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Rapid-Sequence Intubation in Adults: Indications and Concerns

2001; Lippincott Williams & Wilkins; Volume: 8; Issue: 3 Linguagem: Inglês

10.1097/00045413-200105000-00004

1536-5956

Charles E. Smith,

Respiratory Support and Mechanisms

Rapid-sequence induction and intubation (RSI) is a technique that is designed to provide optimal tracheal intubating conditions and reduce the risk of pulmonary aspiration. RSI has a higher success rate, fewer complications, and better outcome compared with orotracheal intubation without neuromuscular relaxants and blind nasotracheal intubation. Before considering performing RSI, the clinician must ensure that intubation is predicted to be successful based on assessment of the airway. Failure to intubate and subsequent inability to ventilate can lead quickly to death or cerebral hypoxia and brain injury. Maximal preoxygenation can be attained by providing 100% oxygen through a sealed system for 3 to 5 minutes of normal tidal volume ventilation or by hyperventilation with 8 deep breaths of 100% oxygen within 60 seconds. Cricoid pressure prevents passive regurgitation of stomach contents and reduces the risk of gastric insufflation during bag-mask ventilation. Cricoid pressure can also distort upper airway anatomy and make glottic visualization more difficult or impossible. Brief release of cricoid pressure or external laryngeal manipulation and depression of the thyroid cartilage often improves the view at direct laryngoscopy. The use of neuromuscular relaxants to facilitate intubation is associated with side effects regardless of whether depolarizing (e.g., succinylcholine) or nondepolarizing (e.g., rocuronium or rapacuronium) agents are used. Avoidance of relaxants, however, results in inferior intubating conditions unless large doses of induction agents and opioids are given. Tracheal intubation aids such as the gum elastic bougie are useful whenever difficult glottic visualization occurs. The bougie is relatively easy to insert through the glottic opening when only the epiglottis (grade III view) or tip of the arytenoids (grade II view) can be visualized. The tracheal tube is then threaded over the bougie and tracheal placement is confirmed using capnography. Special laryngoscopes, such as the Bullard, WuScope, and McCoy, and lighted stylets are also valuable for facilitating difficult intubation. The short learning curve with the McCoy hinged-blade tip is of obvious benefit. Contingency plans for failed intubation include use of the laryngeal mask airway (LMA), Combitube, and cricothyrotomy.