emDOCs Podcast – Episode 128: Intubation EBM Updates Part 2

What induction medication should we use?

• Medications include propofol, etomidate, and ketamine. Etomidate and ketamine are more hemodynamically neutral.
• Propofol: primarily works through GABA receptors.
  • Commonly used for intubation of status epilepticus, hypertensive emergencies, intracranial emergencies, or severe alcohol withdrawal syndrome (63,64).
  • Dosing is 0.5-1.0 mg/kg IV over 10 seconds. Rapid onset of action (less than one minute), and a duration of 2-8 minutes (64).
  • Can potentially lead to significant hypotension
• Etomidate: non-barbiturate hypnotic IV anesthetic with no analgesic properties.
  • Dosing is 0.2-0.3 mg/kg IV. Onset of action of 30–60 seconds, peak effect of 1 minute, and lasts 200-300 seconds.
  • There have have been concerns of adrenal suppression with etomidate, but this is controversial.
• Ketamine: NMDA antagonist with sedative and analgesic properties.
  • Dosing is 1-2 mg/kg IV or 4-5 mg/kg intramuscular (IM). It has an onset of action within 30-60 seconds, peak effect within 1 minute, and half-life of 2-4 hours (68).
• Multiple studies have compared ketamine and etomidate, with varying results regarding peri-intubation adverse events (69-71).
  • 2024 meta-analysis including 7 RCTs and 1 propensity-matched study evaluated critically ill adult patients who underwent emergency ETI (69). Smilar mortality between ketamine and etomidate (RR 0.96; 95% credible interval 0.8-1.1). No difference in the Sequential Organ Failure Assessment (SOFA) score, vasopressor-free days, ventilator-free days, blood pressure, and first-attempt success (69). With Bayesian analysis of the trial results, 68.6% probability that ketamine would reduce mortality by up to 1% when compared to etomidate. Probability of 41.6% that ketamine would reduce mortality by ≥ 1% when compared to etomidate (69).
  • 2025 meta-analysis of 14 studies found no difference in 30 day survival. Ketamine associated with a higher requirement for post-intubation vasopressor support (OR 0.71, 95% CI: 0.53-0.96) but an increase in ICU-free days. Etomidate use correlated with higher incidence of adrenal insufficiency (OR 2.43, 95% CI: 1.67-3.53, P < 0.001). No significant differences in intubation difficulty, cardiovascular collapse, or systemic steroid use between the groups.
• Guidelines:
  • SCCM 2023 Clinical Practice Guidelines (published before these meta-analyses) suggest there is no difference between etomidate and other agents in terms of mortality, hypotension, or vasopressor use in the peri-intubation period or through hospital discharge (61).
  • ACEP provides a level B recommendation supporting etomidate or ketamine to reduce the risk of peri intubation hypotension. Level c recommendation to avoid fentanyl, midazolam, or propofol in patients are increased risk for postintubation hypotension.
  • European Society for Emergency Medicine recognize that both ketamine and etomidate have nearly neutral hemodynamic properties, but etomidate may potentially result in adrenal suppression, and that led them to recommend ketamine (62).
• Summary: Based on the literature, this is an extremely nuanced decision. Both ketamine and etomidate are great options. Propofol may be a good option for patients with status epilepticus, alcohol withdrawal syndrome, and severe hypertension.

What paralytic should we use?

