Rapid sequence airway (RSA) and PALM
Reviewed and revised 7 March 2015
OVERVIEW
Rapid sequence airway (RSA)
- Rapid sequence airway (RSA) is a modified form of rapid sequence intubation that uses an LMA inserted following induction (+/- administration of neuromuscular blockade) to maximise peri-intubation oxygenation prior to endotracheal tube insertion
- Apneic oxygenation with nasal prongs or CPAP, and delayed sequence intubation (DSI) are alternative strategies for difficult to pre-oxygenate patients
Pharmacologically assisted laryngeal mask insertion (PALM)
- PALM is a related technique called pharmacologically assisted laryngeal mask insertion, which involves the use of induction agents to facilitate LMA placement in lieu of rapid sequence intubation
- unlike the RSA approach, neuromuscular blockade is not administered as part of the PALM approach
- it is included in the UK Faculty of Prehospital Care Guidelines, but the consensus was not supported by the Royal College of Anaesthetists
- its role is primarily in the pre-hospital environment in rare circumstances with the following criteria according to UK Faculty of Prehospital Care Guidelines:
- hypoxic patient for whom rapid sequence intubation (RSI) is not possible and other basic measures have been exhausted
e.g. polytrauma patients with a reduced level of consciousness and ongoing airway obstruction, or airway soiling from facial injuries - used as a rescue technique, not as a primary airway management strategy
- should be checklist driven
- should involve use of at least a second generation supraglottic airway device (SAD)
- ETCO2 monitoring is mandatory
- should only be carried out by trained, competent practitioners (training should in-hospital insertion of SADs, simulation training and training in the transfer of critically ill patients)
- hypoxic patient for whom rapid sequence intubation (RSI) is not possible and other basic measures have been exhausted
These techniques are controversial, and are primarily considered in the prehospital environment where RSI is also controversial in certain circumstances (e.g. level of training, relative merits of less invasive airway measures and potential for delayed transfer).
PROS AND CONS OF RSA
(compared to standard RSI)
Advantages
- maintains patent airway for apnoeic oxygenation
- allows CPAP to maintain oxygenation during apnea
- allows PPV to prevent respiratory acidosis during apnea
- allows gastric decompression via gastric port on LMA prior to intubation (benefit is questionable)
- has been used
Disadvantages
- more complex
- LMA difficult to insert/ use in selected patients (RODS: Restricted mouth opening, Obstruction, Distorted airway, Stiff lungs or c-spine)
- requires ablation of airway reflexes (by deep sedation or paralysis) in an inadequately preoxygenated patient before an LMA can be inserted
- LMA does not provide definitive protection against aspiration
- minimal experience and evidence base is scant (few case reports)
Similar pros and cons apply to PALM, though the risks are greater as there is a longer and indefinite period until a definitive airway will be obtained
VIDEO
RSA approach demonstrated by Darren Braude:
References and Links
CCC Airway Series
Emergencies: Can’t Intubate, Can’t Intubate, Can’t Oxygenate (CICO), Laryngospasm, Surgical Cricothyroidotomy
Conditions: Airway Obstruction, Airway in C-Spine Injury, Airway mgmt in major trauma, Airway in Maxillofacial Trauma, Airway in Neck Trauma, Angioedema, Coroner’s Clot, Intubation of the GI Bleeder, Intubation in GIH, Intubation, hypotension and shock, Peri-intubation life threats, Stridor, Post-Extubation Stridor, Tracheo-esophageal fistula, Trismus and Restricted Mouth Opening
Pre-Intubation: Airway Assessment, Apnoeic Oxygenation, Pre-oxygenation
Paediatric: Paediatric Airway, Paeds Anaesthetic Equipment, Upper airway obstruction in a child
Airway adjuncts: Intubating LMA, Laryngeal Mask Airway (LMA)
Intubation Aids: Bougie, Stylet, Airway Exchange Catheter
Intubation Pharmacology: Paralytics for intubation of the critically ill, Pre-treatment for RSI
Laryngoscopy: Bimanual laryngoscopy, Direct Laryngoscopy, Suction Assisted Laryngoscopy Airway Decontamination (SALAD), Three Axis Alignment vs Two Curve Theory, Video Laryngoscopy, Video Laryngoscopy vs. Direct
Intubation: Adverse effects of endotracheal intubation, Awake Intubation, Blind Digital Intubation, Cricoid Pressure, Delayed sequence intubation (DSI), Nasal intubation, Pre-hospital RSI, Rapid Sequence Intubation (RSI), RSI and PALM
Post-intubation: ETT Cuff Leak, Hypoxia, Post-intubation Care, Unplanned Extubation
Tracheostomy: Anatomy, Assessment of swallow, Bleeding trache, Complications, Insertion, Insertion timing, Literature summary, Perc. Trache, Perc. vs surgical trache, Respiratory distress in a trache patient, Trache Adv. and Disadv., Trache summary
Misc: Airway literature summaries, Bronchoscopic Anatomy, Cuff Leak Test, Difficult airway algorithms, Phases of Swallowing
Journal articles
- Braude D, Richards M. Rapid Sequence Airway (RSA)–a novel approach to prehospital airway management. Prehosp Emerg Care. 2007 Apr-Jun;11(2):250-2. PMID: 17454819.
- Braude D, Southard A, Bajema T, Sims E, Martinez J. Rapid sequence airway using the LMA-Supreme as a primary airway for 9 h in a multi-system trauma patient. Resuscitation. 2010 Sep;81(9):1217. PMID: 20599313.
- Moss R, Porter K, Greaves I; Consensus Group Faculty of Pre-Hospital Care. Pharmacologically assisted laryngeal mask insertion: a consensus statement. Emerg Med J. 2013 Dec;30(12):1073-5. PMID: 24232013.
- Southard A, Braude D, Swenson K, Sullivan A (2010) Using Rapid Sequence Airway to Facilitate Preoxygenation and Gastric Decompression Prior to Emergent Intubation. J Anesthe Clinic Res 1:113. [Free Full Text]
FOAM and web resources
- PHARM Podcast 11 – Rapid Sequence Airway with Dr Darren Braude (2012)
- Minh Le Cong and Nicholas Chrimes — RSA: A 4 Day Twitter Conversation (2013)
- Resus.ME — Guidelines on Prehospital Drug-assisted LMA insertion (2013)
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC
