critical care review

Airway Management of the Critically Ill

Patient*
Rapid-Sequence Intubation
Stuart F. Reynolds, MD; and John Heffner, MD, FCCP

Advances in emergency airway management have allowed intensivists to use intubation tech-
niques that were once the province of anesthesiology and were confined to the operating room.
Appropriate rapid-sequence intubation (RSI) with the use of neuromuscular blocking agents,
induction drugs, and adjunctive medications in a standardized approach improves clinical
outcomes for select patients who require intubation. However, many physicians who work in the
ICU have insufficient experience with these techniques to adopt them for routine use. The
purpose of this article is to review airway management in the critically ill adult with an emphasis
on airway assessment, algorithmic approaches, and RSI. (CHEST 2005; 127:1397–1412)

Key words: airway management; ICU; induction agents; intensivist; intubation; neuromuscular blocking agents;
rapid-sequence intubation; respiratory failure

Abbreviations: NMBA ⫽ neuromuscular blocking agent; RSI ⫽ rapid-sequence intubation; V̇o2 ⫽ oxygen uptake

T hepatients
ability to place a secure airway in a variety of
and clinical circumstances represents an
vascular disease that may further increase the risk for
myocardial or cerebral ischemia when intubation
obligatory skill for critical care physicians. In the attempts are prolonged.2
ICU, these skills are regularly tested by the suscep- Unfortunately, multiple factors complicate rapid
tibility of critically ill patients to hypoxic injury when stabilization of the airway for critically ill patients in
emergency intubation is required. These patients the ICU. Patients who require emergency intubation
typically have varying degrees of acute hypoxemia, frequently become combative during intubation at-
acidosis, and hemodynamic instability when intuba- tempts. Conditions that complicate assisted ventila-
tion is required, and tolerate poorly any delays in tion and airway intubation, such as supraglottic
establishing an airway.1 Associated conditions, such edema, may go undetected before airway placement
as intracranial hypertension, myocardial ischemia, attempts. Also, critical care physicians cannot always
upper airway bleeding, or emesis can be aggravated count on having the most highly skilled members of
by the intubation attempt itself. And many critically the nursing and respiratory therapy staff on duty to
ill patients, especially elderly patients, have a high assist with difficult intubations.
frequency of comorbid conditions and underlying All of these factors warrant the standardization of
the approaches used for emergency intubation in the
*From the Medical-Surgical Intensive Care Unit (Dr. Reynolds), ICU to ensure proper airway placement. Emergency
University Health Network and Mount Sinai Hospital, Toronto, medicine physicians have adopted algorithmic ap-
ON, Canada; and the Division of Pulmonary and Critical Care
Medicine, Allergy, and Clinical Immunology (Dr. Heffner), proaches for airway assessment and for rapid-
Medical University of South Carolina, Charleston, SC. sequence intubation (RSI) as the primary approach
Manuscript received April 14, 2004; revision accepted August 31, for emergency airway management.3,4 RSI is the
2004.
Reproduction of this article is prohibited without written permis- nearly simultaneous administration of a potent in-
sion from the American College of Chest Physicians (e-mail: duction agent with a paralyzing dose of a neuromus-
permissions@chestnet.org). cular blocking agent (NMBA). When applied by
Correspondence to: John Heffner, MD, FCCP, Medical Univer-
sity of South Carolina, 169 Ashley Ave, PO Box 250332, Charles- skilled operators for appropriately selected patients,
ton, SC 29425; e-mail: heffnerj@musc.edu RSI increases the success rate of intubation to 98%

www.chestjournal.org CHEST / 127 / 4 / APRIL, 2005 1397

while reducing complications.4 –15 Moreover, adjunc- within 30 min of emergency intubation, and as many
tive medications incorporated into the RSI algorithm as 8% of intubation attempts result in an esophageal
reduce the physiologic pressor response to endotra- placement. Li and coworkers7 have demonstrated
cheal intubation, which can induce cardiovascular that complications occur in up to 78% of patients
complications. The present review outlines these requiring emergency intubation. The incidence of
standardized approaches for airway assessment and esophageal intubation and aspiration ranged from 8
RSI with the intent of widening the use of these to 18%, and 4 to15%, respectively.1,7 Identification
techniques in the ICU setting. of the difficult airway before initiating intubation
attempts, therefore, has heightened importance in
the ICU.
Airway Assessment Examination of the airway to predict difficulties
with face mask ventilation and intubation is an
The American Society of Anesthesiology defines a essential component of the preoperative assessment
difficult airway by the existence of clinical factors of patients who are scheduled for elective surgery.
that complicate either ventilation administered by Multiple approaches exist to identify patients with a
face mask or intubation performed by experienced difficult airway. Unfortunately, the utility of these
and skilled clinicians. Difficult ventilation has been airway assessment methods has not been adequately
defined as the inability of a trained anesthetist to evaluated in critically ill patients who undergo urgent
maintain the oxygen saturation ⬎ 90% using a face intubation. Moreover, a recent retrospective analysis
mask for ventilation and 100% inspired oxygen, by Levitan and coworkers18 has indicated that per-
provided that the preventilation oxygen saturation forming a thorough airway assessment of a critically
level was within the normal range.16 Difficult intu- ill patient in the emergency department is often not
bation has been defined by the need for more than feasible in 70% of patients. Nevertheless, intensivists
three intubation attempts or attempts at intubation who are skilled in intubation should have an under-
that last ⬎ 10 min.16 This latter definition provides a standing of these techniques to allow their applica-
margin of safety for preoxygenated patients who are tion when it is practical to do so.
undergoing elective intubation in the operating
room. Such patients in stable circumstances can
usually tolerate 10 min of attempted intubation Assessment for Difficult Ventilation
without adverse sequelae. Critically ill patients with
preexisting hypoxia and poor cardiopulmonary re- Both anatomic and functional factors can interfere
serve, however, may experience adverse events after with the use of a face mask for ventilation. Anatomic
shorter periods of lack of response to ventilation or factors include abnormalities of the face, upper
intubation.1,2,17 Schwartz and coworkers1 reported airway, lower airway, and thoracoabdominal compli-
that 3% of hospitalized critically ill patients die ance (Table 1). Obesity represents an important

Table 1—Anatomic Factors Associated With Difficult Ventilation*

Anatomic Location Airway Issue Intervention

Face Facial wasting; facial hair; Patient positioning: sniffing position, and/or jaw thrust; ensure proper fit
edentulous snoring history of mask to face; variety of different mask sizes; oropharyngeal and
nasopharyngeal airways; team ventilation, with one person “bagging”
while the other person ensures a proper seal; leave the dentures in
while ventilating the patient
Upper airway Abscess; hematoma; Assist ventilation and avoid neuromuscular paralysis; awake intubation,
neoplasm; epiglottitis possible fiberoptic with double set up for cricothyrotomy; call for help
if an upper airway obstruction is suspected
Lower airway Reactive airways Preinduction administration of bronchodilators, nitrates, and diuretics
Airspace disease PEEP valve for oxygenation in pulmonary edema, ARDS, and pneumonia;
Pneumonia decompress a pneumothorax if you are going to apply positive pressure
ARDS ventilation
Pulmonary edema
Hemo/pneumothorax
Thorax-abdomen Ascites; obesity; Use of a bag-valve-mask with a PEEP valve may help oxygenation and
hemoperitoneum; ventilation
abdominal compartment
syndrome
*PEEP ⫽ positive end-expiratory pressure.

