ACEP launches 2025 clinical policy for Endotracheal Intubation in the Emergency Department

Headline change

Noninvasive ventilation (NIV) is now recommended over conventional oxygen therapy for preoxygenation when feasible, based on moderate-certainty evidence.

Bedside action

For adult ED patients requiring intubation, use etomidate or ketamine as the induction agent to reduce the risk of peri-intubation hypotension.

The American College of Emergency Physicians (ACEP) has released its 2025 clinical policy on adult endotracheal intubation, shifting focus from the mechanics of the procedure to the critical task of physiologic optimization. Landing at a time of increasing recognition of the 'physiologically difficult airway,' this guideline provides actionable recommendations to reduce the incidence of peri-intubation hypoxemia and hypotension. The headline takeaway is a new emphasis on proactive strategies, including advanced preoxygenation techniques and hemodynamically stable induction agents, to improve patient safety during this high-risk procedure.

How It Compares Across Societies

This ACEP policy focuses broadly on all adult ED intubations, whereas the 2021 ERC/ESICM guideline specifically addresses post-cardiac arrest care. This difference in scope leads to more granular targets for oxygenation, ventilation, and hemodynamics in the European guideline, which are not specified by ACEP.

ERC/ESICM 2021

Recommends titrating inspired oxygen to achieve an arterial oxygen saturation of 94–98%.

This guideline

The policy recommends interventions to reduce hypoxemia but does not specify a target SpO2 range.

Why they differThe ERC/ESICM guideline is specific to post-ROSC care, a distinct physiologic state, and incorporates evidence on avoiding both hypoxemia and hyperoxemia in this context. ACEP's scope is broader, covering all ED intubations.

For the clinicianFor general ED intubations, follow ACEP's guidance on preoxygenation. For post-cardiac arrest patients, consider the more specific ERC/ESICM SpO2 target of 94-98% to avoid potential harm from hyperoxia.

ERC/ESICM 2021

Recommends adjusting ventilation to target a normal PaCO2 (35–45 mmHg) and using a lung-protective strategy with tidal volumes of 6–8 mL/kg ideal body weight.

This guideline

Does not provide specific targets for mechanical ventilation settings.

Why they differThe ERC/ESICM guideline incorporates principles of critical care management for post-ROSC patients, including lung-protective ventilation to mitigate ARDS, a known complication. ACEP's focus is on the immediate peri-intubation period.

For the clinicianWhile ACEP guides the intubation itself, clinicians should apply standard ICU lung-protective ventilation principles, like those outlined by ERC/ESICM, immediately post-intubation, especially in post-arrest patients.

ERC/ESICM 2021

Recommends avoiding hypotension (MAP < 65 mmHg) and targeting MAP to achieve adequate urine output and lactate clearance in post-ROSC patients.

This guideline

Recommends specific induction agents (etomidate, ketamine) to reduce the risk of hypotension but does not set a post-intubation blood pressure target.

Why they differACEP focuses on preventing the initial hypotensive event caused by induction agents. ERC/ESICM addresses the sustained hemodynamic management required in the post-cardiac arrest syndrome.

For the clinicianUse ACEP's guidance for induction agent choice. Post-intubation, especially in critically ill patients, adopt a specific MAP target, such as the >65 mmHg goal suggested by ERC/ESICM, to ensure adequate organ perfusion.

Where they agree

Both guidelines strongly emphasize the importance of avoiding peri-procedural hypoxemia.

Practice Notes

Do not miss

Use noninvasive ventilation for preoxygenation over conventional methods when feasible.

This is a Level B recommendation to reduce peri-intubation hypoxemia. It represents a significant shift in pre-procedural preparation for critically ill patients.

Stop doing this

Avoid fentanyl, midazolam, or propofol for induction in patients at high risk for hypotension.

In patients with a high shock index or other markers of instability, these agents are associated with an increased risk of post-intubation hypotension. Etomidate or ketamine are preferred.

Caution

Do not use NIV for preoxygenation in patients with high aspiration risk or agitation.

Relative contraindications to NIV include vomiting, a decreased level of consciousness, and noncompliance due to agitation. In these cases, the risk of aspiration may outweigh the benefits.

Implementation

Consider using a bougie to improve first-pass success in patients with difficult airway characteristics.

Evidence from a Class II RCT (Driver et al. 2018) showed that using a bougie improved first-pass success without hypoxemia from 60% to 82% in patients with at least one difficult airway feature.

