Clinical Use of Endotracheal Intubation Without Neuromuscular Blockade: The Current Stage of Knowledge

Endotracheal intubation is a fundamental component of modern airway management in elective and emergency settings. Neuromuscular blocking agents (NMBAs) are commonly used to optimize intubating conditions by facilitating jaw relaxation, improving vocal cord visualization, and reducing airway trauma. However, their administration can be contraindicated or undesirable in specific situations, such as procedures requiring intraoperative neuromonitoring, short-duration surgeries, patients with neuromuscular disorders, or critically ill individuals at risk of prolonged blockade or adverse reactions. This review examines current evidence regarding the feasibility, effectiveness, and safety of intubation without neuromuscular blockade. Data from randomized trials and meta-analyses indicate that although NMBAs are associated with a higher incidence of optimal intubation conditions and improved first-attempt success rates, their omission does not significantly increase postoperative complications, such as sore throat or hoarseness. The principal concern with NMBA-free techniques remains hemodynamic instability, particularly hypotension and bradycardia, associated with the deeper levels of anesthesia required to suppress airway reflexes. Alternative strategies include short-acting opioids (remifentanil, alfentanil, fentanyl, and sufentanil), intravenous hypnotics (propofol, ketamine, and etomidate), inhalational agents (sevoflurane), and adjuncts (dexmedetomidine and magnesium sulfate). These agents attenuate sympathetic responses to laryngoscopy while preserving neuromonitoring compatibility. Their distinct pharmacodynamic profiles influence intubation conditions, apnea duration, and cardiovascular stability. Current evidence supports the feasibility of NMBA-free intubation in carefully selected patients when performed by experienced clinicians. Individualized risk assessment and careful drug titration are essential. Further large-scale studies are needed to establish standardized protocols and define patient populations most likely to benefit from this approach.