Not All Intubations Are the Same: Choosing the Right Airway Strategy in Acute Care
Intubation Is More Than a Tube — It’s a Strategy Under Pressure
If airway management were just about “putting the tube in,”
RSI would solve everything.
But every emergency physician eventually learns the hard truth:
👉 Intubation is not one technique. It’s a strategic decision.
RSI, DSI, awake intubation, ketamine-only breathing approaches — each exists because physiology, cooperation, and risk are different in every patient.
And yet…
I still see it far too often in wards and non-ED settings.
A hypoxic patient.
No proper preoxygenation.
No induction.
No paralysis.
Just under minimal analgesia, a struggling, awake patient — eyes wide, gagging — while a tube is forced through their throat.
It’s horrible to watch.
Not just because it’s uncomfortable.
But because it’s unsafe.
Because airway management reduced to “get the tube in somehow” ignores everything we’ve learned about hypoxia, aspiration, hemodynamic collapse, and first-pass success.
This is exactly why modern airway practice evolved beyond brute force.
Not to make things fancy.
But to make them safer, smarter, and physiology-aware.
But every acute care physician eventually learns the hard truth:
👉 Intubation is not one technique. It’s a strategic decision.
RSI, DSI, awake intubation, ketamine-only breathing approaches — each exists because physiology, cooperation, and risk are different in every patient.
As emphasized repeatedly in Walls Manual of Emergency Airway Management,
successful airway control is less about devices and more about choosing the right approach for the patient in front of you.
Let’s walk through these approaches the way real ED airways unfold — with judgment, not just drug lists.
First Principle: What Are You Actually Optimizing?
Before naming an approach, pause and ask:
✔ Can this patient tolerate apnea?
✔ Is the physiology apt for the so thought strategy?
✔ Can I safely paralyze them?
✔ What happens if my first attempt fails?
Every airway strategy is simply a different balance between oxygenation, safety, and speed.
1. Rapid Sequence Intubation (RSI): The Workhorse of the ED
RSI pairs a sedative with a fast neuromuscular blocker to create ideal intubating conditions — minimizing aspiration while maximizing first-pass success.
Large emergency department cohorts consistently show higher first-pass success with RSI compared to non-RSI approaches (Okubo et al., 2017).
But RSI itself has evolved.
It’s no longer the rigid “no ventilation at all costs” technique many of us were first taught.
Modern guidelines now accept gentle positive-pressure ventilation after induction to prevent dangerous desaturation — particularly in critically ill and hypoxemic patients (Acquisto et al., 2023; Kriswidyatomo & Paramitha, 2020).
In other words, RSI has shifted from dogma to physiology-guided pragmatism.
RSI works best when:
• Preoxygenation is achievable
• A short apneic period is tolerated
• Aspiration risk is high
Where RSI becomes dangerous:
• Profound hypoxemia
• Severe shock or metabolic acidosis
• Minimal physiologic reserve
As emphasized repeatedly in Walls Manual of Emergency Airway Management, RSI is incredibly powerful — but only when its physiologic assumptions hold true.
A newer controversy: should the paralytic given first?
Recently, some clinicians have explored a “paralytic-first” RSI sequence — giving the neuromuscular blocker a few seconds before the sedative instead of the traditional sedative-then-paralytic order.
A secondary analysis of an ED randomized trial found that NMBA-first shortened the time to intubation by only about 6 seconds, with both approaches considered acceptable (Driver et al., 2019).
However, larger reviews emphasize that:
• Evidence is insufficient to mandate changing practice (Engstrom et al., 2023)
• There are real concerns about awareness, psychological trauma, and sympathetic surges if paralysis precedes adequate sedation (Tsai et al., 2020)
• Major guidelines continue to define RSI as near-simultaneous sedative plus paralytic, without endorsing paralytic-first as standard (Acquisto et al., 2023; Stollings et al., 2014)
Recent editorials sum it up well:
Paralytic-first RSI may slightly shorten apnea time — but whether it improves outcomes or introduces new harms remains uncertain (Ehrman et al., 2025).
👉 For now, the priority remains reliable, timely sedation, excellent preoxygenation, and careful physiologic optimization, rather than rearranging drug order.
2. Delayed Sequence Intubation (DSI): When the Setup Is the Problem
DSI exists for one frustrating — and common — ED scenario:
The patient who NEEDS RSI but REFUSES preoxygenation.
