Table 2 Modes of induction

Rapid sequence induction and intubation (RSII)

• Use of rapidly acting inducing agent (ketamine and etomidate preferred agents in critically ill)

• Short acting muscle relaxant (succinylcholine or rocuronium)

• Cricoid pressure

• Key strategy for patients at high risk for aspiration

• In inexperienced hands RSII can lead to CICO situation (cannot intubate, cannot oxygenate)

• FONA (front of airway) techniques should be available as backup plan

Delayed sequence intubation (DSI

• Preoxygenation done after judicious use of sedation in delirious patients

• Key strategy in patients difficult to pre-oxygenate due to agitation

• Even low doses of sedation can cause blunting of airway reflexes and apnoea in critically ill patients

Awake intubation

• Intubation is done without use of muscle relaxant (spontaneous respiration is remains intact)

• Flexiblescope intubation and videolaryngoscopy are used to aid awake intubation

• Key strategy in anatomically as well as physiologically difficult airway

• Spontaneous respiration remains intact

• Physiological compensatory response remains relatively intact

• Significant expertise and skill is required to perform awake intubation safely

• Attempts to intubate without proper blunting of airway reflexes can precipitate laryngospasm and severe hypoxemia

• Failed attempts can cause vomiting, aspiration, local injury and bleeding.

• Critically ill patients can develop toxicity of local anaesthetics at very low doses due to compromised hepatic and renal function

Double setup approach

• Two approaches are prepared simultaneously in anticipated failed intubation.eg. RSII and surgical airway

• Increased safety and reduced time required for switching from one approach to other

• May increase the cost of care