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Letters to the Editor: Letters & Announcements

Which Is the Original and Which Is the Modified Rapid Sequence Induction and Intubation? Let History Be the Judge!

Salem, M. Ramez MD; Clark-Wronski, Julianna MD; Khorasani, Arjang MD; Crystal, George J. PhD

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doi: 10.1213/ANE.0b013e31827696fa
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To the Editor

Based on their recent survey, Ehrenfeld et al.1 identified 3 components of the “modified” rapid sequence induction and intubation (RSII) technique: (1) oxygen administration before induction, (2) the use of cricoid pressure (CP), and (3) an attempt to ventilate the patient’s lungs before securing the airway.1

A review of the pertinent literature since the inception of RSII allows us to judge the validity of applying the adjective “modified” to this technique. Suggestions to use the “intravenous barbiturate/muscle relaxant/rapid intubation” technique in patients at risk of aspiration of gastric contents originally appeared in the 1950s in the British anesthesia literature. A 1951 recommendation by Morton and Wylie2 led to the widespread use of the technique with the patient in the sitting position. In 1959, Snow and Nunn3 described the technique as “a rapid induction of anesthesia with thiopentone and suitable relaxant combined with foot-down tilt.” They used a 40-degree head-up tilt so that the larynx would be raised to a height above the cardia greater than the intragastric pressure. After the introduction of CP by Sellick4 in 1961, CP gained acceptance worldwide and rapidly became an integral component of the RSII technique. The CP maneuver seemed to overcome many of the disadvantages of the sitting position.4 In their reports, Snow and Nunn,3 as well as Sellick,4 emphasized the importance of oxygen administration before anesthetic induction. Furthermore, manual ventilation before securing the airway with an endotracheal tube was an integral component of the technique.3,4 In fact, Sellick4 used CP to prevent gastric inflation during manual ventilation. Thus, it is obvious that these early investigators recommended and used manual ventilation before intubation during RSII.

In 1963, Wylie5 introduced the concept that “inflation of the patient’s lungs with oxygen must not be carried out until endotracheal intubation has been completed.” This view was also held by Stevens,6 who in 1964 wrote, “lungs must not be ventilated until the cuffed endotracheal tube is in place.” Both of these authors hypothesized that positive pressure ventilation before intubation increases the risk of gastric inflation and the potential for regurgitation.5,6 Thereafter, avoidance of manual ventilation during RSII, before tracheal intubation, has been perpetuated in reviews and textbooks.7–9 This has led to the current teaching, which erroneously refers to the original (classic) RSII technique as the one in which manual ventilation is avoided until tracheal intubation is accomplished, and the modified RSII technique as the one in which manual ventilation is allowed. Our historical review of the literature reveals that the opposite is true! We suggest that the “original” or “classic” RSII technique should indicate the use of positive pressure ventilation before intubation, whereas the “modified” RSII technique should indicate the avoidance of positive pressure ventilation.

M. Ramez Salem, MD

Julianna Clark-Wronski, MD

Arjang Khorasani, MD

George J. Crystal, PhD

Department of Anesthesiology

Advocate Illinois Masonic Medical Center

Chicago, Illinois

[email protected]


1. Ehrenfeld JM, Cassedy EA, Forbes VE, Mercaldo ND, Sandberg WS. Modified rapid sequence induction and intubation: a survey of United States current practice. Anesth Analg. 2012;115:95–101
2. Morton HJ, Wylie WD. Anaesthetic deaths due to regurgitation or vomiting. Anaesthesia. 1951;6:190–201
3. Snow RG, Nunn JF. Induction of anaesthesia in the foot-down position for patients with a full stomach. Br J Anaesth. 1959;31:493–7
4. Sellick BS. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Lancet. 1961;2:404–6
5. Wylie WD. The use of muscle relaxants at the induction of anaesthesia of patients with a full stomach. Br J Anaesth. 1963;35:168–73
6. Stevens JH. Anaesthetic problems of intestinal obstruction in adults. Br J Anaesth. 1964;36:438–50
7. Salem MR. Anesthetic management of patients with “a full stomach”: a critical review. Anesth Analg. 1970;49:47–55
8. Stept WJ, Safar P. Rapid induction-intubation for prevention of gastric-content aspiration. Anesth Analg. 1970;49:633–6
9. Suresh MS, Munnur U, Wali AHagberg CA. The patient with a full stomach. In: Benumof’s Airway Management. 20072nd ed Philadelphia Mosby Elsevier:756–82
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