16. Equipment for failed intubation: laryngeal mask airway (LMA).
Advantages of LMA
Relatively easy to insert when direct
laryngoscopy has been difficult or
impossible
Does not require “sniffing” position or
laryngoscopy for insertion
More reliable airway than face mask
Easier to learn compared with tracheal
intubation with high skills retention
Multiple sizes: pediatric to adult
No risk of endobronchial or
esophageal intubation
Can be used as a conduit for tracheal
intubation with flexible fiberoptic
bronchoscope
May protect against aspiration of
upper airway material
Modified from Smith CE, Walls RM, Lockey D, et al. Advanced airway management and use of
anesthetic drugs. In: Grande CM, Soreide E, eds. Prehospital Trauma Care. New York, NY: Marcel
Dekker Inc; 2001:203–253.
the perforations, an oropharyngeal bal-
loon is used to seal the oral and nasal
cavity (85 to 100 mL of air). At the
distal end, a conventional cuff (5 to 15
mL of air) seals either the esophagus
(esophageal position) or trachea (tra-
cheal position).
The size 41F is for patients ⱖ5.5 feet
tall and the size SA 37F is for patients
between 4 and 6 feet tall. With blind
insertion, there is a high probability of
esophageal insertion, and ventilation is
performed through the pharyngeal
perforations.
The success rate of insertion and
ventilation was higher with the Com-
bitube than with the LMA in a random-
ized prehospital comparative study of
Disadvantages of LMA
Supraglottic device; does not
protect against risk of aspiration
of gastric contents
May require release of cricoid
pressure for insertion
Requires absent glossopharyngeal
reflexes
Leak with positive pressure
ventilation, especially if
decreased pulmonary
compliance
Can be dislodged or kinked
Case reports of epiglottic swelling
Cannot suction trachea
470 cases of cardiac arrest (166). Simi-
larly, the Combitube was more suc-
cessful with respect to insertion and
adequacy of ventilation when com-
pared with the LMA in a study of
12,020 cases of nontraumatic cardiac
arrest in Japan (167). The Combitube
was used successfully in 10 patients
after failed RSI and may be particularly
useful in patients with maxillofacial
trauma as an alternative to cricothy-
rotomy in difficult airway situations
(168).
Indications for the Combitube in-
clude emergency airway control in pa-
tients with difficult anatomy, difficult
circumstances with respect to space
and illumination, and trauma patients
with massive oral bleeding or regurgi-
tation (165). Advantages of the Combi-
tube include noninvasive compared
with surgical airway, blind insertion
possible, neck movement not required,
and functions whether in the esopha-
geal or tracheal position (Table 17)
(165). Complications include esopha-
geal perforation and death, especially
associated with overfilling of the distal
balloon in the esophageal position
(169).
Finally, a surgical airway may be re-
quired with transtracheal jet ventila-
tion (TTJV) or cricothyrotomy. Tran-
161

TABLE 17. Equipment for failed intubation: Combitube.
Advantages of Combitube
Easy to insert blindly
May protect against aspiration
of gastric contents and upper
airway material
Does not require head and neck
movement
Allows for tracheal suctioning
(tracheal position)
Allows for stomach
decompression (esophageal
position)
Modified from Smith CE, Walls RM, Lockey D, et al. Advanced airway management and use of
anesthetic drugs. In: Grande CM, Soreide E, eds. Prehospital Trauma Care. New York, NY: Marcel
Dekker Inc; 2001:203–253.
stracheal jet insufflation can be
provided with a 14-gauge catheter in-
serted through the cricothyroid mem-
brane or through the tracheal wall and
attached directly to a Sanders Injector
or the gas outlet of an appropriate an-
esthesia machine. By intermittently
pressing on the injector (50 psi pres-
sure) or oxygen flush, a Venturi effect
is created that entrains air together
with oxygen flow to produce lung in-
flation (TTJV) (170). Complications of
this technique usually result from pul-
monary barotrauma to the lung and/or
obstruction to gas outflow through the
larynx (170). This technique is only a
temporary alternative until a more per-
manent cricothyroidotomy or tracheos-
tomy is performed. Surgical cricothy-
roidotomy is at the end of most
difficult intubation protocols. The most
common technique for cricothyroid-
otomy is direct incision of the cricothy-
roid membrane via a horizontal skin
incision (171).
The prepackaged cricothyroidotomy
kits available contain all the necessary
equipment and may save time and con-
fusion during resuscitation, but the
user must become familiar with a par-
ticular kit before the emergency to
avoid misuse and loss of precious time.
Compared with a tracheostomy, crico-
thyroidotomy is less time-consuming,
162
Disadvantages of Combitube
Supraglottic device (esophageal position)
May require release of cricoid pressure
for insertion
Requires absent glossopharyngeal reflexes
Case reports of esophageal and piriform
sinus perforation and massive
subcutaneous emphysema
Leak with positive pressure ventilation,
especially if decreased pulmonary
compliance
May require direct laryngoscopy to
facilitate insertion
Cannot suction trachea (esophageal
position)
Usually needs to be removed before
tracheal intubation
easier to perform, associated with
fewer complications, and more likely
to result in a dependable airway. It
may later be converted to a tracheos-
tomy under more controlled condi-
tions.
SUMMARY
RSI is an extremely useful technique
to intubate the trachea and minimize
the risk of pulmonary aspiration. How-
ever, complications resulting from RSI
can and will arise, especially if the tech-
nique is used incorrectly or by un-
skilled laryngoscopists. Performing the
sequence of events correctly is just as
important (if not more important) than
the rapidity of the intubation. First and
foremost, the patient must be assessed
and the airway must be examined. All
necessary equipment, 100% oxygen,
monitors, drugs, and assistance must
be available, including specific contin-
gency plans for failed intubation (e.g.,
LMA, Combitube, two-person bag-
mask ventilation, cricothyrotomy) and
management of complications arising
from RSI (e.g., hypotension, tension
pneumothorax).
Use of induction agents, neuromus-
cular relaxants, adjuvant drugs, a hock-
ey-stick-shaped stylet, gum elastic bou-
gie, and depression of the thyroid
cartilage can all enhance the ability to
safely intubate the trachea with mini-
mal stimulation of airway reflexes and
low incidence of cardiovascular and
other side effects. Special laryngo-
scopes such as the Bullard, WuScope,
and McCoy and intubating aids such as
rigid stylets, gum elastic bougie, and
lighted stylets are invaluable.
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