BJA Education, 22(12): 484e490 (2022)

doi: 10.1016/j.bjae.2022.09.001
Advance Access Publication Date: 1 November 2022

Matrix codes: 1C02,

2A01, 3C00

Rapid sequence induction and intubation

J. Collins* and E.P. O’Sullivan
St James’s Hospital, Dublin 8, Ireland
*Corresponding author. [email protected]

Keywords: airway management; rapid sequence induction and intubation; respiratory aspiration

Learning objectives Key points

By reading this article, you should be able to:  Pulmonary aspiration remains the commonest
 Identify the patient at risk of pulmonary aspira- cause of anaesthesia-related death and brain
tion during airway management. damage.
 Generate a plan to prepare a patient safely for  Rapid sequence induction and intubation has
rapid sequence induction and intubation (RSII). evolved since its classical description; however,
 Describe the Project for Universal Management of recent modifications are poorly defined.
Airways (PUMA) universal principles for RSII and  Adequate preparation for RSII helps to mitigate
recall the components which are recommended, risk, increase success and address patient-
suggested and optional. specific challenges.
 Discuss the current evidence base supporting  The PUMA collaboration has proposed universal
various components of the RSII procedure. principles for RSII.
 The PUMA universal principles aim to overcome
practice variation and outline recommended,
suggested and optional components of RSII.
Evolution of rapid sequence induction and
intubation
identified that pulmonary aspiration accounted for 50% of
Pulmonary aspiration is defined as the introduction of gastric deaths reported in NAP4, and was the most common cause of
or oropharyngeal matter into the lower respiratory tract.1 anaesthesia related death.2 Aspiration events are less com-
Rapid sequence induction and intubation (RSII) is a proced- mon in the appropriately fasted patient. Despite this, 28% of
ure that aims to reduce the incidence of pulmonary aspiration aspiration events in NAP4 occurred in fasted patients. Signif-
during airway management. This is achieved by minimising icant risk factors for pulmonary aspiration were present in
the time between drug-induced loss of protective airway re- many of these cases. These results have been replicated more
flexes and the successful insertion and inflation of a cuffed recently in the USA. An ASA closed claims analysis revealed
tracheal tube. The fourth UK National Audit Project (NAP4) that in 115 cases of pulmonary aspiration, death occurred in
57% and severe permanent injury in 14%.3 It was found that
61% of those patients had presented with clear indications for
RSII. The appropriate use of RSII when indicated is therefore
Jack Collins BSc FCAI is undertaking a fellowship in advanced as important as the technique. Pulmonary aspiration remains
airway management and simulation at St James’s Hospital, Dublin. a significant risk in emergency surgery and in specific patient
groups such as obstetrics where Mendelson first described the
Ellen P. O’Sullivan FRCA FCAI is a consultant anaesthetist at St
eponymous aspiration syndrome in 1946.4 Commentary on
James’s Hospital, Dublin where she specialises in difficult airway
pulmonary aspiration has long featured in the medical liter-
management. She has been involved in the Difficult Airway Society
ature. Snow and Nunn reported in 1959 that aspiration of
since its foundation and has contributed significantly to the devel-
gastric contents was the most common cause of death asso-
opment of several airway management guidelines. Professor O’Sul-
ciated with anaesthesia.5 Strategies to avoid pulmonary
livan is the past president of the College of Anaesthetist of Ireland;
aspiration were identified as early as 1951 when Morton and
she was until recently an elected council member of the Royal College
Wylie discussed the concepts of positioning and
of Anaesthetists and chaired their global partnership committee.

Accepted: 1 September 2022

© 2022 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
For Permissions, please email: [email protected]

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 Rapid sequence induction and intubation