• Paralytic agents are associated with a greater rate of first-pass success; should be using these in the majority of cases of intubation.
• Succinylcholine: first used in the late 1940s (75).
  • Depolarizing muscle relaxant that directly binds to postsynaptic acetylcholine receptors. Dosing is 1.0-1.5 mg/kg IV. Onset of 45 seconds and duration of 4-6 minutes (76). May also be administered IM, with a time of onset of 2-3 minutes and duration 10-30 minutes (76).
• Rocuronium: introduced in the 1990s.
  • Nondepolarizing agent that competitively antagonizes the acetylcholine receptor (77,78). Dosing is 0.6-1.2 mg/kg IV, and it has a time of onset 45-120 seconds (dose dependent) and duration of action 30-90 minutes (78).
• 2017 meta-analysis included 50 studies comparing succinylcholine with rocuronium found succinylcholine was superior to low dose rocuronium (0.6-0.7 mg/kg) for excellent intubating conditions (RR 0.86; 95% CI 0.81-0.92) and clinically acceptable conditions (RR 0.97; 95% CI 0.95-0.99) (79). No difference in studies utilizing higher doses of rocuronium (≥ 0.9 mg/kg IV).
• National Emergency Airway Registry (NEAR) study found no difference in succinylcholine or rocuronium in first-pass success (87.0% versus 87.5%) or adverse events (14.7% versus 14.8%) (80). Mean dose was succinylcholine 1.8 mg/kg IV and rocuronium 1.2 mg/kg IV.
• Both succinylcholine and high-dose rocuronium achieve similar intubating conditions, they have a similar onset of action, and ultimately both are effective paralytics.
• Must several different factors when choosing the paralytic.
  • Succinylcholine has a duration of 4-6 minutes, so can perform a neurologic examination soon after intubation.
  • Rocuronium is longer acting but has a reversal agent if it’s necessary (81,82). If further airway management is needed, like a cricothyrotomy, the patient is already paralyzed. Rocuronium should also be used if there is concern for severe hyperkalemia (succinylcholine is a depolarizing paralytic and can result in release of potassium. Succinylcholine not recommended for myasthenia gravis; for these patients use half dose rocuronium (85).
• Several studies have evaluated administering the the paralytic before the sedative based on the onset of action for sedatives being faster than paralytics. May result in cessation of respiration without paralysis, leading to pulmonary derecruitment, CO₂ retention, and hypoxia (86-88).
  • 2019 study evaluated RSI medication order in ED patients undergoing ETI (89). Found administration of a paralytic before the sedative agent was associated with a reduced time from medication administration to the time of the end of the ETI attempt by 6 seconds (95% CI 0-11 seconds) (89). The difference was not clinically significant, and the risk of paralysis without sedation greatly outweighs this (90).
  • 2024 study included 2,2116 patients and found first-attempt failure occurred in 54 (4.3%) patients in the paralytic-first group and 56 (5.9%) in the sedative-first group.
  • May consider this, but ensure team is comfortable with it.

Should we use VL or DL?

• Two primary techniques for ETI: DL versus VL with a hyperangulated blade or standard-geometry blade (3,91-93).
  • DL: uses a blade with a light source attached to a battery-contained handle to displace the tongue, manipulate the epiglottis, directly visualize the glottic structures, and pass the ETT through the vocal cords.
  • VLL: uses the same components as DL but the blade contains a camera in the distal half that transmits images to a screen. See the ETT passing the glottic structures without direct line of sight (91).With hyperangulated blade, the increased curvature doesn’t allow direct visualization, but with a standard geometry VL blade, can visualize directly or with the video monitor (91,93).
• DL is the most commonly utilized technique in ED and ICU settings worldwide, but VL use has increased.
• 2024 meta-analysis including RCTs conducted in the ED and ICU found VL increased first-pass success (RR 1.12; 95% CI 1.04-1.20) and reduced esophageal intubations (RR 0.44; 95% CI 0.24-0.80) and aspiration (RR 0.63; 95% CI 0.41-0.96) (94).
• DEVICE was a multicenter RCT published in 2023 in NEJM that included 1417 patients undergoing ETI in the ED or ICU (93). For the first attempt, patients were randomized to VL or DL. 70% were intubated in the ED. VL improved first-pass attempt success compared to DL (85.1% versus 70.8%; absolute difference 14.3%; 95% CI 9.9% to 18.7%). No difference in complications (hypotension, hypoxia, vasopressor use, cardiac arrest, death, aspiration, esophageal intubation, or teeth injury). Less benefit with VL in first-pass success for those with at least 100 intubations, and DL was favored in those clinicians who had performed > 250 prior intubations (93).
• ACEP provides a level C recommendation to consider VL when available.
• Summary: VL is associated with greater first attempt success, particularly for novice intbuatiors. If you’re a more experienced intubator, go with what you’re comfortable with. No matter the device you use, you must have an established back up plan if your first attempts are unsuccessful.

When should we use a bougie?

• Bougie is a flexible, 60-cm device with a small 35–40-degree angle at the distal end (coudé tip) (95). Sizes range between 10-15 French.
• Used to consider bougie only after a failed attempt, but more recent studies have looked at using a bougie on the first ETI attempt (96).
  • 2018 BEAM RCT randomized patients undergoing ETI to a first attempt facilitated by bougie or ETT with stylet (97). Included 757 patients and found first-attempt success was higher with the bougie (98% versus 87%), but median duration of the attempt and incidence of hypoxia were no different. This trial was conducted at a center where bougie was commonly used (97).
  • 2021 RCT with 1,102 patients found no significant difference in first-attempt success (80.4% versus 83.0%) (98).
  • 2024 meta-analysis with18 studies found improved first-attempt success overall with use of a bougie (RR 1.11; 95% CI 1.06-1.17), as well as across all subgroups (95). Greatest improvement in patients with a Cormack-Lehane III or IV airway (RR 1.60; 95% 1.40-1.84) (95).
• Advantages for bougie use: improved view of passage of the bougie through the vocal cords, (lowers the likelihood of passing the ETT into the esophagus); allows ETT confirmation within the trachea by feeling the trachea rings or being held up when the bougie reaches the carina; may also facilitate advancing the ETT into a single mainstem bronchus when single lung intubation is needed (99).

