Facilitated Intubation: Time to Re-examine an Old Technique With Its Associated Risks Mitigated by New Technology

Area of Science:

• Critical Care Medicine
• Anesthesiology
• Pulmonology

Background:

• Facilitated intubation (FI) uses sedatives without paralytics, unlike rapid sequence intubation (RSI).
• Ketamine-only intubation is used for difficult airways, but shortages prompt interest in alternative FI methods.
• Modern adjuncts like video laryngoscopy (VL) may improve FI success rates.

Purpose of the Study:

• To evaluate the feasibility and outcomes of FI in profoundly hypoxic COVID-19 patients during a ketamine shortage.
• To assess the efficacy of midazolam-based FI with advanced intubation techniques.
• To determine the safety and success rate of first-pass intubation in physiologically difficult airways.

Main Methods:

• A case series of 29 COVID-19 patients with pre-intubation oxygen saturation <80% was conducted.
• Patients received midazolam for induction, without paralytics, utilizing video-assisted laryngoscopy.
• Semi-Fowler positioning and bilevel positive pressure pre-oxygenation were employed to minimize complications.

Main Results:

• All 29 intubations were successful on the first attempt (100% first-pass success).
• Only one patient required a rescue paralytic for oral opening.
• No peri-intubation arrest or aspiration events occurred.

Conclusions:

• Facilitated intubation with midazolam, VL, and optimized positioning is highly effective for physiologically difficult airways.
• This approach achieved excellent first-pass success without serious peri-intubation complications.
• FI with midazolam may be a viable alternative to ketamine-only intubation, warranting further investigation.