1398 Critical Care Review

anatomic barrier to successful face-mask ventila- ability to visualize posterior pharyngeal structures
tion.19 Obese patients experience an increased risk of (Fig 1). The Mallampati class is devised by having
arterial oxygen desaturation due to difficulties with patients sit up, open their mouth, and pose in the
face mask ventilation and intubation because of “sniffing position” (ie, neck flexed with atlantoaxial
redundant oral tissue, decreased respiratory system extension) with the tongue voluntarily protruded
compliance due to chest and diaphragmatic restric- maximally while the physician observes posterior
tion, and cephalomegaly, which interferes with pharyngeal structures. A tongue blade is not used. A
proper face-mask placement.20 Mallampati class of I or II predicts a relatively easy
Altered mental status with loss of airway tone is laryngoscopy. A Mallampati class ⬎ II indicates an
the most common functional hindrance to assisted increased probability of a difficult intubation and the
ventilation.21 Critical illness and medications com- need for specialized intubation techniques.
monly used in the ICU, such as sedatives, NMBAs,
The Mallampati system has an application in the
and opioids, produce increased upper airway resis-
ICU, however, for the evaluation of mentally alert
tance by relaxing the muscles of the soft palate.22,23
patients who require elective intubation for proce-
Because the soft palate rather than the tongue is the
site of obstruction, ventilation is assisted by a jaw dures. Critically ill patients with altered mental
thrust or head tilt, the placement of either a naso- status or acute respiratory failure are unlikely to
pharyngeal or oropharyngeal airway, and the appli- cooperate with the procedure. In approaching such
cation of positive-pressure assisted ventilation. Con- patients, the evaluation of the oropharyngeal cavity
versely, inadequate sedation, saliva levels, and with a tongue blade or laryngoscope allows the
oropharyngeal instrumentation can precipitate laryn- intensivist who is familiar with the Mallampati sys-
gospasm, which can result in an obstructed airway. tem to assess the patient to some degree for a
This involuntary spasm of the laryngeal musculature difficult intubation and also provides an opportunity
may be ablated with positive-pressure ventilation, to detect any obvious signs of upper airway obstruc-
suctioning of secretions, cessation of airway manip- tion.26
ulation, and jaw thrust. Severe instances may require Other factors that predict a difficult intubation
neuromuscular blockade. include a mouth opening ⬍ 3 cm (ie, two fingertips),
a cervical range of motion of ⬍ 35° of atlantooccipi-
tal extension, a thyromental distance of ⬍ 7 cm (ie,
Assessment for Difficult Intubation three finger breadths), large incisor length, a short,
thick neck, poor mandibular translation, and a nar-
Multiple methods exist to identify patients who are row palate (ie, three finger breadths).27–31 Models
at risk for difficult intubations in the operating room. developed by multivariate analysis have incorporated
Unfortunately, no studies have assessed their utility multiple clinical factors to derive highly accurate
for patients in the ICU. predictive models (sensitivity, 86.8%; specificity,
The Mallampati classification system,24 as modi- 96.0%) for identifying difficult intubations among
fied by Samsoon and Young,25 is a widely utilized patients who are undergoing elective intubations in
approach for evaluating patients in the preoperative the operating room.32 Because the incidences of
setting. This system predicts the degree of antici- both difficult laryngoscopy (1.5 to 8.0%) and failed
pated difficulty with laryngoscopy on the basis of the intubation (0.1 to 0.3%) are low in the operating

Figure 1. Mallampati classification for grading airways from the least difficult airway (I) to the most
difficult airway (IV). Class I ⫽ visualization of the soft palate, fauces, uvula, and anterior and posterior
pillars; class II ⫽ visualization of the soft palate, fauces, and uvula; class III ⫽ visualization of the soft
palate and the base of the uvula; and class IV ⫽ soft palate is not visible at all.

www.chestjournal.org CHEST / 127 / 4 / APRIL, 2005 1399

room with expert anesthesiologists working with iologic stresses after the placement of an airway may
patients from the healthy population, these models unmask relative hypovolemia and/or vasodilation,
have a high negative predictive value (99.7%) but a which result in postintubation hypotension.40 Endo-
low positive predictive value (30.7%).32–34 Their tracheal intubation also can provoke bronchospasm
routine use in the operating room, therefore, has and coughing that may aggravate underlying condi-
questionable cost-effectiveness. Although the inci- tions, such as asthma, intraocular hypertension, and
dence of difficult intubations is higher in the ICU, intracranial hypertension. Patients who are at risk for
these multivariate predictive models have not been adverse events from airway manipulation benefit
tested in that setting. In the emergency department, from the use of preinduction drugs, which include
nearly 70% of patients undergoing RSI have either opioids, lidocaine, ␤-adrenergic antagonists, and
altered mental status or cervical spine collars in place non-depolarizing neuromuscular blockers (Table 2).
that prevent the assessment of these predictive Opioids have a long history of use in anesthesia
factors.18 Consequently, no data support the value of because of their analgesic and sedative effects. Fen-
these predictive models for routine use of RSI in the tanyl is commonly used because of its rapid onset of
ICU to identify patients who will experience a action and short duration of action. Fentanyl blunts
difficult or failed intubation. the hypertensive response to intubation (40% inci-
Despite the absence of validation studies to dem- dence of hypertensive response compared with 80%
onstrate the utility of airway assessment techniques in control subjects),41 although it has only marginal
to identify patients who will experience difficult effects on attenuating tachycardia.41,42 Derivatives of
intubations in the ICU, a quick examination of the fentanyl, sufentanil and alfentanil, are more effective
patient for functional and anatomic factors has been than fentanyl at blunting both the tachycardic and
shown to be predictive in the operating room setting hypertensive responses to intubation.42– 45 Fentanyl
and can assist preintubation planning. and its derivatives can occasionally cause rigidity of
the chest wall. This idiosyncratic reaction appears to
occur more commonly with higher doses and rapid
Advanced Airway Pharmacology injections. Studies in rats46 and case reports in
adults47,48 have suggested that opioid-induced chest
Advanced airway management requires the selec-
wall rigidity may be reversed by treatment with IV
tion of appropriate drugs for a particular clinical
naloxone, although some patients in our experience
situation. Proper drug selection facilitates laryngos-
may require neuromuscular blockade.
copy, improves the likelihood of successful intuba-
Caution is advised when using opioids in patients
tion, attenuates the physiologic response to intuba-
who are in severe shock states. Opioids can block the
tion, and reduces the risk of aspiration and other
sympathetic compensatory response to hypotension,
complications of intubation by a factor of 50 to
resulting in cardiovascular collapse.
70%.35–38 Depending on the clinical circumstances,
Lidocaine, a class 1B antiarrhythmic drug, has
the intensivist may utilize a combination of prein-
been used to diminish the hypertensive response, to
duction agents, an induction agent, and a paralytic
reduce airway reactivity, to prevent intracranial hy-
agent.
pertension, and to decrease the incidence of dysr-
rhythmias during intubation.49 –51 Demonstrated ef-
Preinduction Drugs
fectiveness for these end points, however, has varied
Stimulation of the airway with a laryngoscope and among reports,50,52,53 and no evidence has clearly
endotracheal tube presents an extremely noxious established that lidocaine improves outcomes in
stimulus,39 which is associated with an intense sym- terms of a lower incidence of myocardial infarction
pathetic discharge resulting in hypertension and or stroke. North American physicians use lidocaine
tachycardia (called the pressor response). The phys- more commonly as a preinduction agent for patients
iologic consequences of this pressor response are who are at risk of elevated intracranial pressure
well-tolerated by healthy persons undergoing elec- compared with physicians in Europe.52 To be most
tive intubation. A hypertensive response, however, effective, lidocaine should be administered 3 min
may induce myocardial and cerebrovascular injury in prior to intubation at a dose of 1.5 mg/kg.
critically ill patients with limited reserves for ade- Esmolol is a rapid-onset, short-acting, cardioselec-
quate tissue oxygenation.2 Moreover, critically ill tive ␤-adrenergic receptor-site blocker that effec-
patients who require emergent intubation experi- tively mitigates the tachycardic response to intuba-
ence hypoxia, hypercarbia, and acidosis, which in- tion with an inconsistent effect on the hypertensive
duce an extreme sympathetic outflow that is associ- response.41,42,54 –56 However, most studies,41,54,56 but
ated with tachycardia, labile BP, and an increased not all,53 have indicated that esmolol is more effec-
myocardial contractility.40 Attenuation of these phys- tive than lidocaine or fentanyl in reducing the pres-

1400 Critical Care Review

 sor response. The combined use of esmolol (2

Avoid doses ⬎ 0.06 mg/kg because a paralytic effect

bolus injected; bradycardia with large bolus doses
mg/kg) and fentanyl (2 ␮g/kg) has a synergistic effect

Primary preinduction agent that provides sedation and Hypotension; masseter and chest wall rigidity if
for reducing both the tachycardia and hypertension

Bradycardia; hypotension; increased airway

associated with tracheal intubation and laryngeal
manipulation.35,41 Caution is needed with the use of
esmolol in trauma victims and other patients who are
Cautions

at risk for hypovolemia and may require a tachy-

cardic response to maintain BP.
Some protocols for RSI recommend the use of a
subparalytic preinduction dose of a non-depolarizing
neuromuscular blocking drug for patients with sus-

may occur.
Hypotension

pected raised intracranial or intraocular pressure (eg,

reactivity
those with acute traumatic brain injury) who will
receive succinylcholine during induction for intuba-
isolated head trauma in the emergency department tion.42,57 Succinylcholine can cause fasciculations
the following: coronary artery disease; hypertensive

Elevated intracranial/intraocular pressure; prevention that may promote transient intracranial hyperten-
analgesia in hemodynamically stable patients with

emergencies; arterial aneurysms and dissections;

