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Table 2 Modes of induction

From: Difficult tracheal intubation in critically ill

  Salient features Advantages Disadvantages
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