neuromuscular block.6 Sellick and Lond first suggested the use aspiration (e.g. bowel obstruction, gastric outlet
of cricoid pressure at induction of anaesthesia in 1961.7 obstruction, acute severe pain, upper gastrointestinal
Approximately 10 yr later, Stept and Safar8 published the bleeding).
first complete description of ‘rapid induction/intubation’. The (iii) Obstetric patients requiring elective or emergency
paper outlined a 15-step procedure to avoid the aspiration of anaesthesia.
gastric contents.8 Many of the key components of this ‘clas- (iv) Critical care patients who require tracheal intubation
sical’ RSII still exist in current practice. Their procedure (e.g. those with altered consciousness, respiratory fail-
included preoxygenation of the lungs, giving predetermined ure, or multiple trauma).
doses of drug, the application of cricoid pressure, omission of
facemask ventilation and tracheal intubation with a cuffed
tube. More than 50 yr have passed since RSII was first Risks of RSII
described, and a number of recent surveys of anaesthetists
suggest there is little consensus over the delivery of RSII and Adverse events may occur during RSII, the most significant of
practice is highly variable.9e11 The term ‘modified rapid which include hypoxia, hypotension and pulmonary aspira-
sequence induction’ is in common use but its meaning is tion. Rapid sequence induction and intubation is associated
poorly defined. The Project for Universal Management of with an increased risk of difficulty in airway management.
Airways (PUMA) group is a collaboration of airway experts The NAP4 identified that failed intubation occurs in 1 in 2,000
who propose a universal description of RSII. This group aims elective cases, but this number increases to 1 in 300 with RSII.
to standardise the conduct of RSII internationally. Their pro- The incidence of failed intubation is even higher (1 in 50e100)
posed universal guidelines for rapid sequence intubation with RSII in the emergency department, critical care or ob-
contain recommended, suggested and optional components stetric patients.2 Hypoxia can occur despite adequate preox-
which represent a benchmark for future practice.12 ygenation of the lungs in a patient who is critically ill, obese or
in the peripartum period. Oxygen desaturation may occur
even when successful intubation is performed swiftly. Hypo-
Indications tension and cardiovascular instability is another concern,
particularly in a frail patient or those in circulatory shock.
The indications for RSII can be divided into:
Although the objective of RSII is to prevent pulmonary aspi-
(i) Patients in whom fasting has occurred but is unreliable. ration, it is recognised that this may still occur during airway
(ii) Patients in whom the fasting time is inadequate or management. The risk of pulmonary aspiration also exists
unidentified. during extubation of the trachea. The anaesthetist must
ensure the patient can protect their airway before removing
Risk factors for pulmonary aspiration are outlined in
the cuffed tracheal tube. If a nasogastric tube is present it
Table 1.
should be aspirated before extubation. The prospect of RSII
An anaesthetist should perform RSII in the following
can generate much anxiety in patients, particularly if cricoid
situations:
pressure is planned. Anaesthetists should remain mindful of
(i) Patients for elective surgery who are adequately fasted this and explain the procedure carefully.
but have risk factors for aspiration (e.g. hiatus hernia,
gastro-oesophageal reflux, previous bariatric surgery,
oesophageal pathology, delayed gastric emptying). Preparation and performance
(ii) Patients for emergency surgery who are not fully fasted, Creating a plan for RSII can help to reduce some of the asso-
or, regardless of fasting status, have risk factors for ciated risks. A recent Difficult Airway Society (DAS) guideline
recommends the use of an intubation checklist for RSII (Fig 1).13
Although this checklist was developed for the critical care
Table 1 Risk factors for pulmonary aspiration. environment, the four headings e prepare the patient, prepare
the equipment, prepare the team and prepare for difficulty e
Fasting unreliable Pregnancy (>20 weeks) neatly summarise a safe approach to RSII in any group.
Obesity (BMI 40 kg m 2)
Hiatus hernia/gastro-
oesophageal reflux The patient
History of oesophageal cancer/
An airway assessment is essential to help anticipate difficulty
stricture or upper gastrointestinal
surgery/bariatric surgery/gastric with airway management and generate a plan. Predicting a
outlet obstruction difficult airway is addressed by a recent paper in this journal;
Advanced chronic disease however, a DAS guideline suggests use of the MACOCHA score
resulting in gastroparesis (Table 2).13e15 A MACOCHA score of >2 predicts difficulty.
(diabetes mellitus/chronic kidney Reliable intravenous access must be established to deliver
disease/neuromuscular
medications for induction. The ideal patient position for RSII
disorders)
is one which facilitates preoxygenation, optimises laryngo-
Not fasted/emergency Patient who is not fasted as per scopic view and opposes passive regurgitation of gastric
procedure local guideline or fasting status contents. The head up position appears to meet these criteria,
unknown but the optimal degree is not yet determined by evidence. The
Acute intra-abdominal pathology most common position described in practice is 20 head up. A
(bowel obstruction)
‘ramped’ position with horizontal alignment of the tragus and
Acute pain or trauma resulting in
gastric stasis the sternal notch is recommenced for obese and obstetric
patients.16,17

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Rapid sequence induction and intubation

Intubation Checklist: critically ill adults - to be done with whole team present.