Synergistic with fentanyl; most commonly used for

sion, hyperkalemia, and postintubation myalgia. A

neurosurgical patients with raised intracranial
As with fentanyl; asthma; COPD; often used in

pressures; limited but growing experience in

low “defasciculating dose” dose (ie, one tenth of the

intubation dose) of a non-depolarizing NMBA, such
as rocuronium, has been recommended58 – 60 to pre-
intracranial/intraocular hypertension

of succinylcholine-induced myalgia
Table 2—Preinduction Agents Used for RSI

vent fasciculations and a succinylcholine-induced

Indications

cerebrovascular accidents; and

rise in intracranial pressure. One systematic litera-

conjunction with fentanyl

ture review,57 however, found no evidence that

pretreatment with a defasciculating dose of compet-
itive neuromuscular blockers in patients with acute
brain injury is beneficial. The available studies were
limited by weak designs and small sample sizes, so a
positive effect has not yet been excluded. Level II
evidence exists that pretreatment before succinyl-
choline administration lowers intracranial pressure
in patients undergoing neurosurgery for brain tu-
⬍ 5–10 min
Duration

10–20 min

10–30 min

mors.57 It is not the practice of the authors, however,

Almost immediate 0.5–1 h

to use a subparalyzing dose of rocuronium or any

other non-depolarizing muscle relaxant as an adjunc-
tive premedication because of the limited evidence
for efficacy.
Onset

2–10 min

1–2 min
45–90 s

Induction Agents
Induction agents are used to facilitate intubation
2–3 min before
IV push over
2–3 ␮g/kg slow

by rapidly inducing unconsciousness. Familiarity

1.5 mg/kg IV
Dosage

intubation
2 mg/kg IV

with a range of induction drugs is important because

0.06 mg/kg
1–2 min

the specific clinical circumstance dictates the appro-

priate induction method (Table 3). Agents that are
indicated for patients with respiratory failure may be
contraindicated in other clinical settings. Intensivists
should, therefore, avoid using a single standardized
induction approach.
defasciculating dose

Etomidate is a nonbarbiturate hypnotic agent that

Drug

Rocuronium at a

is used for the rapid induction of anesthesia. This

imidazole derivative has a rapid onset of action and a
Lidocaine

short half-life. It predictably does not affect BP.

Fentanyl

Esmolol

Etomidate has cerebral-protective effects by reduc-

ing cerebral blood flow and cerebral oxygen uptake

www.chestjournal.org CHEST / 127 / 4 / APRIL, 2005 1401

 (V̇o2). It does not, however, attenuate the pressor

Bronchospasm; hypotension; poor availability

response that is related to intubation or provide

Inhibits cortisol synthesis; decreases focal

analgesia.

Head injury; ischemic heart disease;

because of controlled drug status
Adverse effects of etomidate include nausea, vom-
iting, myoclonic movements, lowering of the seizure

Hypotension; lecithin allergy

hypertensive emergencies
threshold in patients with known seizure disorders,
Cautions

and adrenal suppression.43,49,61– 63 Etomidate, even

after a single bolus dose, inhibits cortisol production
seizure threshold

in the adrenal gland at various enzymatic levels and

reduces adrenal responsiveness to exogenous adrenal

Tachycardia
corticotrophin hormone for up to12 h.49,64 Deleteri-
ous effects of etomidate-induced adrenal suppres-
sion have not been established after a single induc-
tion dose.
Because of its rapid onset, short half-life, and good
risk-benefit profile, etomidate has become the pri-
Normotensive; normovolemic before barbiturate

mary induction agent for emergency airway manage-

therapy for status epilepticus or control of

ment. It is especially useful for patients with hypo-

tension and multiple trauma because it does not alter
Isolated head injury; status epilepticus

systemic BP.
Multitrauma; existing hypotension

Propofol is a rapid-acting, lipid-soluble induction

Indications

drug that induces hypnosis in a single arm-brain

Table 3—Drugs Used for Induction*

intracranial hypertension

circulation time. The characteristics of propofol in-

clude a short half-life and duration of activity, anti-
Uncompensated shock

convulsive properties, and antiemetic effects. Propo-

fol reduces intracranial pressure by decreasing
Asthma/COPD

intracranial blood volume and decreasing cerebral

metabolism.65,66 These mechanisms may underlie
the improved outcomes with the use of propofol that
have been demonstrated in patients with traumatic
brain injury who are at risk of raised intracranial
pressure.42,63,67
At doses that induce deep sedation, propofol
3–10 min

5–30 min

5–15 min
Duration

3–5 min

causes apnea and produces profound relaxation of

2h

laryngeal musculature. This profound muscular re-

laxation effect allows propofol, when used in combi-
nation with a non-depolarizing NMBA (rocuronium)
or opioids (remifentanil or alfentanil) to produce
1–2 min

intubation conditions that are similar to those ob-

30–60 s

30–60 s
Onset

10 min
9–50 s

tained with succinylcholine.68 –71 However, we con-

tinue to favor its use with succinylcholine to ensure
adequate intubating conditions. Propofol facilitates
RSI, to a greater degree than etomidate, because it
provides a deeper plane of anesthesia, thereby atten-
Stable, 0.3 mg/kg IVP,

unstable, 0.5 mg/kg

unstable, 1.5 mg/kg

kg IVP; onset, 30 s
unstable, 0.15 mg/

Stable, 2 mg/kg IVP;

Stable, 3 mg/kg IVP;

uating any effects of incomplete muscle paralysis.38

IVP; onset, 30 s

IVP; onset, 30 s

The most important adverse effect of propofol is

0.2–0.4 mg IVP
Dosage

drug-induced hypotension, which occurs by reducing

2 mg/kg IVP

systemic vascular resistance and, possibly, by de-

pressing inotropy.63 Hypotension usually responds to
a rapid bolus of crystalloid fluids and can be pre-
vented by expanding intravascular volume before
*IVP ⫽ IV push.

giving propofol or by pretreating patients with

ephedrine.72 Some patients with allergies to soy or
Scopolamine
Thiopental
Etomidate

Ketamine

eggs may experience hypersensitivity reactions to

Drug

Propofol

propofol. Propofol has no analgesic properties.

For hemodynamically stable patients who have

1402 Critical Care Review

either a contraindication to succinylcholine or re- Barbituates cause allergic reactions in 2% of pa-
ceive non-depolarizing neuromuscular blockers for tients, and also induce laryngospasm, hypersaliva-
paralysis, propofol may be the induction agent of tion, and bronchospasm.63 Just as barbiturates are
choice. Many clinicians use propofol as an induction generally not used in the ICU for sedation purposes,
drug for patients with isolated head injury or status they are not used to the same extent for emergency
epilepticus. airway management. Sodium thiopental is rarely
Ketamine, a phencyclidine derivative, is a rapidly used in the ICU for emergency intubation, although
acting dissociative anesthetic agent that has potent it has applications for normotensive, normovolemic
amnestic, analgesic, and sympathomimetic qualities. patients who have status epilepticus or require intu-
Ketamine acts by causing a functional disorganiza- bation prior to entering barbiturate coma for the
tion of the neural pathways running between the control of intracranial hypertension.
cortex, thalamus, and limbic system.49 It does so by Scopolamine is a muscarinic anticholinergic agent
selectively inhibiting the cortex and thalamus while with a short half-life that has sedative and amnestic
stimulating the limbic system. Ketamine is also a effects, but no analgesic properties. It can cause
unique induction agent because it does not abate tachycardia but otherwise produces no hemody-
airway-protective reflexes or spontaneous ventila- namic consequences.74 Scopolamine induces less
tion.49 tachycardia, however, compared with other available
The central sympathomimetic effects of ketamine muscarinic agents (eg, atropine and glycopyrro-
can produce cardiac ischemia by increasing cardiac late).49 This hemodynamic profile makes scopol-
output and BP, thereby increasing myocardial V̇o2. amine a preferred induction agent for patients with
Patients can experience “emergence phenomena” as uncompensated shock when RSI is used. Adverse
they resurface from the dissociative state induced by effects include psychotic reactions in addition to
ketamine. This frightening event, characterized by tachycardia and occur related to the dose adminis-
hallucinations and extreme emotional distress, can tered.49 Scopolamine causes profound papillary dila-
be attenuated or prevented with benzodiazepine tion, complicating neurologic evaluations.
drugs. Because ketamine is a potent cerebral vaso-
dilator, intracranial hypertension is a contraindica-
tion for its use. Other side effects include salivation NMBAs
and bronchorrhea, both of which can be prevented
NMBAs are used to facilitate laryngoscopy and
with the administration of an anticholinergic agent
tracheal intubation by causing profound relaxation of
such as glycopyrrolate or scopolamine.
skeletal muscle. There are two classes of NMBAs,
The bronchodilator properties of ketamine make it
depolarizing and non-depolarizing (Table 4). Both
suitable for patients with bronchospasm due to status
classes act at the motor end plate. These drug classes
asthmaticus or COPD. No outcome studies exist,
differ in that depolarizing agents activate the acetyl-
however, to demonstrate improved outcomes in
choline receptor, whereas non-depolarizing agents
these clinical settings. The sympathomimetic effects
competitively inhibit the acetylcholine receptor.
of ketamine warrant avoiding its use in patients with
NMBAs have no direct effect on BP.
acute coronary syndromes, intracranial hypertension,
or raised intraocular pressure.
Depolarizing Agents: Succinylcholine
Sodium thiopental is a thiobarbiturate with a rapid
30-s onset of action and a short half-life. Its use for Succinylcholine, a depolarizing NMBA, is a dimer
RSI is limited because it is a controlled substance of acetylcholine molecules that causes muscular re-
and propofol has similar characteristics. Barbiturates laxation via activity at the motor end plate.74 Succi-
in general decrease cerebral V̇o2, cerebral blood nylcholine acts at the acetylcholine receptor in a
flow, and intracranial pressure. They are associated, biphasic manner. It first opens sodium channels and
however, with hypotension secondary to the inhibi- causes a brief depolarization of the cellular mem-
tion of CNS sympathetic outflow, which results in brane, noted clinically as muscular fasciculations.49 It
decreased myocardial contractility, systemic vascular then prevents acetylcholine-medicated synaptic
resistance, and central venous return.63,73 Hypovole- transmission by occupying the acetylcholine recep-
mia accentuates barbituate-induced hypotension. tor. Succinylcholine is enzymatically degraded by
Sodium thiopental, therefore, should not be used as plasma and hepatic pseudocholinesterases.76
an induction agent in patients who have hypovolemic Succinylcholine is the most commonly adminis-
or distributive shock. The central sympatholytic ef- tered muscle relaxant for RSI, owing to its rapidity of
fect induced by barbiturates has a positive effect in onset (30 to 60 s) and short duration (5 to 15 min).76
its blunting of the pressor response to intuba- Effective ventilation may return after 9 to 10 min.
tion.58,74,75 The effects of succinylcholine on potassium balance

