Intubate like it’s 2025

Emergency tracheal intubation still carries major peri-intubation risk, with hypoxemia and hypotension remaining common complications. Current ED airway evidence favors positive-pressure preoxygenation, routine video laryngoscopy, and using either a stylet-loaded endotracheal tube or a bougie rather than a bare tube.

Evidence-Based ED Intubation

• Positive-pressure preoxygenation: Noninvasive ventilation is now the preferred preoxygenation strategy when feasible, cutting hypoxemia and even lowering peri-intubation cardiac arrest compared with oxygen delivery that does not provide positive pressure.
• Bag-mask during induction: Ventilation between induction and laryngoscopy reduces hypoxemia without increasing aspiration, making bag-mask support a default move rather than something to avoid reflexively, and we get into the setup details in the episode.
• Limited role for apneic oxygenation: Routine nasal-cannula or high-flow apneic oxygenation has not improved nadir oxygen saturation or reduced hypoxemia during laryngoscopy, so it should not be treated as a cornerstone maneuver.
• RSI medication fab four: For standard ED rapid sequence intubation, etomidate or ketamine for induction and succinylcholine or rocuronium for paralysis remain the practical first-line choices; familiarity is the deciding principle.
• Post-intubation hypotension readiness: Peri-intubation hypotension is driven by vasodilation, loss of catecholamine tone, and reduced venous return under positive pressure, and prophylactic fluid boluses have not prevented it in normotensive patients.
• Video plus introducer strategy: Video laryngoscopy outperforms direct laryngoscopy even in contaminated airways, and first-pass technique should include either an endotracheal tube with stylet or a bougie. We walk through why the bare tube should be retired in the chapter.

References:

1. DeMasi SC, Casey JD, Semler MW. Evidence-based Emergency Tracheal Intubation. Am J Respir Crit Care Med. Published online April 16, 2025. PMID: 40238943
2. Gibbs KW, et al. Protocol and statistical analysis plan for the PREOXI trial of preoxygenation with noninvasive ventilation vs oxygen mask. PMID: 36993496
3. Casey JD, et al. PreVent Investigators and the Pragmatic Critical Care Research Group. Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. N Engl J Med. 2019 Feb 28;380(9):811-821. PMID: 30779528
4. Jabre P, et al. KETASED Collaborative Study Group. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial. Lancet. 2009 Jul 25;374(9686):293-300. PMID: 19573904
5. Janz DR, et al. PrePARE Investigators; Pragmatic Critical Care Research Group. Effect of a fluid bolus on cardiovascular collapse among critically ill adults undergoing tracheal intubation (PrePARE): a randomised controlled trial. Lancet Respir Med. 2019 Dec;7(12):1039-1047. PMID: 31585796
6. Prekker ME, et al. DEVICE Investigators and the Pragmatic Critical Care Research Group. Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults. N Engl J Med. 2023 Aug 3;389(5):418-429. PMID: 37326325
7. Jaber S, et al. STYLETO trial group. Effect of the use of an endotracheal tube and stylet versus an endotracheal tube alone on first-attempt intubation success: a multicentre, randomised clinical trial in 999 patients. Intensive Care Med. 2021 Jun;47(6):653-664. doi: 10.1007/s00134-021-06417-y. PMID: 34032882
8. Driver BE,et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018 Jun 5;319(21):2179-2189. PMID: 29800096
9. Driver B, et al. BOUGIE Investigators and the Pragmatic Critical Care Research Group. BOugie or stylet in patients UnderGoing Intubation Emergently (BOUGIE): protocol and statistical analysis plan for a randomised clinical trial. BMJ Open. 2021 May 25;11(5):e047790. PMID: 34035106