Prepare the patient Prepare the equipment Prepare the team Prepare for difficulty
Reliable IV / IO access Apply monitors Allocate roles Can we wake the patient
Optimise position SpO2 / waveform ETCO2 / One person may have more than if intubation fails?
ECG / BP one role.
Sit-up?
Mattress hard Check equipment Team Leader Verbalise “Airway Plan is:”
Airway assessment Tracheal tubes x 2 1st Intubator
nd Plan A:
- cuffs checked 2 Intubator
Identify cricothyroid membrane Drugs & laryngoscopy
Direct laryngoscopes x 2 Cricoid force
Awake intubation option? Plan B/C:
Videolaryngoscope Intubator’s assistant
Optimal preoxygenation Supraglottic airway
Bougie / stylet Drugs
Face-mask
3 min or ETO2 > 85% Working suction Monitoring patient
Fibreoptic intubation via
Consider CPAP / NIV Supraglottic airways Runner
supraglottic airway
Nasal O2 Guedel / nasal airways MILS (if indicated)
Plan D:
Flexible scope / Aintree Who will perform FONA?
Optimise patient state FONA
FONA set Who do we call for help? Scalpel-bougie-tube
Fluid / pressor / inotrope
Aspirate NG tube Check drugs Who is noting the time? Does anyone have questions
Delayed sequence induction Consider ketamine or concerns?
Relaxant
Allergies?
Pressor / inotrope
n Potassium risk? Maintenance sedation
- avoid suxamethonium

Figure 1 Intubation checklist for critically ill adults. CPAP, continuous positive airway pressure; FONA, front-of-neck airway; MILS, manual in-line stabilisation;
NG, nasogastric; NIV, noninvasive ventilation.

Preoxygenation of the lungs is essential before RSII. The integrated valve in these appliances requires the generation of
aim of preoxygenation is to accumulate a reservoir of oxygen, considerable negative pressure to open it.18 There is an
which will help to delay the onset of hypoxia during the period emerging role for high-flow nasal oxygen (HFNO) techniques
of apnoea which follows induction and before successful in preoxygenation and apnoeic oxygenation during RSII. High-
tracheal intubation and ventilation are achieved. The ade- flow nasal oxygen has been investigated as an alternative to
quacy of preoxygenation can be evaluated by measurement of preoxygenation using a facemask, and although the safe
the fraction of expired oxygen (FE’O2). An FE’O2 of 0.85 or greater apnoea period may be extended, there is no evidence to sug-
indicates adequate preoxygenation. Preoxygenation in a gest HFNO is a superior device for preoxygenation.19 Alter-
spontaneously ventilating patient is performed using a closed natively, a standard nasal cannula may be used for apnoeic
anaesthetic machine circuit with a fraction of inspired oxygen oxygenation after loss of consciousness using an oxygen flow
(FIO2) of 1.0. Otherwise a semi-closed circuit such as the rate of 15 L min 1: this can also extend the safe apnoea period
Mapleson C circuit with a fresh gas flow of 15 L min 1 can be after spontaneous breathing ceases. In critically ill adults who
used. A high fresh gas flow is required to prevent rebreathing are hypoxaemic, adding continuous positive airway pressure
with a Mapleson C circuit. Preoxygenation is performed by (CPAP) of 5e10 cmH2O during facemask preoxygenation is
tidal volume breathing of oxygen with a tight fitting facemask advised.13 Continuous positive airway pressure can help pre-
for 3 min, or alternatively with eight vital capacity breaths. vent the development of absorption atelectasis associated
Preoxygenation involves denitrogenation of the functional with breathing high concentration oxygen. Finally, if a naso-
residual capacity of the lungs. Patients who are pregnant or gastric tube is present it should be aspirated and left open to
obese have a reduced functional residual capacity, therefore air before RSII. The insertion and aspiration of a nasogastric
optimal positioning and adequate preoxygenation is espe- tube before RSII can be considered in patients who are likely to
cially important in these groups. The use of a self-inflating a have a significant volume of gastric residue.
bag-valve-mask resuscitator to preoxygenate the lungs of a
patients breathing spontaneously is inappropriate as the
Equipment
Minimum monitoring, as described by the Association of
Anaesthetists, should be applied to the patient before RSII.
Table 2 MACOCHA score (score >2 predicts difficulty).15 Waveform capnography is essential to confirm correct
tracheal tube placement. The insertion of an arterial cannula
Factors Points
for invasive blood pressure measurement is recommended in
Mallampati class III or IV 5 patients with haemodynamic instability. Central venous ac-
Obstructive sleep Apnoea syndrome 2 cess may also be required for vasoactive infusions in the
Reduced mobility of Cervical spine 1 critically ill. A functioning airway suction device should be
Limited mouth Opening <3 cm 1 available and placed under the patient’s pillow. The presence
Coma 1 of two active suction catheters is recommended if significant
Hypoxaemia 1
airway contamination is likely. A recent Cochrane systematic
Non-Anaesthetist 1
review concluded that when compared with direct laryngos-
copy, videolaryngoscopy results in higher rates of successful