www.chestjournal.org CHEST / 127 / 4 / APRIL, 2005 1403

 Table 4 —Neuromuscular Blocking Agents
Duration,
Drug Dosage Onset, s min Indications Cautions

Succinylcholine 1.5 mg/kg IV push 30–60 5–15 Use as default paralytic Contraindications: personal or family
agent unless there is history of malignant hyperthermia;
contraindication likely difficult intubation or mask
ventilation; known uncontrollable
hyperkalemia; myopathy; chronic
neuropathy/stroke; denervation
illness or injury after ⬎ 3 d; crush
injury after ⬎ 3 d; sepsis after ⬎ 7
d; severe burns after ⬎ 24 h
Caution: chronic renal insufficiency
Rocuronium High dose: 1 mg/kg IV push 45–60 45–70 When succinylcholine Predict difficult intubation and
is contraindicated ventilation; allergy to aminosteroid
neuromuscular blocking agents

and cardiac rhythm represent its major complica- myopathies with elevated serum creatine kinase val-
tions. It can also induce malignant hyperthermia.77 ues, sepsis after the seventh day, narrow-angle glau-
Most reports76,78,79 of deaths, secondary to succi- coma, cutaneous burns, penetrating eye injuries,
nylcholine-induced hyperkalemia, involve children hyperkalemia, and disorders of plasma pseudocho-
with previously undiagnosed myopathies who under- linesterase. Succinylcholine may be used safely
went surgery. Although deaths related to succinyl- within 24 h of experiencing acute burns,95–97 and
choline-induced hyperkalemia are rare, cardiac ar- within 3 days of experiencing acute denervation
rest has been reported.80 – 83 Three studies84 – 86 of syndromes and crush injuries.97–100 The drug should
adult patients have reported that the mean values of be used with caution in patients with preexisting
serum potassium levels for the study populations chronic renal insufficiency, although a literature
before and after an intubating dose of succinylcho- review101 has indicated that succinylcholine may be
line changed by as little as ⫺0.04 mmol/L to as much used safely in this setting in the absence of other risk
as 0.6 mmol/L. factors for drug-induced hyperkalemia. Such pa-
The hyperkalemic effect may be exaggerated in tients must be closely monitored for severe hyper-
patients with subacute or chronic denervation con- kalemia.
ditions (eg, congenital or acquired myopathies, cere- Succinylcholine-associated dysrrhythmias are me-
brovascular accidents, prolonged pharmacologic diated by postganglionic muscarinic receptors and
neuromuscular blockade, wound botulism, critical preganglionic sympathetic receptors. Bradydysr-
illness polyneuropathy, corticosteroid myopathies, rhythmias are most commonly observed, with rare
and muscle disuse atrophy), burns, intraabdominal reports of asystole and ventricular tachyarrhythmias.
infections, sepsis, and muscle crush injuries.81,83,87–91 Most instances occur in pediatric patients or in
The exaggerated hyperkalemic response is mediated adults after the use of multiple doses of succinylcho-
through the up-regulation of skeletal muscle nico- line.76,102,103 Dysrrhythmias may be prevented in
tinic acetylcholine receptors.88 Acute rhabdomyoly- adults by premedication with a vagolytic dose of
sis can produce hyperkalemia, which is aggravated by atropine (0.4 mg IV) prior to repeating a dose of
the effects of succinylcholine, through mechanisms succinylcholine.75,76
of drug-induced increases in muscle cell membrane Succinylcholine may cause an increase in intragas-
permeability.83,88,92 tric pressure, presumably because of drug-induced
A personal or family history of malignant hyper- muscular fasciculation. Aspiration usually does not
thermia represents an absolute contraindication to occur by way of this effect because of a coincident
succinylcholine therapy, which may trigger a hyper- increase in tone of the esophageal sphincter.104,105
thermic response. Patients who experience masseter Succinylcholine increases both intraocular and intra-
spasm on induction with either thiopental or fentanyl cranial pressure, but these effects are transient and
are at an increased risk of developing malignant clinically unimportant.106,107 Patients should receive
hyperthermia when treated with succinylcholine.93,94 succinylcholine only if adequate face-mask ventila-
Other contraindications that require special precau- tion can be achieved if intubation fails.
tions include denervation of muscles due to under- Because of the extensive risks associated with the
lying neuromuscular diseases or injury to the CNS, use of succinylcholine in critically ill patients, some