Agitated trauma patients.
Hypoxic ARDS or COVID-19 patients pulling off masks.
Delirious, air-hungry patients who cannot cooperate.
Instead of forcing an immediate RSI and risking profound desaturation, DSI uses dissociative-dose ketamine to preserve spontaneous breathing, allowing proper preoxygenation before committing to paralysis and laryngoscopy.
What does the evidence show?
A 2023 randomized trial in agitated trauma patients showed:
👉 Peri-intubation hypoxia dropped dramatically with DSI (8% vs 35%)
👉 First-pass success improved (83% vs 69%)
when compared with conventional RSI performed without dissociative preoxygenation (Bandyopadhyay et al., 2023).
Earlier ED and ICU series demonstrated mean oxygen saturation rising from around 90% to nearly 99% after ketamine-facilitated preoxygenation — with very low complication rates (Weingart et al., 2015; Merelman et al., 2019).
Prehospital systems that incorporated DSI into airway bundles saw peri-intubation hypoxia fall from 44% to just 3.5% (Jarvis et al., 2018).
Where DSI seems especially useful
Evidence (mostly observational but growing) supports benefit in:
• Agitated trauma patients (Bandyopadhyay et al., 2023)
• Prehospital and flight medicine (Waack et al., 2018)
• Severe hypoxemia including COVID-19 ARDS (De Oliveira & De Souza, 2020; Lemos et al., 2022)
• Non-cooperative pediatric patients (Rebollar et al., 2024 – limited data)
The core technique (unchanged)
DSI is not complicated:
Ketamine 1–2 mg/kg IV (or 4–6 mg/kg IM)
Maintain spontaneous breathing
Aggressive preoxygenation (NIV, HFNC, positioning)
Then give paralytic and proceed like standard RSI
(Weingart et al., 2015; Merelman et al., 2019)
Important perspective
DSI is not a replacement for RSI.
It is a targeted strategy for patients who block preoxygenation.
Most reviews and guidelines emphasize:
✔ Strong physiologic logic
✔ Improving oxygen reserve before apnea
❗ But still limited large multicenter outcome trials
(Taylor & Hohl, 2017; Merelman et al., 2019; Acquisto et al., 2023)
DSI is about buying oxygen and safety before committing to paralysis — not about avoiding RSI altogether.
3. Awake Intubation: When Losing the Airway Is Not an Option
If RSI is about speed and control,
awake intubation is about safety and foresight.
Despite newer devices and drugs, awake tracheal intubation (ATI) remains the gold standard for anticipated difficult airways — not because it’s flashy, but because it preserves what matters most:
👉 spontaneous breathing.
What’s changed in recent years isn’t the philosophy.
It’s how comfortable, efficient, and predictable awake intubation has become.
Why awake intubation still leads the way
Across modern reviews and trials, awake intubation consistently shows:
• 98–99% success rates
• Extremely low catastrophic complication rates
(Cabrini et al., 2019; Hyman & Rosenblatt, 2022; Warwick et al., 2024)
It’s recommended when you anticipate:
✔ Difficult laryngoscopy
✔ Difficult mask ventilation
✔ Cervical spine immobility
✔ Tumors, trauma, airway distortion
The principle is simple:
Don’t take away breathing when losing the airway would be disastrous.
💉 What’s actually new?
→ Better sedation + better airway anesthesia
Modern ATI is no longer just “spray and pray.”
Recent protocols emphasize:
🔹 Light, titrated sedation
Most commonly:
• Dexmedetomidine (1mcg/kg iv bolus over 10mins) with low-dose ketamine (0.3-0.5 mg/kg)
• Sometimes low-dose ketamine (0.5mg/kg)
— enough to relax the patient without suppressing respiration
(Myatra et al., 2023; Warwick et al., 2024)
🔹 Meticulous topicalization (2–4% lidocaine)
Still effective on its own — but now often combined with targeted nerve blocks for near-complete airway comfort.
🎯 The Big Upgrade: Airway Nerve Blocks
Evidence now strongly supports combining three key blocks for optimal awake intubation:
👉 Glossopharyngeal nerve (gag reflex)
👉 Superior laryngeal nerve (supraglottic sensation)
👉 Translaryngeal / recurrent laryngeal nerve (tracheal anesthesia)
Often called the “triple block” approach.