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 Rapid sequence induction and intubation

Table 3 Medications for rapid sequence induction and intubation.

Indication Medication Dose Specific considerations

Induction Etomidate 200e300 mg kg 1

Consider in patients with hypovolaemia or circulatory shock
Propofol 1e3 mg kg 1 Universal intravenous induction agent but can cause significant
cardiovascular depression
1
Thiopental 3e5 mg kg Consider in patients in refractory status epilepticus
1
Ketamine 1e2 mg kg Consider in patient with hypovolaemia, circulatory shock or life-
threatening asthma
1
Neuromuscular Suxamethonium 1e2 mg kg Avoid in patients with hyperkalaemia, crush injuries and more
blocking agent than 24 h after severe burns
1
Rocuronium 1e1.2 mg kg Reversible with sugammadex 16 mg kg 1
Optional adjuncts Fentanyl 1e3 mg kg 1 To attenuate the sympathetic response to laryngoscopy.
Alfentanil 10e50 mg kg 1
Consider in patients with raised intracranial pressure, malignant
Remifentanil 1 mg kg 1 hypertension, aortic dissection, pre-eclampsia/eclampsia or
1
Lidocaine 1e1.5 mg kg significant cardiovascular disease

tracheal intubation on the first attempt.20 A video- however, a number of subsequent studies involving radio-
laryngoscope may be advantageous for RSII if difficulty is logical imaging have concluded that this is unreliable.22 The
anticipated providing the operator is familiar with its use. A oesophagus appears to reside posterolaterally to the cricoid
tracheal tube introducer, such as a bougie, should be imme- cartilage in many humans and cricoid pressure simply results
diately available to assist tracheal intubation. in further lateral displacement of the oesophagus. Direct
The ideal medications to induce anaesthesia in the setting compression may not be the actual mechanism by which
of RSII are specific to the patient and the situation. Whichever cricoid pressure works. It is possible that cricoid pressure
agents are used, it is established practice to use pre- actually prevents regurgitation through occlusion of the
determined doses of an intravenous anaesthetic agent and a postcricoid hypopharynx. A Cochrane review conducted in
neuromuscular blocking drug in immediate succession. The 2015 concluded that no randomised controlled trial exists to
combination of thiopental and suxamethonium is being support or refute the use of cricoid pressure.23 In the absence
replaced with agents such as propofol and rocuronium. of such evidence, when considering the potential benefits,
Although not described in classical RSII, using opioids to blunt many experts continue to recommend the use of cricoid
the sympathetic response to laryngoscopy has become com- pressure.24
mon practice, though this remains optional. The use of a rapid Several techniques to apply cricoid pressure are described
acting neuromuscular blocking drug is mandatory. The choice in the literature. Correct identification of the cricoid cartilage
between rocuronium and suxamethonium is a source of is essential. The cricoid cartilage is found in the midline of the
debate and has been discussed recently in this journal.21 neck, inferior to the thyroid cartilage. Cricoid pressure in-
Table 3 summarises potential choices of medications for in- volves the application of vertical, downward pressure using
duction and neuromuscular block in RSII. The dose for each the thumb and first or middle finger. A force of 10 N is applied
adjunct and induction medication is given as a range and when the patient is awake, and increased to 30 N once the
must take account of the specific clinical context and cumu- patient becomes unresponsive.25 The pressure is maintained
lative effect if multiple agents are used. Conservative doses until inflation of the tracheal tube cuff and confirmation of
are required in patients who are older, frail or hypovolaemic. successful placement with waveform capnography.
The application of cricoid pressure is associated with dif-
ficulty in facemask ventilation and placement of supraglottic
The team airways. Recently a randomised controlled trial involving
Rapid sequence induction and intubation for an elective case 3,472 patients undergoing RSII found pulmonary aspiration
may involve only the anaesthetist and a trained assistant. The occurred in 10 patients (0.6%) in the group receiving cricoid
conduct of RSII in the critical care setting necessitates a larger pressure and in 9 patients (0.5%) in the control group.26
team. In such cases, the following roles should be assigned Laryngoscopy was more difficult and intubation times were
before commencing the procedure: longer in the group receiving cricoid pressure. Studies con-
cerning the performance of cricoid pressure by clinicians
(i) Airway management/intubator
suggest that’s its use is inconsistent. A survey of anaesthetists
(ii) Airway assistant/application of cricoid pressure
in the UK identified significant variability around the timing of
(iii) Team leader/medications/monitor/second intubator
its application.27 There is also concern that applying cricoid