1404 Critical Care Review

intensivists have argued that its role in the ICU is such as neostigmine or edrophonium, and vagolytic
obsolete.108 We believe that its superiority to other doses of glycopyrolate or atropine. The only absolute
available neuromuscular blocking drugs (infra vida) contraindication to the use of rocuronium is allergy
warrant its use in patients without risk factors for to aminosteroid neuromuscular drugs. Extreme cau-
adverse events. Its use requires extensive education tion should be exercised in selecting appropriate
of critical care physicians to ensure their understand- patients for its use. Patients for whom intubation
ing of the contraindications for use of the drug. One appears likely to be difficult may experience hypoxia
survey study109 observed that there was a poor if face mask ventilation is unsuccessful during the
understanding among critical care physicians of the prolonged period of drug-induced paralysis (45 to 70
risks of succinylcholine for patients with critical min) before intubation can be achieved.
illness polyneuropathy.
Succinylcholine is given in a dose of 1.5 mg/kg for
intubation because a lower dose may induce relax- Airway Management in the ICU
ation of the central laryngeal muscles before periph-
eral musculature. This circumstance may promote In 199316 and again in 2003,111 the American
aspiration and complicate intubation by relaxing Society of Anesthesiologists task force on difficult
laryngeal muscles and promoting glottic incompe- airways published guidelines for the management of
tence, while leaving masseter muscle function in- difficult airways in the operating room. The applica-
tact.49 A recent study,110 however, suggests that tion of these structured approaches to airway man-
comparable intubation conditions for surgical pa- agement appears to have decreased closed claims
tients undergoing elective intubation can be costs in anesthesia.112 The guidelines are widely
achieved after 0.3, 0.5, or 1.0 mg/kg succinylcholine endorsed by anesthesiologists, with 86% stating that
when induced with propofol or fentanyl. These lower they use the algorithms in their clinical practice.113
doses allow a more rapid return of spontaneous These particular algorithms, however, have limited
respiration and airway reflexes.110 In the absence of applicability to the ICU because they rely on preop-
such data for critically ill patients who require urgent erative assessment and exercise the option of delay-
intubation, we continue to recommend the use of ing surgery in the operating room if it appears that
succinylcholine, 1.5 mg/kg, for RSI. intubation will be overly difficult.
Although not validated, algorithms reported by
Walls and coworkers114 provide a standardized ap-
Non-Depolarizing NMBAs
proach to emergency airway management. Such
Non-depolarizing NMBAs provide an alternative algorithmic approaches for emergent intubation that
to succinylcholine for RSI. Rocuronium, an aminos- appropriately select patients for RSI have demon-
teroid drug, has a short onset of action (1 to 2 min) strated improved outcomes in both emergency de-
and an intermediate duration of action (45 to 70 partment and field intubation settings.5–13,15 Emer-
min). gency medicine practitioners who utilize airway
A systematic review68 compared relative outcomes management protocols that incorporate RSI experi-
with the use of succinylcholine for intubation to ence airway failures with a need to progress to
those with the use of rocuronium. This study con- emergency cricothyrotomy in only 0.5% of intuba-
cluded that the use of succinylcholine produced tions.5,6 The National Emergency Airway Registry
superior intubation conditions compared to that of II,6 a data bank of 7,712 intubations, has demon-
rocuronium (0.6 mg/kg) when rigorous standards strated that RSI is the most common technique of
were used to define the term excellent conditions intubation with a success rate ⬎ 98.5%. These re-
(relative risk of poor conditions with rocuronium use, sults contrast with the 18% incidence of failed
0.87; 95% confidence interval, 0.81 to 0.94; intubation in the absence of RSI reported by Li and
n ⫽ 1,606). The two agents had similar efficacy when coworkers.7 This prospective study compared com-
less rigorous definitions were used to define ade- plications arising from intubation utilizing paralytic
quate intubation conditions. No differences were agents within an RSI protocol to intubations those
found, however, if propofol was used for induction, arising from intubations without the use of NMBAs.
or if the dose of rocuronium was 1.0 mg/kg. The use Esophageal intubations and airway trauma occurred
of this higher dose of rocuronium prolongs the with greater frequency in the group that did not
duration of paralysis. The success rate of intubation receive RSI (18% vs 3%, respectively, and 28% vs
was similar for both rocuronium and succinylcholine 0%, respectively).7
under all of the study conditions.68 The intubation algorithms modified from Walls
The effects of non-depolarizing blocking drugs can and coworkers114 (Figs 2–5) classify intubation at-
be reversed using acetylcholinesterase inhibitors, tempts into the following categories: (1) universal;

www.chestjournal.org CHEST / 127 / 4 / APRIL, 2005 1405

 intubation. First developed to facilitate intubation in
the operating room and to reduce the risks of
aspiration for patients with full stomachs, RSI has
been adopted by emergency physicians and is now
being used for intubating patients in the field.
Studies4 –15 have demonstrated increased intubation
success rates and decreased complications with air-
way protocols that utilize RSI compared with those
using traditional intubation techniques.
Several factors underlie the improved outcomes
with RSI. Preoxygenation reduces the need for
face-mask ventilation in preparation for intubation,
and thereby decreases the risks for gastric insuffla-
tion and the aspiration of stomach contents. The use
of a potent induction agent with a neuromuscular
blocking drug allows the airway to be rapidly con-
trolled, further reducing the risk of aspiration. The
use of adjunctive medications in appropriate clinical
settings can reduce the pressor response and other
physiologic consequences of laryngoscopy and tra-
cheal intubation. Table 5 presents an example of the
authors’ typical RSI protocol.
Not all critically ill patients are candidates for RSI,
however. The presence of severe acidosis, intravas-

Figure 2. Universal airway algorithm. BNTI ⫽ blind nasotra-

cheal intubation.

(2) crash; (3) difficult; and (4) failed. The universal

algorithm (Fig 2) is the beginning point for intuba-
tion for all patients. The initial assessment requires
the intensivist to determine whether the patient is
unresponsive or near death, or whether a difficult
airway appears likely. The former requires activation
of the crash airway algorithm (Fig 3), and the latter
activation of the difficult airway algorithm (Fig 4).
The absence of any of these conditions allows the
physician to initiate RSI.
Failure to intubate a patient with three or more
attempts directs the intensivist to the failed airway
algorithm (Fig 5). This algorithm calls for immediate
assistance in preparation for emergency criciothy-
roidotomy if measures to oxygenate or intubate the
patient have failed. Success with the use of these
algorithms requires the presence of personnel who
are skilled in the specialized techniques needed to
manage a difficult airway and failed intubation.
These algorithms can serve as a training curriculum
for preparing critical care physicians to manage
airways in the ICU.

RSI
As described above, RSI is a critical element in the Figure 3. Crash airway algorithm. See Fig 2 for abbreviations
establishment of a secure airway during emergency not used in text.

1406 Critical Care Review

 Preoxygenation, also termed alveolar denitrogena-
tion, is performed with the patient breathing 100%
oxygen through a nonrebreather mask for 5 min.
Mentally alert patients are asked to perform eight
deep breaths to total lung capacity. Alveolar denitro-
genation creates a reservoir of oxygen in the lung
that limits arterial desaturation during subsequent
intubation attempts. The use of positive-pressure
ventilation administered by face mask is reserved for
patients who cannot achieve adequate oxygenation
while breathing 100% oxygen by nonrebreather
mask.
Premedication entails the use of drugs to provide
sedation and analgesia, and to attenuate the physio-
logic response to laryngoscopy and intubation. Two
to three minutes before the patients undergoes

Figure 4. Difficult airway algorithm. BNTI ⫽ blind nasotra-

cheal intubation.

cular volume depletion, cardiac decompensation,

and severe lung injury may complicate the adminis-
tration of preinduction and induction agents, which
may result in vasodilation and hypotension. Acute
lung injury may prevent an adequate response to
preoxygenation efforts. Such patients require crash
intubation and usually tolerate intubation attempts
without extensive premedication because of the
presence of depressed consciousness.
The general sequence of RSI consists of the “six
P’s,” as follows: preparation, preoxygenation, pre-
medication, paralysis, passage of the endotracheal
tube, and postintubation care. Preparation begins
when the clinician identifies the need for intubation.
A period of 5 to 10 min before intubation allows for
the evaluation of the patient for signs of a difficult
airway, as described above, and for the preparation
of the equipment. Among the various mnemonics
that are used to assist preparation, the phrase “Y
BAG PEOPLE?” (Table 6) allows physicians to
recall the essential elements of the preparatory phase
and emphasizes the need to avoid positive-pressure Figure 5. Failed airway algorithm. See Fig 2 for abbreviations
face mask ventilation whenever possible. not used in text.

www.chestjournal.org CHEST / 127 / 4 / APRIL, 2005 1407

1408

Table 5—Schematized Example of an RSI

Time ⫺ 10 min Time ⫺ 5 min Time ⫺ 2 min Time 0 Time ⫹ 30–45 s Time ⫹ 45 s
(Prepare) (Preoxygenate) (Pretreat) (Paralysis) (Pass the Tube) (Postintubation Management)