What the data shows:
A 2023 meta-analysis (14 RCTs, 658 patients) found airway blocks:
✅ Shortened intubation time
✅ Reduced coughing & gagging
✅ Improved patient comfort
✅ Increased “no reaction” success
✅ Lowered overall complications
(Zheng et al., 2023)
Case series using newer ultrasound-guided triple-block techniques show:
• Fast intubation (often under 3 minutes)
• Minimal hemodynamic change
• Excellent patient tolerance
(Kojima et al., 2025; Wada et al., 2023)
🌬️ Topical vs Blocks: which is better?
Topical methods (nebulization, atomization, spray-as-you-go) still work well.
But studies show:
👉 Transtracheal injection often provides faster and more comfortable conditions than topical spray alone
(Vasu et al., 2017; Kostyk et al., 2021)
👉 Nerve blocks outperform topical anesthesia alone in comfort and efficiency
(Zheng et al., 2023)
⚠ But blocks need expertise
They carry risks:
• Bleeding
• Intravascular injection
• Local anesthetic toxicity
So they’re best in trained hands with strict dose awareness
(Pearson & Chiam, 2020; Pintaric, 2016).
The modern awake intubation formula
Today’s best practice often looks like:
1️⃣ Light sedation (dexmedetomidine/remifentanil)
2️⃣ Careful topical lidocaine
3️⃣ Targeted nerve blocks (if skilled)
4️⃣ Gentle scope or videolaryngoscopy
All while the patient keeps breathing.
4. Ketamine-Only “Breathing” Intubation (KOBI): From Clever Hack to High-Risk Niche
Ketamine-only intubation was built on an attractive idea:
👉 Keep the patient dissociated but breathing.
👉 Avoid apnea and paralysis in fragile physiology.
In theory, it sounds like the perfect middle ground between RSI and awake intubation.
In reality?
Newer multicenter data paint a far less reassuring picture.
📉 What the real-world evidence now shows
Large registry data from multiple emergency departments found that ketamine-only intubation:
• Was rarely used (less than 1% of intubations)
• Had much lower first-pass success than RSI or topical/awake approaches
• Had higher complication rates, especially hypoxemia
(Driver et al., 2020)
First-pass success:
Ketamine-only: ~61%
Topical/awake: ~85%
RSI: ~90%
Any adverse event:
Ketamine-only: 32%
Topical/awake: 19%
RSI: 14%
The authors didn’t mince words:
Ketamine-only intubation is uncommon and associated with lower success and higher complications.
So why did it ever make sense?
Conceptually, KOBI was meant for the extreme edge cases:
• Near-crash hypoxemia
• Severe shock where apnea felt dangerous
• Impossible awake cooperation
(Merelman et al., 2019)
The hope was that “some breathing” would always be safer than none.
But ketamine doesn’t guarantee preserved ventilation.
Even low doses have caused apnea and respiratory depression in real cases (Driver & Reardon, 2017).
Prehospital studies also show higher ketamine doses correlate with more airway interventions and intubations (Sergot et al., 2023).
👉 In short: spontaneous breathing is not reliable protection.
🚨 The big risk with KOBI
KOBI sits in an uncomfortable zone:
Not fully controlled like RSI.
Not truly safe like awake intubation.
You get:
❗ Movement
❗ Unpredictable ventilation
❗ Poorer laryngoscopy conditions
❗ Higher hypoxia risk
Yet still risk sudden apnea.
Which is why many airway experts now frame it as:
👉 a last-ditch strategy for extreme scenarios — not a standard alternative.
The Real Danger: Mixing Strategies
Most airway catastrophes don’t come from the wrong drug.
They come from confused mental models.
Examples seen in real EDs:
❌ Planning DSI but pushing paralytic early
❌ Starting awake intubation then sedating like RSI
❌ Assuming apnea tolerance when physiology says no
Clear communication matters:
“This is RSI.”
“This is DSI.”
“This is an awake fiberoptic.”
As emphasized in airway guidelines (Ahmad et al., 2019; Frerk et al., 2015) — shared strategy prevents preventable disasters.
🧩 Final Takeaway
Airway management is not about bravery.
It’s about matching strategy to physiology.
RSI is powerful — but not universal.
DSI buys preparation.
Awake intubation buys safety.
Ketamine-only buys time — at risk.
As Walls Manual puts it best:
The best airway clinicians don’t rush the tube.
They control the situation.
If you found this helpful, share it with your airway team or residents starting nights in the ED.
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