💉🩺Rapid sequence intubation in 2026: we are no longer “protecting the airway.” We are managing physiology under extreme stress. The latest evidence challenges one of the oldest dogmas in critical care. RSI was designed to prevent aspiration. But today, the real enemy is often hypoxemia and cardiovascular collapse. 1. Aspiration is no longer the central problem For decades, RSI was built around one fear: aspiration. But emerging data suggest: RSI may not significantly reduce aspiration It may increase hypoxemia and hemodynamic instability The paradigm is shifting: 👉 From aspiration avoidance → to physiologic optimization 2. First-pass success is everything Every additional attempt increases: Hypoxia Hemodynamic collapse Mortality Modern RSI is built around one goal: Get it right the first time. That means: Videolaryngoscopy first-line Stylet routinely Team choreography, not improvisation 3. Preoxygenation is now a therapeutic intervention Not just a step—a determinant of survival NIV > face mask HFNO as adjunct Semi-upright positioning And one key shift: 👉 Gentle ventilation is no longer taboo Done correctly, it reduces hypoxemia without increasing aspiration risk. 4. Hemodynamics matter more than ever Up to 40–50% of patients experience peri-intubation instability. The modern approach: Avoid propofol in unstable patients Favor etomidate or ketamine Consider prophylactic vasopressors Fluid loading? Not routinely beneficial. 5. Cricoid pressure: from dogma to doubt No clear benefit in preventing aspiration May worsen laryngoscopy and ventilation Current thinking: 👉 Use selectively, or not at all 6. RSI is no longer a rigid protocol It is now: Patient-specific Physiology-driven Team-dependent With tools like: Gastric ultrasound POCUS-guided decisions Structured airway protocols 7. The real determinant of success: human factors Preparation, communication, and coordination matter as much as drugs. Because in critical care: The airway is not just anatomy. It is a moment of systemic vulnerability. 🤓Final message RSI has evolved: From speed → to precision From protocol → to physiology From individual skill → to team performance And ultimately: The goal is no longer just to intubate. It is to intubate without killing the patient. 📃Reference Boulos NM et al. Anaesth Crit Care Pain Med. 2026. doi.org/10.1016/j.accpm.2026…