Predict difficult intubation: stop if Provide 100% with Suspected intracranial Induction: Intubate Confirm placement after inflation
not RSI candidate nonrebreather mask or hypertension, myocardial 1. Etomidate Observe ETT pass between of cuff:
Hypotensive patient: BVM ischemia, or hypertensive (default vocal cords 1. Auscultate abdomen, then
1. Good vascular access emergency. Fentanyl with or induction agent) If problems with visualization hemithoraces for air entry
2. Vasopressors readily available without lidocaine (more or remember to “BURP” 2. Detect ETco2
We use as needed commonly we use fentanyl alone) 2. Propofol 1. Backwards color change or waveform
Phenylephrine 10 mg in or 2. Upward, and 3. Reassess oxygenation status
100 mL NS (100 ␮g/mL)— 3. Ketamine 3. Rightward 4. Once ETT placement
and give 1 mL aliquots prn or 4. Pressure on the thyroid confirmed, cease Sellick
Or 4. Scopalamine cartilage maneuver
Ephedrine, 5–10 mg 5. Secure tube
boluses as needed
Mnemonic “Y BAG PEOPLE” No PPV unless patient’s Spo2 Asthma lidocaine Sellick maneuver with Consider placement of OGt or
⬍ 90% administration of NG
If PPV required, then induction agent Post ETI, ABG analysis and CXR
provide cricoid pressure
(Sellick maneuver)
If patient is hypotensive, ensure It is not our practice to use Neuromuscular If patient Spo2 ⬍ 90% during As many of the drugs used in RSI
good vascular access, and have defasciculating doses of blockade: attempt, stop and provide have short half-life consider
available drugs rocuronium or other 1. Succinylcholine PPV and oxygenation until continued sedation with or
nondepolarizing NMBAs or Spo2 ⬎ 90% without paralysis
2. Rocuronium
*ABG ⫽ arterial blood gas; SCI ⫽ spinal cord injury; BVM ⫽ bag-valve-mask ventilation; CXR ⫽ chest radiograph; ETco2 ⫽ end-tidal CO2; ETI ⫽ endotracheal intubation; NG ⫽ nasogastric tube;
OG ⫽ orogastric tube; PPV ⫽ positive-pressure ventilation; SPo2 ⫽ pulse oximetry oxygen saturation; ETT ⫽ endotracheal tube.
Critical Care Review
 Table 6 —Preparation for Intubation Mnemonic level falls to ⬍ 90%, assisted ventilation is initiated
Mnemonic Description
with a bag-valve-mask device and cricoid pressure to
oxygenate and ventilate the patient before attempt-
Y Yankauer suction
ing laryngoscopy again. After successful tracheal
B Bag-valve-mask
A Access vein intubation and cuff inflation, the confirmation of
G Get your team, get help if predict a difficult airway intubation is required.
P Position patient (sniffing position if no The goal in the immediate postintubation period is
contraindications) and place on monitor
to confirm correct tracheal intubation, and the ade-
E Endotracheal tubes and check cuff with syringe
O Oxygen, oropharyngeal airway available quacy of oxygenation and ventilation. Epigastric
P Pharmacy: draw up adjunctive medications, auscultation followed by auscultation of both
induction agent, and neuromuscular blocker hemithoraces in the axillas assists in assessing for an
L Laryngoscope and blades: ensure a variety and that
esophageal or mainstem intubation. The rise and fall
they are working
E Evaluate for difficult airway: look for obstruction, of the chest and the maintenance or improvement of
assess thyromental distance ⬍ 3 finger breadths, oxygenation should be noted. The measurement of
interincisor distance ⬍ 2 finger breadths, neck end-tidal CO2 by either a colorimetric or waveform
immobilization
device has become a necessary step in confirming
tracheal intubation. Once satisfied that the endotra-
cheal tube is in the trachea, cricoid pressure may be
laryngoscopy, a combination of drugs individualized released. The cuff is then rechecked, and the endo-
to a patient’s needs and clinical circumstances is tracheal tube is secured to the patient. A postintu-
administered (Table 2). bation chest radiograph and arterial blood gas assess-
The induction and neuromuscular blocking drugs ment should be obtained. Many of the induction
are administered immediately after the patient agents and succinylcholine have a short duration of
achieves adequate preoxygenation and receives the action. Thus, sedation should be considered at this
preinduction medication. An assistant performs the point.
Sellick maneuver (ie, cricoid pressure) to prevent
passive aspiration and reduce gastric insufflation if
the patient is receiving positive-pressure ventilation Conclusion
by face mask. If the patient vomits, cricoid pressure
should be released and the patient should be log- Advanced airway management is an obligatory skill
rolled to allow dependent suctioning of the pharynx. for critical care physicians to acquire. The adoption
Although many emergency physicians use etomi- of algorithmic approaches and RSI by anesthesiolo-
date as their primary induction drug, other drugs gists and emergency medicine physicians has im-
have specific advantages in certain clinical settings proved the success rates for the emergency intuba-
(Table 3). The selection of a neuromuscular blocking tion of unstable patients and has decreased the
drug also depends on clinical circumstances, as number of complications related to airway control.3,4
previously described. Succinylcholine provides safe Although limited outcomes data exist for the use of
and effective neuromuscular blockade for most pa- these techniques in the ICU, similarities of patients
tients. Rocuronium may be a more appropriate and conditions with the emergency setting warrant
choice for patients if there are contraindications or the adoption of algorithmic approaches and RSI as
concerns about the use of succinylcholine. the standard mode of intubation for critically ill
Forty-five seconds to 1 min after induction and patients. RSI requires a thorough understanding of
paralysis, the adequacy of paralysis is assessed by the physiology of intubation, and of the various drugs
checking mandibular mobility. Resistance to motion used for induction and paralysis in addition to careful
indicates incomplete paralysis, which requires that patient selection. The standardization of intubation
the patient start to receive oxygen again, with reas- efforts with well-conceived algorithms requires a
sessment of relaxation taking place in 15 to 30 s. regimented approach that is similar to that employed
Once the patient is relaxed, laryngoscopy is per- for cardiopulmonary resuscitation. The training of
formed and the vocal cords visualized. Visualization critical care physicians requires greater attention to
of the vocal cords and the glottic opening may be teaching these advanced airway management skills,
improved by placing pressure on the thyroid carti- more collaboration between anesthesiologists and
lage in a backward, upward, and rightward direction critical care physicians to promote these skills,4 and
(the mnemonic “BURP” or backwards, upwards, careful monitoring for adverse events and outcomes
right, and pressure).8 If laryngoscopy is not immedi- to improve patient selection for the various intuba-
ately successful and the patient’s oxygen saturation tion approaches that are available.115

