There are a range of pharmacologic options available for intubation. The overarching goal of using any combination of drugs with airway management is to reduce patient awareness, create adequate intubating conditions to facilitate laryngoscopy and tube passage, and blunt airway reflexes to reduce the effects of upper airway manipulation with a laryngoscope. In some patients, this requires just topicalization; in others, it requires full induction. The pharmacologic strategies can be fundamentally grouped into three separate options: rapid sequence intubation (RSI), spontaneously breathing intubation (i.e., “awake intubation”), and delayed sequence intubation (DSI).

When RSI is the planned strategy, the patient is fully induced with a sedative agent and relaxed with a neuromuscular blocking agent (NMBA). This combination rapidly creates unconsciousness and motor relaxation to optimize intubating conditions as quickly as possible after infusion. They are typically given by rapid intravenous push, sedative first followed by the NMBA, without a flush or time delay in between. The key principle is that they are both administered. There is never an indication to give a full dose of a sedative without a NMBA. The sedative is the dangerous drug of the two; the NMBA is what provides most of the intubating conditions that make induction and intubation successful. RSI is the default strategy given its profile of safety and improved outcomes compared to sedation-only approaches.^1,2,3 There are occasional modifications to RSI, such as giving lower doses of sedatives, slowly injecting the sedative, or using various combinations of agents, but those modifications are based largely on the underlying physiologic abnormalities, and all still have the same goal, inducing unconsciousness and neuromuscular blockade.