To the Editor:—

We read with interest the article by Heier et al.  entitled “Hemoglobin Desaturation After Succinylcholine-induced Apnea.”1In our practice, we are often called on to perform emergency airway management, and after reading this article, it appears that the safety of rapid sequence induction (RSI) has been called into question. The study by Heier et al. ; demonstrated that there is a potential risk of desaturation with the RSI sequence. We believe, however, that the methodology used by the authors does not permit formulation of a definitive answer in this regard. In the authors’ study, the facemask was removed after induction and remained off throughout the period of apnea. In emergency airway management, when difficult intubation occurs, the bag mask must be applied against the face of the patient with continuous oxygen infusion, but without active ventilation, until oxygen saturation is greater than 90%. Several studies have demonstrated that oxygenation may be maintained for more than 30 min with passive oxygenation in the absence of active ventilation. 2The true clinical relevance of the author's study is apparently in the situation of complete airway obstruction or in the “cannot intubate, cannot ventilate” situation. However, this latter situation is very rare (about 0.01–0.2 per 10,000). 3In short, we believe that the degree of hemoglobin desaturation during apnea from the RSI procedure may be more appropriately assessed with a bag-mask connected to a high-flow oxygen source applied to the face of the patient. The RSI technique was designed to reduce pulmonary aspiration, and, to our knowledge, the combination of a rapid neuromuscular blocker (succinylcholine) and a hypnotic remains the anesthetic procedure of choice in the case of emergency invasive airway management. 4 


Heier T, Feiner JR, Lin J, Brown R, Caldwell JE: Hemoglobin desaturation after succinylcholine-induced apnea. A nesthesiology 2001; 94: 754–9
Frumin MJ, Epstein RM, Cohen G: Apneic oxygenation in man. A nesthesiology 1959; 20: 789–98
Benumof JL: Management of the difficult adult airway. A nesthesiology 1991; 75: 1087–1110
Walls RM: Emergency airway management. Philadelphia, Lippincott Williams & Wilkins, 2000