www.chestjournal.org CHEST / 127 / 4 / APRIL, 2005 1409

 References in emergency department intubated patients [abstract].
Acad Emerg Med 2003; 10:468
1 Schwartz DE, Matthay MA, Cohen NH. Death and other
19 Langeron O, Masso E, Huraux C, et al. Prediction of
complications of emergency airway management in critically
difficult mask ventilation. Anesthesiology 2000; 92:1229 –
ill adults: a prospective investigation of 297 tracheal intuba-
1236
tions. Anesthesiology 1995; 82:367–376
20 Juvin P, Lavaut E, Dupont H, et al. Difficult tracheal
2 Gajapathy M, Giuffrida JG, Stahl W, et al. Hemodynamic
intubation is more common in obese than in lean patients.
changes in critically ill patients during induction of anesthe-
Anesth Analg 2003; 97:595– 600
sia. Int Surg 1983; 68:101–105
21 Wilson WC, Benumof JL. Pathophysiology, evaluation, and
3 Butler KH, Clyne B. Management of the difficult airway:
treatment of the difficult airway. Anesth Clin N Am 1998;
alternative airway techniques and adjuncts. Emerg Med Clin
16:29 –75
North Am 2003; 21:259 –289
22 Mathru M, Esch O, Lang J, et al. Magnetic resonance
4 Kovacs G, Law JA, Ross J, et al. Acute airway management
imaging of the upper airway: effects of propofol anesthesia
in the emergency department by non-anesthesiologists. Can
and nasal continuous positive airway pressure in humans.
J Anaesth 2004; 51:174 –180
Anesthesiology 1996; 84:273–279
5 Sakles JC, Laurin EG, Rantapaa AA, et al. Airway manage-
23 Nandi PR, Charlesworth CH, Taylor SJ, et al. Effect of
ment in the emergency department: a one-year study of 610
general anaesthesia on the pharynx. Br J Anaesth 1991;
tracheal intubations. Ann Emerg Med 1998; 31:325–332
66:157–162
6 Bair AE, Filbin MR, Kulkarni RG, et al. The failed intuba-
24 Mallampati SR. Clinical sign to predict difficult tracheal
tion attempt in the emergency department: analysis of
intubation (hypothesis). Can Anaesth Soc J 1983; 30:316 –
prevalence, rescue techniques, and personnel. J Emerg Med
317
2002; 23:131–140
25 Samsoon GL, Young JR. Difficult tracheal intubation: a
7 Li J, Murphy-Lavoie H, Bugas C, et al. Complications of
retrospective study. Anaesthesia 1987; 42:487– 490
emergency intubation with and without paralysis. Am J
26 Duchynski R, Brauer K, Hutton K, et al. The quick look
Emerg Med 1999; 17:141–143 airway classification: a useful tool in predicting the difficult
8 Jones JH, Weaver CS, Rusyniak DE, et al. Impact of out-of-hospital intubation; experience in an air medical
emergency medicine faculty and an airway protocol on transport program. Air Med J 1998; 17:46 –50
airway management. Acad Emerg Med 2002; 9:1452–1456 27 Wilson ME, Spiegelhalter D, Robertson JA, et al. Predicting
9 Tayal VS, Riggs RW, Marx JA, et al. Rapid-sequence difficult intubation. Br J Anaesth 1988; 61:211–216
intubation at an emergency medicine residency: success rate 28 Bellhouse CP, Dore C. Criteria for estimating likelihood of
and adverse events during a two-year period. Acad Emerg difficulty of endotracheal intubation with the Macintosh
Med 1999; 6:31–37 laryngoscope. Anaesth Intensive Care 1988; 16:329 –337
10 Rose WD, Anderson LD, Edmond SA. Analysis of intuba- 29 Finucane BT, Santora AH. Evaluation of the airway prior to
tions: before and after establishment of a rapid sequence intubation: principles of airway management. Philadelphia,
intubation protocol for air medical use. Air Med J 1994; PA: Norris Company 1988; 69
13:475– 478 30 Randell T. Prediction of difficult intubation. Acta Anaesthe-
11 Bernard S, Smith K, Foster S, et al. The use of rapid siol Scand 1996; 40:1016 –1023
sequence intubation by ambulance paramedics for patients 31 Watson CB. Prediction of difficult intubation. Respir Care
with severe head injury. Emerg Med (Fremantle) 2002; 1999; 44:777–798
14:406 – 411 32 Karkouti K, Rose DK, Wigglesworth D, et al. Predicting
12 Bozeman WP, Kleiner DM, Huggett V. Intubating condi- difficult intubation: a multivariable analysis. Can J Anaesth
tions produced by etomidate alone vs rapid sequence intu- 2000; 47:730 –739
bation in the prehospital aeromedical setting [abstract]. 33 Benumof JL. Management of the difficult adult airway: with
Acad Emerg Med 2003; 10:445– 446 special emphasis on awake tracheal intubation. Anesthesiol-
13 Bulger EM, Copass MK, Maier RV, et al. An analysis of ogy 1991; 75:1087–1110
advanced prehospital airway management. J Emerg Med 34 Bamber J. Airway crises. Curr Anaesth Crit Care 2003;
2002; 23:183–189 14:2– 8
14 Pearson S. Comparison of intubation attempts and comple- 35 Chung KS, Sinatra RS, Halevy JD, et al. A comparison of
tion times before and after the initiation of a rapid sequence fentanyl, esmolol, and their combination for blunting the
intubation protocol in an air medical transport program. Air haemodynamic responses during rapid-sequence induction.
Med J 2003; 22:28 –33 Can J Anaesth 1992; 39:774 –779
15 Davis DP, Ochs M, Hoyt DB, et al. Paramedic-administered 36 Swanson ER, Fosnocht DE. Effect of an airway education
neuromuscular blockade improves prehospital intubation program on prehospital intubation. Air Med J 2002; 21:
success in severely head-injured patients. J Trauma 2003; 28 –31
55:713–719 37 Dufour DG, Larose DL, Clement SC. Rapid sequence
16 American Society of Anesthesiologists. Practice guidelines intubation in the emergency department. J Emerg Med
for management of the difficult airway: a report by the 1995; 13:705–710
American Society of Anesthesiologists Task Force on Man- 38 Sivilotti ML, Filbin MR, Murray HE, et al. Does the
agement of the Difficult Airway. Anesthesiology 1993; 78: sedative agent facilitate emergency rapid sequence intuba-
597– 602 tion? Acad Emerg Med 2003; 10:612– 620
17 Reid C, Chan L, Tweeddale M. The who, where, and what 39 Takahashi S, Mizutani T, Miyabe M, et al. Hemodynamic
of rapid sequence intubation: prospective observational responses to tracheal intubation with laryngoscope versus
study of emergency RSI outside the operating theatre. lightwand intubating device (Trachlight) in adults with
Emerg Med J 2004; 21:296 –301 normal airway. Anesth Analg 2002; 95:480 – 484
18 Levitan RM, Dickinson ET, McMaster J, et al. Assessing 40 Horak J, Weiss S. Emergent management of the airway: new
malampati scores, thyromental distance, and neck mobility pharmacology and the control of comorbidities in cardiac

1410 Critical Care Review

 disease, ischemia, and valvular heart disease. Crit Care Clin non-depolarizing relaxant to prevent succinylcholine fascicu-
2000; 16:411– 427 lations and myalgia. Can J Anaesth 1998; 45:521–525
41 Feng CK, Chan KH, Liu KN, et al. A comparison of 61 Ledingham IM, Watt I. Influence of sedation on mortality in
lidocaine, fentanyl, and esmolol for attenuation of cardiovas- critically ill multiple trauma patients. Lancet 1983; 1:1270
cular response to laryngoscopy and tracheal intubation. Acta 62 Bergen JM, Smith DC. A review of etomidate for rapid
Anaesthesiol Sin 1996; 34:61– 67 sequence intubation in the emergency department. J Emerg
42 Wadbrook PS. Advances in airway pharmacology: emerging Med 1997; 15:221–230
trends and evolving controversy. Emerg Med Clin North 63 Angelini G, Ketzler JT, Coursin DB. Use of propofol and
Am 2000; 18:767–788 other nonbenzodiazepine sedatives in the intensive care
43 Doenicke AW, Roizen MF, Kugler J, et al. Reducing unit. Crit Care Clin 2001; 17:863– 880
myoclonus after etomidate. Anesthesiology 1999; 90:113– 64 Schenarts CL, Burton JH, Riker RR. Adrenocortical dys-
119 function following etomidate induction in emergency de-
44 Pathak D, Slater RM, Ping SS, et al. Effects of alfentanil and partment patients. Acad Emerg Med 2001; 8:1–7
lidocaine on the hemodynamic responses to laryngoscopy 65 Merlo F, Demo P, Lacquaniti L, et al. Propofol in single
and tracheal intubation. J Clin Anesth 1990; 2:81– 85 bolus for treatment of elevated intracranial hypertension.
45 Mahesh K. Attenuation of cardiovascular responses to intu- Minerva Anestesiol 1991; 57:359 –363
bation with combination of labetalol and sufentanyl. Can J 66 Ludbrook GL, Visco E, Lam AM. Propofol: relation be-
Anaesth 1990; 37:S114 tween brain concentrations, electroencephalogram, middle
46 Negus SS, Pasternak GW, Koob GF, et al. Antagonist effects cerebral artery blood flow velocity, and cerebral oxygen
of beta-funaltrexamine and naloxonazine on alfentanil-in- extraction during induction of anesthesia. Anesthesiology
duced antinociception and muscle rigidity in the rat. J Phar- 2002; 97:1363–1370
macol Exp Ther 1993; 264:739 –745 67 Kelly DF, Goodale DB, Williams J, et al. Propofol in the
47 Caspi J, Klausner JM, Safadi T, et al. Delayed respiratory treatment of moderate and severe head injury: a random-
depression following fentanyl anesthesia for cardiac surgery. ized, prospective double-blinded pilot trial. J Neurosurg
Crit Care Med 1988; 16:238 –240 1999; 90:1042–1052
48 Roy S, Fortier LP. Fentanyl-induced rigidity during emer- 68 Perry JJ, Lee J, Wells G. Are intubation conditions using
gence from general anesthesia potentiated by venlafexine. rocuronium equivalent to those using succinylcholine? Acad
Can J Anaesth 2003; 50:32–35 Emerg Med 2002; 9:813– 823
49 Miller RD. Anesthesia. 5th ed. New York, NY: Churchill 69 Wong AK, Teoh GS. Intubation without muscle relaxant: an
Livingstone, 2000 alternative technique for rapid tracheal intubation. Anaesth
50 Lev R, Rosen P. Prophylactic lidocaine use preintubation: a Intensive Care 1996; 24:224 –230
review. J Emerg Med 1994; 12:499 –506 70 Erhan E, Ugur G, Alper I, et al. Tracheal intubation without
51 Brucia JJ, Owen DC, Rudy EB. The effects of lidocaine on muscle relaxants: remifentanil or alfentanil in combination
intracranial hypertension. J Neurosci Nurs 1992; 24:205–214 with propofol. Eur J Anaesthesiol 2003; 20:37– 43
52 Robinson N, Clancy M. In patients with head injury under- 71 Senel AC, Akturk G, Yurtseven M. Comparison of intuba-
going rapid sequence intubation, does pretreatment with tion conditions under propofol in children: alfentanil vs
intravenous lignocaine/lidocaine lead to an improved neuro- atracurium. Middle East J Anesthesiol 1996; 13:605– 611
logical outcome? A review of the literature. Emerg Med J 72 el-Beheiry H, Kim J, Milne B, et al. Prophylaxis against the
2001; 18:453– 457 systemic hypotension induced by propofol during rapid-
53 Levitt MA, Dresden GM. The efficacy of esmolol versus sequence intubation. Can J Anaesth 1995; 42:875– 878
lidocaine to attenuate the hemodynamic response to intu- 73 Stoelting RK, Miller RD. Basics of anesthesia. 2nd ed. New
bation in isolated head trauma patients. Acad Emerg Med York, NY: Churchill Livingstone, 1989
2001; 8:19 –24 74 Blosser SA, Stauffer JL. Intubation of critically ill patients.
54 Helfman SM, Gold MI, DeLisser EA, et al. Which drug Clin Chest Med 1996; 17:355–378
prevents tachycardia and hypertension associated with tra- 75 Rodricks MB, Deutschman CS. Emergent airway manage-
cheal intubation: lidocaine, fentanyl, or esmolol [abstract]? ment. Indications and methods in the face of confounding
Anesth Analg 1991; 72:482– 486 conditions. Crit Care Clin 2000; 16:389 – 409
55 Kindler CH, Schumacher PG, Schneider MC, et al. Effects 76 Orebaugh SL. Succinylcholine: adverse effects and alterna-
of intravenous lidocaine and/or esmolol on hemodynamic tives in emergency medicine. Am J Emerg Med 1999;
responses to laryngoscopy and intubation: a double-blind, 17:715–721
controlled clinical trial. J Clin Anesth 1996; 8:491– 496 77 Naguib M, Magboul MM. Adverse effects of neuromuscular
56 Singh H, Vichitvejpaisal P, Gaines GY, et al. Comparative blockers and their antagonists. Drug Saf 1998; 18:99 –116
effects of lidocaine, esmolol, and nitroglycerin in modifying 78 Rosenberg H, Gronert GA. Intractable cardiac arrest in
the hemodynamic response to laryngoscopy and intubation. children given succinylcholine. Anesthesiology 1992; 77:
J Clin Anesth 1995; 7:5– 8 1054
57 Clancy M, Halford S, Walls R, et al. In patients with head 79 Delphin E, Jackson D, Rothstein P. Use of succinylcholine
injuries who undergo rapid sequence intubation using suc- during elective pediatric anesthesia should be reevaluated.
cinylcholine, does pretreatment with a competitive neuro- Anesth Analg 1987; 66:1190 –1192
muscular blocking agent improve outcome? A literature 80 Huggins RM, Kennedy WK, Melroy MJ, et al. Cardiac arrest
review. Emerg Med J 2001; 18:373–375 from succinylcholine-induced hyperkalemia. Am J Health
58 Rubin MA, Sadovnikoff N. Neuromuscular blocking agents Syst Pharm 2003; 60:694 – 697
in the emergency department. J Emerg Med 1996; 14:193– 81 Dornan RI, Royston D. Suxamethonium-related hyperkal-
199 aemic cardiac arrest in intensive care. Anaesthesia 1995;
59 Motamed C, Choquette R, Donati F. Rocuronium prevents 50:1006
succinylcholine-induced fasciculations. Can J Anaesth 1997; 82 Berkahn JM, Sleigh JW. Hyperkalaemic cardiac arrest fol-
44:1262–1268 lowing succinylcholine in a long-term intensive care patient.
60 Martin R, Carrier J, Pirlet M, et al. Rocuronium is the best Anaesth Intensive Care 1997; 25:588 –589

