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Facilitated intubation, also known as medication- or sedation-assisted intubation, involves using a sedative or anesthetic induction agent during intubation without a paralytic agent (neuromuscular blocking agent). In contrast, rapid sequence intubation uses both an induction and a paralytic agent. Intubation with a sedative medication alone requires an awareness of the difference in physiological and anatomical responses that may occur in the absence of a paralytic agent, such as laryngospasm and increased intracranial pressure due to the stimulation of the laryngeal reflex. Understanding the nuances of facilitated intubation is crucial, especially in the prehospital setting, where the availability of paralytics is service-dependent, and in many cases, paralytics may not be available, particularly in ground emergency medical services (EMS). This activity reviews the indications, contraindications, complications, and techniques for intubation without a paralytic agent, emphasizing the vital role EMS providers play in the chain of survival of critically ill patients. Objectives: Assess the criteria for evaluating the need for intubation. Identify the indications for intubation without paralytic agents. Compare the different available induction agents for medication-assisted intubation and rapid sequence induction intubation. Communicate the importance of effective care coordination among the interprofessional team to improve outcomes for patients requiring intubation without paralytics. Access free multiple choice questions on this topic.

Facilitated intubation, also known as medication- or sedation-assisted intubation, refers to using a sedative or anesthetic to decrease consciousness, muscle tone, and protective airway reflexes to improve visualization during laryngoscopy. In contrast, rapid sequence intubation uses both an anesthetic and a paralytic agent to quickly induce decreased mental status, complete muscle paralysis, and apnea, aiming to create optimal intubating conditions. Emergency medical services (EMS) agencies perform both medication-assisted intubation and rapid sequence intubation throughout the United States and Europe. Geographic Variation Drug-assisted intubation protocols, including regulations for both sedation-assisted intubation and rapid sequence induction, vary between states and, in many cases, between regional and local EMS agencies. Although rapid sequence intubation and medication-assisted intubation are included in the paramedic's national scope of practice, each state, region, and local EMS agency establishes airway management protocols that may vary significantly. A study found that 18 states (35.3%) have statewide drug-assisted intubation protocols. Of these, only 1 state (5.6%) has a protocol for sedation-assisted intubation,[1] with the remaining 17 states (94.4%) using rapid sequence intubation. Regional and local rates of medication-assisted intubation and rapid sequence intubation are difficult to ascertain, as there are no published studies or surveys at the local level.

Limited data exist regarding the success of sedation-assisted intubation using current induction agents. Two studies show different endotracheal intubation success rates that are less than ideal, 85% and 67.5%.[10][11]  Success intubation rates reported with rapid sequence intubation tend to be higher than medication-assisted intubation. A study conducted in an aeromedical setting reported a significant difference between rapid sequence intubation and medication-assisted intubation success rates. In this study, the success rate when etomidate was used alone was only 25%, compared to a 92% success rate when the same dose of etomidate was combined with the paralytic agent succinylcholine.[12] Studies conducted by anesthesiology in the operating room setting show similar results. Rapid sequence induction has been chosen over medication-assisted intubation in the emergency department setting due to its lower risk of complications.[13] A study conducted in a large urban emergency department found that the absence of a neuromuscular blocking agent was associated with a higher incidence and severity of complications, including aspiration (15%), airway trauma (28%), and even death (3%).[14] The risk of these complications was much reduced when rapid sequence intubation was performed instead of medication-assisted intubation. The same study showed a lower rate of intubation attempts, esophageal intubations, and cases of intubation failure when the healthcare provider used rapid sequence intubation.

Intubation is performed in many different settings. More resources are available to ensure success when intubation is performed in a controlled environment, such as the operating room, intensive care unit, or emergency department. In contrast, the prehospital setting is an uncontrolled and variable environment where this intubation may have to be performed with or without access to paralytic medications and minimal backup resources. To optimize patient outcomes and increase the chance of successful intubation in the prehospital setting, selecting the appropriate patient, identifying potential difficult airways early, and performing the procedure without harming the patient or delaying transport to definitive care are essential. Clinical judgment is also required; in some cases, the patient should only have basic airway maneuvers and bag-valve-mask ventilation performed while being transported rapidly to the nearest emergency department. Avoiding failed intubation is critical, as it is associated with high morbidity and mortality.