(iv) Runner (any healthcare staff member who can reliably
pressure can cause relaxation of the lower oesophageal
fetch equipment)
sphincter, thereby increasing the risk of passive regurgitation.
Perhaps the most debated element of RSII is the application Although its use remains controversial, it is recommended
of cricoid pressure. Cricoid pressure involves applying force to that if difficulty is encountered with airway management
the cricoid cartilage in an attempt to compress the oesoph- cricoid pressure should be released. Educating staff to apply
agus between the posterior cricoid ring and the body of the cricoid pressure correctly is a further challenge. Training can
fifth cervical vertebra. Sellick proposed that pulmonary aspi- be facilitated with the use of a biofeedback device, which in-
ration could be prevented by compression of the oesophagus; dicates the amount of pressure applied in a simulated setting.

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Rapid sequence induction and intubation

Such equipment can be purchased or constructed locally with adequate preoxygenation, gentle bag-mask ventilation and
clinical equipment found in any anaesthetic department.28 apnoeic oxygenation are all recommended during RSII in ob-
The ergonomics of the patient, equipment and team stetric anaesthesia. Furthermore, because of the higher inci-
should also be considered. If possible all team members dence of difficult airway in obstetric practice, it is suggested a
should be able to view the patient monitor. If a second intu- videolaryngoscope be used as first line.31
bator is present they should be positioned appropriately,
facilitating rapid handover if necessary. The monitor’s pulse
oximeter tone should be audible, and this may require Defining RSII
adjustment in the critical care or emergency department The PUMA group is an international collaboration of experts
setting. who have proposed a set of universal principles for the
conduct of RSII.12 The principles (listed in Table 4) include
recommended, suggested and optional components of the
Prepare for difficulty
procedure based on consensus and the current evidence base.
An airway plan should be shared with the team members Project for Universal Management of Airways recommend 10
before RSII. The presence of all of the equipment necessary to core elements that must be completed to meet the definition
execute the airway plan must be confirmed before of RSII. Steps applicable to a standard induction of anaes-
commencing the procedure. In the event of failed intubation, thesia such as monitoring do not feature as they are not
the team should focus on rescue oxygenation. This will specific to RSII. The suggested components should be included
include facemask ventilation or the placement of a supra- but may be omitted in specific situations. The optional com-
glottic airway. Gastric insufflation during facemask ventila- ponents are elements of the procedure for which supporting
tion can be reduced by: evidence is weak. This allows a practitioner to use their
judgement for certain components depending on the context.
(i) Maintaining a patent airway, with airway adjuncts and
two-handed technique if necessary.
(ii) Restricting peak inspiratory pressures to 15 cmH2O or less Future directions
during positive pressure ventilation.
Several developments concerning RSII are ongoing. The use of
The specific clinical context will determine if it would be paratracheal force has recently been suggested as an alter-
appropriate to wake the patient in the event of failed intuba- native to cricoid pressure. Paratracheal pressure has been
tion. If the procedure is elective this may be possible, but it is associated with a reduction in gastric insufflation of air during
unlikely to be an option for time-critical surgery. positive pressure ventilation and the effects on view at
laryngoscopy may be non-inferior compared with cricoid
pressure.32 The investigators also reported easier bag-mask
RSII in special groups ventilation and lower peak inspiratory pressures in the para-
Current evidence suggests the use of classical RSII in paedi- tracheal force group. The use of ultrasound to evaluate re-
atric anaesthesia is limited. A survey of British anaesthetists sidual gastric volume is also being explored. Gastric
identified only half would use the classical RSII to intubate a ultrasound could contribute to the assessment of aspiration
child with a ‘full stomach’.29 The various anatomical and risk for individual patients. A retrospective cohort study of
physiological differences in infants and children make the fasted elective surgical patients using point-of-care ultra-
classical approach less favourable have been described pre- sound involving 538 patients found that 6.2% presented with a
viously in this journal.30 Conversely, the use of RSII in ob- ‘full stomach’.33 Furthermore, a randomised controlled trial
stetric anaesthesia has persisted. To avoid desaturation involving healthy volunteers and blinded sonographers found

