Rapid Sequence Intubation

Rapid sequence intubation (RSI) is a way for healthcare providers to quickly insert a breathing tube into your windpipe in an emergency.

Providers give you a sedative and a neuromuscular blocking agent (paralytic) at the same time. The sedative puts you to sleep quickly. The neuromuscular blocking agent (NMBA) temporarily relaxes your muscles. This keeps you from straining, coughing or throwing up, which can lead to problems if substances like vomit or blood get in your airways (aspiration). Relaxing your muscles also makes it easier for providers to insert the breathing tube.

RSI is very common. Providers often use it in emergency situations in which you’re:

• Unable to breathe because of a blockage or damage to your airways (respiratory failure)
• Unable to breathe because of a severe allergic reaction (anaphylaxis)
• Unable to protect your airways due to conditions like a traumatic brain injury or altered mental status
• At a high risk of getting substances in your lungs because you still have food or fluids in your stomach, you’re pregnant or you have upper digestive tract bleeding

Other names for RSI include:

• Tracheal rapid sequence intubation
• Rapid sequence induction
• Rapid sequence induction and intubation (RSII)
• Crash induction

What are the steps?

During rapid sequence intubation, healthcare providers will:

1. Put a nasal cannula and non-rebreather mask on you to give your body extra oxygen for a few minutes before intubation (preoxygenation).
2. Insert an IV needle into your arm to deliver a sedative and neuromuscular blocking agent so you’ll fall asleep, you won’t feel pain and your muscles will relax.
3. Sometimes apply pressure on your neck to compress your esophagus and prevent vomiting (cricoid pressure or Sellick’s maneuver).
4. Wait a few moments for the medications to take effect.
5. Check your eyes, jaw and neck muscles to ensure the NMBA is working.
6. Remove the non-rebreather mask.
7. Tilt your head back and insert the laryngoscope in your mouth, which helps them guide the breathing tube.
8. Insert the breathing tube into your windpipe and secure it in place so it doesn’t move.
9. Ensure the breathing tube is in the right place by doing an X-ray or listening for sounds in your chest or stomach that may indicate problems.
10. Release pressure on your neck.

Providers can usually complete RSI in a few minutes.

What equipment is needed for rapid sequence intubation?

In general, healthcare providers need the following equipment:

• Machines to monitor your vital signs
• Hollow plastic tubes (peripheral IVs) to deliver medications, usually through a vein in your arm
• Medications, including sedatives, paralytics and vasopressor medications
• A non-rebreather mask and nasal cannula to give you oxygen before intubation
• A bag valve mask to give you oxygen after intubation
• Oxygen supply
• An instrument with a light, lens and video camera (laryngoscope) to help them look at your voice box
• A flexible, hollow plastic tube that goes into your airways to deliver oxygen (endotracheal tube or breathing tube)
• Suction tubes to clear your airways and help them see better

What is the success rate?

RSI has a high success rate. Over 95% of the time, providers can successfully place a breathing tube with RSI. With the breathing tube properly in place, providers can connect you to a machine that delivers lifesaving oxygen to your lungs.

What are the potential benefits and risks?

Rapid sequence intubation:

• Provides lifesaving oxygen to your body
• Protects your airways from damage
• Prevents foreign substances from entering your lungs
• Prevents neck movement and possible damage to your spine

RSI risks include:

• Providers are unable to insert the breathing tube, which may require them to use a different way to get your body oxygen.
• The sedative doesn’t work or wears off.
• You have a serious allergic reaction to the sedative or NMBA.
• The breathing tube enters your esophagus.
• You develop an infection, like a sinus infection or pneumonia.
• Too much cricoid pressure damages your esophagus or windpipe.
• The laryngoscope damages your mouth, tongue, teeth, vocal cords or airway.
• You develop a cough, sore throat, hoarse voice or problems swallowing for a few days.

How long will it take for me to feel better?

Your body is unique. How it responds after RSI may be different from others. Many people who have had a breathing tube placed by RSI can swallow and talk comfortably a few hours after the breathing tube is removed. Your healthcare providers will tell you what to expect according to your symptoms.

When should I call my healthcare provider?

It’s normal to have a cough, hoarseness or problems swallowing after RSI. But you should reach out to your provider if any of these issues last longer than a few weeks. They may refer you to a speech-language pathologist to help with any swallowing problems.

You should also call your provider if you develop symptoms of an infection after RSI. These may include:

• Fever
• Cough with yellow, green or bloody mucus
• Headache
• Shortness of breath
• Rapid heart rate
• Sweating or chills
• Chest or abdominal pain
• Extreme tiredness or weakness

What is the difference between RSI and normal intubation?

Healthcare providers are most likely to use RSI in emergency situations when they must place a breathing tube immediately to save your life. They don’t know when you last had anything to eat or drink. RSI helps reduce the risk of food or fluid getting into your lungs while they place the breathing tube.

Providers use “normal” intubation methods for planned surgeries in an operating room. You’re supposed to avoid food and fluids for at least eight hours before a scheduled procedure. This reduces your risk of getting food or fluid in your lungs during the intubation procedure. Because there is no medical emergency, providers can take more time when inserting the breathing tube. They may also use different medicines or techniques during a “normal” intubation to help calm and relax you.