Guide — Airway Management
Rapid Sequence Intubation (RSI)
Rapid sequence intubation gives a sedative and a paralytic almost at once to take control of the airway fast while keeping the aspiration risk low. This guide walks the seven Ps, the induction agents and paralytics, and the preoxygenation and confirmation role the RT owns at the bedside.
9 min read · Airway Management
Written by Apex Respiratory Editorial Team
Educational use only. This material supports respiratory therapy education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional protocols, or physician orders. Always follow facility policies and current provider orders, and verify calculations independently before clinical use.
Overview
Rapid sequence intubation is the near-simultaneous administration of a potent induction (sedative) agent and a rapid-acting paralytic to create optimal intubating conditions while minimizing the risk of aspiration. It is the default approach for emergency airway management in a patient assumed to have a full stomach.
Classically, no bag-mask ventilation is given between induction and intubation — positive pressure can insufflate the stomach and promote regurgitation — unless the patient desaturates and oxygenation must be restored. Preoxygenation is what makes that apneic window safe, which is why the RT’s role at the head of the bed is central to a smooth, controlled intubation.
Key Concepts
RSI is organized as the seven Ps — a checklist that sequences the procedure from preparation through post-intubation care.
| P | Step |
|---|---|
| Preparation | Ready the equipment (SOAP-ME), pick a tube and laryngoscope, and have a plan with a defined backup before any drug is drawn |
| Preoxygenation | 3–5 minutes of 100% oxygen or 8 vital-capacity breaths; add apneic oxygenation by nasal cannula to extend the safe apneic time |
| Pretreatment | Optional adjuncts for selected patients to blunt the physiologic response to laryngoscopy |
| Paralysis with induction | Give the induction (sedative) agent and the rapid-acting paralytic together to create optimal intubating conditions |
| Positioning | Align the airway axes (sniffing position or ramping) to optimize the laryngoscopic view |
| Placement with proof | Intubate and confirm tube position with waveform capnography — the gold standard |
| Post-intubation management | Secure the tube, set the ventilator, continue sedation, and order a chest X-ray to confirm depth |
Two drug classes drive the “paralysis with induction” step. The induction agent provides sedation, amnesia, and loss of consciousness; the paralytic provides the muscle relaxation that optimizes the view. They are chosen for the patient’s physiology.
| Induction Agent | Notes |
|---|---|
| Etomidate | Hemodynamically stable choice; causes transient adrenal suppression |
| Ketamine | Bronchodilation and preserved blood pressure — useful in shock or asthma |
| Propofol | Effective sedative but causes hypotension |
| Midazolam | Benzodiazepine; provides sedation and amnesia |
| Paralytic | Class | Profile |
|---|---|---|
| Succinylcholine | Depolarizing | Fast onset ~45 s, short duration ~6–10 min; contraindicated with hyperkalemia, burns/crush injury beyond ~24–48 h, denervation/neuromuscular disease, or malignant hyperthermia risk |
| Rocuronium | Non-depolarizing | Longer duration than succinylcholine; reversible with sugammadex |
Assessment & Findings
- Indication for a definitive airway. Failure to oxygenate, failure to ventilate, failure to protect the airway, or an anticipated clinical course that demands intubation.
- Difficult-airway prediction. Assess for predictors of a hard intubation up front so the plan and backup match the risk — never paralyze without a rescue path.
- Hyperkalemia risk for succinylcholine. Screen for burns, crush injury, denervation or neuromuscular disease, and malignant hyperthermia history before choosing the paralytic.
- Baseline oxygenation and hemodynamics. Saturation, blood pressure, and the gas frame how much apneic time you have and which induction agent is safest.
- Confirmation after placement. Waveform capnography is the gold standard for verifying the tube is in the trachea, backed by bilateral breath sounds and a chest X-ray for depth.
RT Priorities / Interventions
The RT works the head of the bed before, during, and after the attempt — owning oxygenation, equipment, and confirmation.
- Preoxygenate and denitrogenate. Deliver 3–5 minutes of 100% oxygen or 8 vital-capacity breaths to build the oxygen reserve that buys safe apneic time.