Table 4 Project for Universal Management of Airways (PUMA) universal principles for rapid sequence induction. NMBA, neuromus-
cular blocking agent.

Recommended Suggested Optional

Preoxygenation Apnoeic oxygenation during attempts at Prokinetic drugs

Suction turned on and placed under the laryngoscopy Non-particulate or intravenous antacids
pillow Able to adopt Trendelenburg position if Nasogastric tube placement and suction
Confirmed and reliable intravenous regurgitation occurs Avoid agents with potential sedative or
access Suction and leave open to air an in situ hypnotic effects before induction
Tracheal introducer prepared nasogastric tube Avoid facemask ventilation before
Predetermined dose of induction agent laryngoscopy
No latency between giving induction Position change
agent and NMBA Cricoid pressure
Use of rapid-onset NMBA
Apnoeic oxygenation between attempts
at laryngoscopy if facemask ventilation
not used
Confidence in complete paralysis before
instrumenting airway
Tracheal tube cuff inflation before
positive pressure ventilation

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 Rapid sequence induction and intubation

that gastric ultrasound is highly sensitive and specific when Available from, https://www.universalairway.org.
identifying residual gastric content.34 Fifty years after RSII was [Accessed 25 August 2021]
first described it continues to evolve. The addition of the 13. Higgs A, McGrath BA, Goddard C et al. Guidelines for the
PUMA universal guidelines will address the variability management of tracheal intubation in critically ill adults.
observed in current practice and offer a clear definition for Br J Anaesth 2018; 120: 323e52
this procedure. Future studies will need to assess if these 14. Crawley SM, Dalton AJ. Predicting the difficult airway. BJA
developments reduce the incidence of pulmonary aspiration Educ 2015; 15: 253e7
and the associated mortality and morbidity. 15. De Jong A, Molinari N, Terzi N et al. Early identification of
patients at risk for difficult intubation in the intensive
care unit: development and validation of the MACOCHA
Declaration of interests score in a multicenter cohort study. Am J Respr Crit Care
EPO is a former president of the Difficult Airway Society, past Med 2013; 187: 832e9
president and current airway advisor to the College of 16. The Association of Anaesthetists of Great Britain and
Anaesthesiologists of Ireland, and is on the working group of Ireland and Society for Obesity and Bariatric Anaesthesia.
PUMA. JC declares that they have no conflicts of interest. Peri-operative management of the obese surgical patient. Lon-
don. 2015
17. Mushambi MC, Kinsella SM, Popat M et al. Obstetric Anaes-
MCQs thetists’ Association and Difficult Airway Society guidelines
for the management of difficult and failed tracheal intuba-
The associated MCQs (to support CME/CPD activity) will be
tion in obstetrics. Anaesthesia 2015; 70: 1286e306
accessible at www.bjaed.org/cme/home by subscribers to BJA
18. Hess D, Hirsch C, Marquis-D’Amico C, Kacmarek RM.
Education.
Imposed work and oxygen delivery during spontaneous
breathing with adult disposable manual ventilators.
Anesthesiology 1994; 81: 1256e63
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