Written by Aaron Lacy
40% of patients undergoing endotracheal intubation (ETI) have a major adverse event. This article gets you up to speed on what tools, techniques, drugs, and interventions give your patient the best shot at a successful intubation without adverse events.
Intubate like its 2025
Avoiding Hypoxia
- Unless contraindication, preoxygenation with a dedicated non-invasive ventilator or a tight fitting mask attached to a conventional ventilator prevents critical hypoxia during ETI (see PREOXI)
- Oxygenation, and unless contraindication, oxygenation with positive pressure (BVM or BiPAP), after induction and before laryngoscopy prevents critical hypoxia during ETI (see PreVENT and PREOXI)
Avoiding Hypotension
- There is no clear evidence that prophylactic fluid boluses prevent cardiovascular collapse during ETI (see PrePARE)
- The evidence on prophylactic pressors is still out, but there is an ongoing RCT looking at prophylactic norepinephrine versus no vasopressors
- Hypotension occurs in 25-40% of ETIs, so be prepared to address it by having pressors and fluid boluses readily available in the peri-intubation period
Medication Choices
- For induction, at this time the evidence supports both etomidate or ketamine, and selection should be based on specific patient factors. There is an ongoing RCT comparing these two induction medications, which is slated to finish enrollment in 2025
- For neuromuscular blockade, at this time the evidence supports both succinylcholine and rocuronium, and selection should be based on specific patient factors (see CURASMER)
Laryngoscope and Tube Introducer Choices
- Video laryngoscopy is superior to direct laryngoscopy in all patients, even contaminated airways, and should be used in critically ill patients (see DEVICE)
- You can use either an ETT + Stylet or a bougie for your first attempt (see BOUGIE)
- Please don’t try to intubate using an ETT without a stylet (see STYLETO)
How will this change my practice?
ETI is a core part of the EM physicians identity. Like all facets of medicine, the evidence changes over time and we need to keep up. If you are still intubating like you did during residency you are likely missing out on key advances in our understanding of how to best prevent adverse outcomes and maximize success during ETI. I will continue to follow the evidence and adjust, and teach, as it comes out. You will notice, all of the major studies used to inform these decisions have been covered by us here at JournalFeed, so keep spoon feedin’ and you will be good!
Source
Evidence-based Emergency Tracheal Intubation. Am J Respir Crit Care Med. 2025 Apr 16. doi: 10.1164/rccm.202411-2165CI. Epub ahead of print. PMID: 40238943