- Apneic oxygenation. Leave a nasal cannula running through the apneic period so oxygen keeps diffusing into the blood while the tube is placed.
- Equipment readiness. Confirm SOAP-ME — suction, oxygen, airways, pharmacy, monitoring/capnography, and equipment — with a backup device within reach.
- Bag-mask standing by. Hold ventilation through the apneic window, but be ready to bag if the patient desaturates to restore oxygenation.
- Confirm with capnography. Verify tube placement with waveform capnography immediately after insertion — do not rely on auscultation alone.
- Post-intubation setup. Secure the tube, configure the ventilator, ensure ongoing sedation is running, and confirm depth on the chest X-ray.
Common Pitfalls
- Inadequate preoxygenation. Skipping or rushing the oxygen build-up shrinks the apneic window and sets up a desaturation crisis mid-attempt.
- Awake paralysis. Giving the paralytic without adequate sedation leaves the patient aware but unable to move — always pair and follow paralysis with sufficient induction and sedation.
- Succinylcholine in a hyperkalemia-risk patient. Burns, crush injury, denervation, or neuromuscular disease can turn succinylcholine into a lethal potassium spike — reach for rocuronium instead.
- No rescue device ready. Paralyzing without a backup airway in hand removes every fallback if the first attempt fails.
- Bagging through the apneic period. Routine positive-pressure ventilation between induction and intubation insufflates the stomach and raises aspiration risk — reserve it for the desaturating patient.
Board Exam Pearls
- Know the seven Ps in order: Preparation, Preoxygenation, Pretreatment, Paralysis with induction, Positioning, Placement with proof, and Post-intubation management.
- Memorize the succinylcholine contraindications — hyperkalemia, burns, crush injury, neuromuscular disease, and malignant hyperthermia. A stem with any of these wants rocuronium.
- Etomidate and ketamine are the hemodynamically favorable induction agents; ketamine’s bronchodilation makes it a go-to in asthma and shock.
- Always sedate a paralyzed patient — a paralytic has no sedative effect, and awake paralysis is never an acceptable answer.
- Preoxygenation is the safety buffer that buys apneic time — the more complete it is, the longer you can work before the saturation falls.
FAQ
What are the seven Ps of RSI?
Preparation (equipment, SOAP-ME, and a plan with a backup), Preoxygenation (3–5 minutes of 100% oxygen or 8 vital-capacity breaths, plus apneic oxygenation by nasal cannula), Pretreatment (optional adjuncts for selected patients), Paralysis with induction (the induction agent and paralytic given together), Positioning, Placement with proof (intubate and confirm with waveform capnography), and Post-intubation management (secure, ventilate, sedate, and order a chest X-ray).
When is succinylcholine contraindicated?
Succinylcholine is avoided when it could trigger dangerous hyperkalemia or malignant hyperthermia: pre-existing hyperkalemia, burns or crush injury beyond roughly 24–48 hours, denervation or neuromuscular disease, and a personal or family history of malignant hyperthermia. In those patients a non-depolarizing agent such as rocuronium is used instead.
Why must a paralyzed patient also be sedated?
A paralytic stops movement but provides no sedation, amnesia, or analgesia. Without an adequate induction agent the patient can be fully aware while unable to move or breathe — awake paralysis, a terrifying and harmful experience. Paralysis is always paired with, and followed by, sufficient sedation.
What is apneic oxygenation?
Apneic oxygenation is delivering oxygen by nasal cannula throughout the apneic period between induction and intubation. With the airway open, oxygen continues to diffuse into the blood even without active breaths, slowing desaturation and extending the safe time available to secure the tube.
Put it to work
Securing the airway is half the job — you also have to read the gas before and after. Run a sample through the interpreter to check oxygenation and acid-base before you induce and again once the tube is in.
Open the ABG Interpreter →Related Resources
Sources
- Kacmarek RM, Stoller JK, Heuer AJ. Egan's Fundamentals of Respiratory Care. 12th ed. Elsevier; 2021.
- Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American Society of Anesthesiologists practice guidelines for management of the difficult airway. Anesthesiology. 2022;136(1):31-81.
- Gardenhire DS. Rau's Respiratory Care Pharmacology. 10th ed. Elsevier; 2019.