Facilitated Intubation
refers to the use of a sedative only (without a paralytic) to pharmacologically assist with intubation. Facilitated intubation, also referred to as “pharmacologically assisted intubation,” has been recommended by some clinicians in specific circumstances because it does not involve neuromuscular blockade. Some advocate the avoidance of a neuromuscular paralysis and the use of sedation alone (“facilitated intubation”) in clinical scenarios in which a difficult airway is anticipated.[21]
For facilitated intubation, the most common sedative used has been etomidate, although midazolam has also bee used. [60] , [61] , [62] Proponents of facilitated intubation suggest that there may be clinical scenarios in which paralysis is not an option.
A study in the prehospital air medical setting, using 0.3 mg/kg of etomidate as their sedative without any NMB reported an 89% rate of successful intubation, difficult intubation in 16%, and episodes of clenched jaws and orofacial muscle spasm.[60] A later study from the same investigators (an air medical transport service) prospectively compared facilitated intubation using etomidate versus RSI using etomidate and succinylcholine. The results were: 63% (15 of 24) of the facilitated intubation (etomidate only) group received additional medications versus 4% (1 of 25) in the RSI group, and laryngoscopic conditions using several scoring systems was significantly more difficult for the facilitated intubation (etomidate only) versus RSI.[61] The conclusion was that facilitated intubation (etomidate only) had a decreased rate of success when compared with RSI (etomidate + succinylcholine). A prehospital study of facilitated intubation using midazolam alone noted a successful intubation rate of only 62.5%, which is less than the usual success rate for prehospital RSI.[62] When comparing successful rates of intubation, based on these studies, RSI has higher success rates than facilitated intubation.
For ED intubations, the results of the NEAR studies confirm the superiority of RSI over facilitated intubation. [6] , [34] The successful intubation rate for first attempt was RSI = 85%, and sedative only (no NMB) = 76%. The successful rate for first intubation was RSI = 91%, and sedative only (no NMB) = 88%.[34] For pediatric patients, the first attempt intubation success rates were RSI, 78%; sedative only, 44%; and no medication 47%.[6]
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