www.chestjournal.org CHEST / 127 / 4 / APRIL, 2005 1411

83 Gronert GA. Cardiac arrest after succinylcholine: mortality 100 Yanez P, Martyn JA. Prolonged d-tubocurarine infusion
greater with rhabdomyolysis than receptor upregulation. and/or immobilization cause upregulation of acetylcholine
Anesthesiology 2001; 94:523–529 receptors and hyperkalemia to succinylcholine in rats. An-
84 Khan TZ, Khan RM. Changes in serum potassium following esthesiology 1996; 84:384 –391
succinylcholine in patients with infections. Anesth Analg 101 Thapa S, Brull SJ. Succinylcholine-induced hyperkalemia in
1983; 62:327–331 patients with renal failure: an old question revisited. Anesth
85 Schaner PJ, Brown RL, Kirksey TD, et al. Succinylcholine- Analg 2000; 91:237–241
induced hyperkalemia in burned patients: 1. Anesth Analg 102 Galindo AH, Davis TB. Succinylcholine and cardiac excit-
1969; 48:764 –770 ability. Anesthesiology 1962; 23:32– 40
86 Dronen SC, Merigian KS, Hedges JR, et al. A comparison of
103 Hunter JM. Adverse effects of neuromuscular blocking
blind nasotracheal and succinylcholine-assisted intubation in
drugs. Br J Anaesth 1987; 59:46 – 60
the poisoned patient. Ann Emerg Med 1987; 16:650 – 652
104 Smith G, Dalling R, Williams TI. Gastro-oesophageal pres-
87 Kindler CH, Verotta D, Gray AT, et al. Additive inhibition of
nicotinic acetylcholine receptors by corticosteroids and the sure gradient changes produced by induction of anaesthesia
neuromuscular blocking drug vecuronium. Anesthesiology and suxamethonium. Br J Anaesth 1978; 50:1137–1143
2000; 92:821– 832 105 Book WJ, Abel M, Eisenkraft JB. Adverse effects of depo-
88 Martyn JA, White DA, Gronert GA, et al. Up-and-down larising neuromuscular blocking agents: incidence, preven-
regulation of skeletal muscle acetylcholine receptors: effects tion and management. Drug Saf 1994; 10:331–349
on neuromuscular blockers. Anesthesiology 1992; 76:822– 106 McGoldrick KE. The open globe: is an alternative to
843 succinylcholine necessary? J Clin Anesth 1993; 5:1– 4
89 Hanson P, Dive A, Brucher JM, et al. Acute corticosteroid 107 Kovarik WD, Mayberg TS, Lam AM, et al. Succinylcholine
myopathy in intensive care patients. Muscle Nerve 1997; does not change intracranial pressure, cerebral blood flow
20:1371–1380 velocity, or the electroencephalogram in patients with neu-
90 Markewitz BA, Elstad MR. Succinylcholine-induced hyper- rologic injury. Anesth Analg 1994; 78:469 – 473
kalemia following prolonged pharmacologic neuromuscular 108 Booij LH. Is succinylcholine appropriate or obsolete in the
blockade. Chest 1997; 111:248 –250 intensive care unit? Crit Care 2001; 5:245–246
91 Chakravarty EF, Kirsch CM, Jensen WA, et al. Cardiac 109 Hughes M, Grant IS, Biccard B, et al. Suxamethonium and
arrest due to succinylcholine-induced hyperkalemia in a critical illness polyneuropathy. Anaesth Intensive Care 1999;
patient with wound botulism. J Clin Anesth 2000; 12:80 – 82 27:636 – 638
92 Genever EE. Suxamethonium-induced cardiac arrest in 110 Naguib M, Samarkandi A, Riad W, et al. Optimal dose of
unsuspected pseudohypertrophic muscular dystrophy: case
succinylcholine revisited. Anesthesiology 2003; 99:1045–
report. Br J Anaesth 1971; 43:984 –986
1049
93 Marohn ML, Nagia AH. Masseter muscle rigidity after
111 American Society of Anesthesiologists. Practice guidelines
rapid-sequence induction of anesthesia. Anesthesiology
1992; 77:205–207 for management of the difficult airway: an updated report by
94 Sims C. Masseter spasm after suxamethonium in children. the American Society of Anesthesiologists Task Force on
Br J Hosp Med 1992; 47:139 –143 Management of the Difficult Airway. Anesthesiology 2003;
95 MacLennan N, Heimbach DM, Cullen BF. Anesthesia for 98:1269 –1277
major thermal injury. Anesthesiology 1998; 89:749 –770 112 Miller CG. Management of the difficult intubation in closed
96 Diefenbach C, Buzello W. Muscle relaxation in patients with malpractice claims. ASA Newsl 2000; 64:13–16
neuromuscular diseases. Anaesthesist 1994; 43:283–288 113 Ezri T, Szmuk P, Warters RD, et al. Difficult airway
97 Gronert GA. Succinylcholine hyperkalemia after burns. management practice patterns among anesthesiologists
Anesthesiology 1999; 91:320 –322 practicing in the United States: have we made any progress?
98 John DA, Tobey RE, Homer LD, et al. Onset of succinyl- J Clin Anesth 2003; 15:418 – 422
choline-induced hyperkalemia following denervation. Anes- 114 Walls RM, Luten RC, Murphy MF. Manual of emergency
thesiology 1976; 45:294 –299 airway management. Philadelphia, PA: Lippincott, Williams
99 Fung DL, White DA, Gronert GA, et al. The changing & Williams, 2000
pharmacodynamics of metocurine identify the onset and 115 Marvez E, Weiss SJ, Houry DE, et al. Predicting adverse
offset of canine gastrocnemius disuse atrophy. Anesthesiol- outcomes in a diagnosis-based protocol system for rapid
ogy 1995; 83:134 –140 sequence intubation. Am J Emerg Med 2003; 21:23–29

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