A rapid sequence intubation video laryngoscope workflow combines two things that emergency teams rely on every day. Rapid sequence intubation (RSI) is the standard way to secure the airway in patients at risk of aspiration. Video laryngoscopy improves the chance of success on the first attempt. This guide walks through each stage of RSI with a video device, from preparation to post-intubation care, and explains where the evidence supports each step.
This article is educational. It does not replace local protocols, drug guidance, or supervised clinical training.
What rapid sequence intubation means
RSI is a technique in which the team gives an induction agent and a neuromuscular blocking drug in quick succession. The goal is to create ideal intubating conditions fast, while limiting the time the airway stays unprotected.
Because the patient is apneic after paralysis, the team has a limited window before oxygen saturation falls. For that reason, RSI depends on careful preparation, good preoxygenation and a high chance of success on the first pass.
RSI is common in emergency medicine. In the National Emergency Airway Registry analysis of 11,714 intubations, RSI accounted for 80.8% of cases.
Why use a video laryngoscope for rapid sequence intubation
Each failed attempt during RSI extends apnea and increases the risk of hypoxemia. Therefore, the device that provides the best first-attempt success matters most.
The DEVICE trial in the New England Journal of Medicine randomized 1,417 critically ill adults in emergency departments and ICUs. First attempt success was 85.1% with video laryngoscopy and 70.8% with direct laryngoscopy.
Registry data agree. In the same NEAR analysis, unaided video laryngoscopy outperformed direct laryngoscopy, even when operators supported DL with a bougie or external laryngeal manipulation. In addition, video laryngoscopy meant fewer esophageal intubations.
For a wider view of the evidence, see our comparison of video laryngoscope vs direct laryngoscope.
Step 1: Prepare the team and equipment
Preparation prevents most RSI problems. Before anyone draws up a drug, the team should agree on roles and a plan.
A practical checklist covers:
- Suction that runs and sits within reach of the operator.
- Oxygen sources for preoxygenation and for apneic oxygenation.
- Airway equipment, including the video laryngoscope, two blade sizes, a stylet, a bougie and a supraglottic airway.
- Pharmacology, with induction and paralytic drugs labeled and checked.
- Monitoring, including continuous pulse oximetry, blood pressure and waveform capnography.
The team should also confirm the video laryngoscope screen is fully charged, and the image is clear. Then, a short verbal briefing sets out Plan A, Plan B and the rescue plan.
Step 2: Position the patient
Positioning still matters with a video device. Most adults do well in a sniffing position with the head slightly raised.
In obese patients, a ramped position aligns the ear with the sternal notch. This improves preoxygenation and mask ventilation. Moreover, a slight head up tilt can increase oxygen reserve before induction.
Step 3: Preoxygenate effectively
Good preoxygenation buys time during apnea. The PREOXI trial published in 2024 enrolled 1,301 critically ill adults across 24 emergency departments and ICUs.
Hypoxemia occurred in 9.1% of patients preoxygenated with noninvasive ventilation, compared with 18.5% with an oxygen mask. First pass success was similar in both groups. As a result, many teams now use noninvasive ventilation for preoxygenation when the patient can tolerate it.
Step 4: Give induction and paralysis
The team gives the induction agent and the neuromuscular blocker in rapid succession, following local protocol. Drug choice depends on hemodynamics, comorbidities, and team familiarity.
Cricoid pressure remains controversial. The IRIS trial in JAMA Surgery randomized 3,472 patients to cricoid pressure or a sham procedure. Aspiration rates were 0.6% and 0.5%, although the trial could not demonstrate noninferiority of the sham. Meanwhile, cricoid pressure meant longer intubation times and poorer laryngeal views. Teams should follow local policy and release pressure if it impairs the view.
Step 5: Perform laryngoscopy with the video laryngoscope
Wait for full paralysis before inserting the blade. Then insert the video laryngoscope in the midline and advance it gently while watching the screen.
Key technique points include:
- Find the epiglottis first, then position the tip in the vallecula or under the epiglottis as the blade design requires.
- Avoid inserting the blade too deep, because this tilts the larynx up and makes tube delivery harder.
- With hyperangulated blades, a partial view of the glottis often gives easier tube passage than a full view.