• Based on the literature, a bougie likely improves first-attempt success with operators who are experienced in its use. We should be comfortable with the bougie.

How can we confirm ETT placement?

• Variety of techniques: assessing for chest rise, auscultation of breath sounds, ETT condensation, direct visualization, and quantitative or qualitative capnometry.
• Chest rise, auscultation of breath sounds, and ETT condensation are not reliable.
• Capnography can be reliable for ETT confirmation, but there are limitations.
  • False positives with hypopharyngeal placement or recent ingestion of a carbonated beverage.
  • False negatives when expired CO₂ levels are low (cardiac arrest, flash pulmonary edema, massive pulmonary embolism) (100-108).
• POCUS: rapid and reliable means of confirming ETT placement within the trachea and looking for mainstem intubation.
• Meta-analysis found POCUS was 99% sensitive and 97% specific for confirming ETT location (109).
• How to do this? Place the linear probe tranversely on the anterior neck at the level of the suprasternal notch (102-106,109-111).
  • The static technique can be performed by one clinician after ETI. Looking for a single air-mucosal interface with posterior shadowing (i.e., the “bullet” sign) to confirm ETT placement in the trachea (Figure 1). Twisting of the ETT can help facilitate visualization within the trachea (112,113). If the esophagus is intubated, you’ll see the double tract sign, or a “second” trachea (Figure 2).
  • The dynamic method requires another person to evaluate for the presence of motion artifact posterior to the trachea as the ETT passes (confirming appropriate placement), or the appearance of the double tract sign (esophageal placement) (104-106). If it’s not clear, look for bilateral lung sliding (112,114).
  • Once the location has been confirmed, may rotate the ultrasound probe 90 degrees clockwise to visualize the ETT cuff in relation to the cricoid and tracheal rings to determine the ETT depth (112,115).
  • If bilateral sliding present, the ETT is not mainstemmed.

What should we consider for post-intubation sedation?

• Must ensure adequate sedation and analgesia as soon as the intubation is completed to reduce the risk of post-intubation awareness while paralyzed (86).
• Awareness with recall of paralysis (AWP) is associated with significant long-term sequelae: posttraumatic stress disorder, depression, and phobias (116-118).
• Several recent studies have evaluated this in the ED.
  • Single-center observational study of 383 mechanically ventilated ED patients found a prevalence of AWP of 2.6%, with rocuronium placing patients at higher risk of AWP (unadjusted odds ratio 5.1; 95% CI 1.30-20.1) (119). Patients with AWP had a higher degree of perceived threat (13.4 versus 8.5; mean difference 4.9; 95% CI 0.94-8), which is a predisposing factor for posttraumatic stress disorder (119).
  • 2023 study including 866 mechanically ventilated ED patients found 66 patients (7.4%; 95% 5.8-9.4) had possible (n=61) or definite (n=5) AWP (120). The specific paralytic or sedative was not significantly associated with recall.
  • 2022 study of 388 mechanically ventilated ED patients found 3.4% (13) had AWP, with the majority of these patients receiving rocuronium (12/13; 92.3%) (121). These patients had higher threat perception scale scores (121).
• Summary:
  • Based on the current literature, a significant proportion of patients experience AWP. No matter the paralytic or sedative agent used for RSI, must provide adequate post-intubation sedation for patient comfort. Also helps with mechanical ventilator synchrony and reduces the work of breathing. Order post-intubation medications and have them in the room when the induction medication is being administered. Administer sedative and analgesic immediately following ETI.

Summary:

• ETI is an essential skill in emergency medicine.
• There are several tools that use anatomic and physiologic factors, and these can assist in predicting a difficult airway, but do not use them in isolation. Always assume the intubation will be difficult, and have a backup plan.
• Predictors of decompensation: hypotension, apnea/oxygen, RV failure, and acidosis.
• Use preoxygenation and apneic oxygenation to reduce the risk of hypoxemia and decompensation.
• Both etomidate and ketamine are reasonable for induction.
• May use either higher-dose rocuronium or succinylcholine for paralysis.
• VL demonstrates higher first pass success for novice intubators.
• In those who are experienced with its use, a bougie can also improve first pass success.
• There are several options for confirming tube placement, and POCUS can be an adjunct.
• No matter what agents used for induction and paralysis, post-intubation sedation is absolutely essential.

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