- Keep the blade still once the view is good, and let an assistant handle the tube or bougie.
Step 6: Deliver and confirm the tube
Tube delivery is the step that most often fails with hyperangulated blades. The operator can see the cords, yet the tube may not follow the curve.
A stylet shaped to match the blade curve helps guide the tube. Similarly, rotating the tube to the right or withdrawing the stylet slightly as the tip enters the glottis can ease passage.
Confirm placement with sustained waveform capnography. Visual confirmation on screen helps, but capnography is the standard.
Step 7: Post-intubation care
After confirmation, secure the tube and record the depth. Then start sedation and analgesia promptly, because paralytic drugs often outlast induction agents.
The team should check ventilator settings, monitor blood pressure closely, and request a chest radiograph. Finally, a short debrief captures what worked and what to improve.
Common rapid sequence intubation video laryngoscope pitfalls
Even experienced teams run into predictable problems. Knowing them in advance makes each rapid sequence intubation video laryngoscope attempt safer.
Starting before full paralysis. Inserting the blade too early can trigger gagging, coughing, or laryngospasm. Instead, wait for the full onset time of the neuromuscular blocker.
Chasing a perfect view. A grade 1 view on screen does not guarantee easy tube passage. In fact, pulling the blade back slightly often improves tube delivery.
Losing sight of the patient. Operators can fixate on the screen and miss falling saturation. For this reason, an assistant should call out oxygen saturation and time aloud.
Ignoring secretions. Blood or vomit can cover the lens fast. Therefore, suction should go in before the blade, not after the view is lost.
No clear rescue plan. If the first attempt fails, the team should change one thing before trying again, such as the blade, the position or the operator. After a second failure, move to a supraglottic airway or the rescue pathway.
Choosing a rapid sequence intubation video laryngoscope
When a department selects a rapid sequence intubation video laryngoscope, the clinical and practical features should match emergency work.
Look for:
- Fast startup, so the screen is ready within seconds.
- Clear image quality under bright resuscitation lighting.
- Blade range, including Macintosh 3 and 4 and a hyperangulated option.
- Battery life long enough for several cases between charges.
- Video recording for review, audit, and teaching.
- Single-use blade options when reprocessing capacity runs short.
The Difficult Airway Society 2025 guidelines also recommend that video laryngoscopy be available for every intubation. Our DAS 2025 summary explains that recommendation in detail, while our guide to the best video laryngoscope for the emergency department covers selection.
How Astra-vue fits an RSI workflow
As a rapid sequence intubation video laryngoscope platform, Astra-vue starts with the Mini Monitor. It has a 4-inch touchscreen, a 720p HD camera, and about 85 minutes of battery life. It records video and still images to 16GB of storage, and mini HDMI output allows a larger teaching display.
Reusable Ultra Blades include Macintosh sizes 1 to 4 and hyperangulated designs, including a channeled hyperangulated blade. For single-use workflows, the Pro Blade and the anti-fog Lite Blade are available. The system is FDA registered and listed, CE marked under MDR, and made under ISO 13485. Explore the full range on our products page or contact our team.
Rapid sequence intubation video laryngoscope FAQs
Is a video laryngoscope recommended for rapid sequence intubation?
Current evidence supports it. DEVICE showed higher first-attempt success with video laryngoscopy in critically ill adults, and DAS 2025 recommends video laryngoscopy be available for every intubation.
Which video laryngoscope blade is best for rapid sequence intubation?
Many teams start with a Macintosh-style video blade because it allows both a screen and a direct view. A hyperangulated blade is useful for predicted difficult airways, but it needs a shaped stylet.
Does a video laryngoscope reduce hypoxemia during rapid sequence intubation?
Video laryngoscopy reduces repeated attempts, which lowers exposure to hypoxemia. However, preoxygenation has a larger direct effect, as PREOXI showed.
Should cricoid pressure be used with video laryngoscopy?
Practice varies. Evidence on aspiration is uncertain, and cricoid pressure can worsen the view. If the view is poor, most protocols advise releasing it.
How is tube placement confirmed after RSI?
Sustained waveform capnography is the standard. Seeing the tube pass the cords on screen is helpful, but it does not replace capnography.