Key Recommendations

This new ACEP policy provides a focused set of recommendations for the critical decisions made during emergency endotracheal intubation. The guidance covers the entire peri-procedural period, from patient preparation and preoxygenation to the choice of laryngoscopy device and induction agent. The central theme is the proactive mitigation of physiologic decompensation—specifically hypoxemia and hypotension—to improve patient safety in this high-stakes environment.

Key recommendations10 highlighted

for adult ED patients requiring endotracheal intubation, when feasible, optimize preoxygenation using noninvasive ventilation (NIV) over conventional oxygen therapy (COT).

Recommendation LevelLevel B

Evidence ClassBased on evidence from one or more Class of Evidence II studies or multiple Class of Evidence III studies that demonstra

EvidenceThis is supported by a Class II RCT (Gibbs et al. 2024) in 24 EDs and ICUs, which found hypoxemia (<85%) occurred in 9.1% of the NIV group versus 18.5% in the oxygen-mask group. A Class III network meta-analysis also found NIV superior to HFNC and COT for reducing desaturation.

For practiceMake NIV the default preoxygenation strategy for hypoxemic patients who can tolerate it.

CaveatNIV is relatively contraindicated in patients with increased aspiration risk (e.g., vomiting) or severe agitation.

p. 4 · Critical Question 1: Patient Management Recommendations

for adult ED patients requiring endotracheal intubation, use etomidate or ketamine as an induction agent to reduce the risk of peri-intubation hypotension.

Recommendation LevelLevel B

Evidence ClassBased on evidence from one or more Class of Evidence II studies or multiple Class of Evidence III studies that demonstra

EvidenceEvidence is based on multiple Class III studies. A prospective observational study (Zed et al. 2006) found etomidate to be hemodynamically stable. An analysis of the NEAR registry found etomidate more stable than ketamine, though confounding was possible. A Japanese registry study found ketamine associated with less hypotension than midazolam or propofol in unstable patients.

For practiceDefault to etomidate or ketamine for induction, especially in patients who are hemodynamically tenuous.

CaveatOne RCT found no difference in hypotension rates between ketamine and etomidate, suggesting equipoise may exist.

p. 7 · Critical Question 2: Patient Management Recommendations

for adult ED patients at increased risk for postintubation hypotension, avoid using fentanyl, midazolam, or propofol as an induction or coinduction agent.

Recommendation LevelLevel C

Evidence ClassBased on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on exper

EvidenceA Class II RCT (Ferguson et al. 2022) found that adding fentanyl to ketamine induction increased hypotension rates (29% vs. 16%). A Class III analysis of the JEAN-2 registry also found fentanyl pretreatment was associated with a higher risk of postintubation hypotension.

For practiceIn patients with a high shock index or borderline blood pressure, avoid these hemodynamically compromising agents.

p. 8 · Critical Question 2: Patient Management Recommendations

for adult ED patients requiring endotracheal intubation, consider using video laryngoscopy (VL) when available.

Recommendation LevelLevel C

Evidence ClassBased on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on exper

EvidenceThe evidence is mixed. Multiple Class III meta-analyses and RCTs show that VL often improves first-pass success (FPS) compared to direct laryngoscopy (DL). However, this has not consistently translated into a reduction in hypoxemia. For example, the Prekker et al. 2023 RCT showed improved FPS (85% vs 71%) but no difference in severe hypoxemia.

For practiceUse VL to potentially improve first-pass success, but do not rely on it alone to prevent hypoxemia.

CaveatOperator familiarity with the specific VL device geometry (standard vs. hyperangulated) is crucial for success.

p. 4 · Critical Question 1: Patient Management Recommendations

for hypoxemic ED patients needing intubation when NIV is not feasible, consider using high-flow nasal cannula (HFNC) for preoxygenation.

Recommendation LevelLevel C

Evidence ClassBased on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on exper

EvidenceEvidence is conflicting. One Class III RCT (Guitton et al. 2019) in non-severely hypoxemic ICU patients showed HFNC reduced the risk of desaturation <95% compared to BVM. Another Class III RCT (Vourc'h et al. 2015) found no difference between HFNC and a high-FiO2 face mask.

For practiceHFNC is a reasonable alternative for preoxygenation if NIV is contraindicated or unavailable.

CaveatNIV, when feasible, is preferred over HFNC based on a network meta-analysis showing NIV results in less desaturation.

p. 4 · Critical Question 1: Patient Management Recommendations

for adult ED patients requiring endotracheal intubation, consider using apneic oxygenation (AO).

Recommendation LevelLevel C (Consensus)

Evidence ClassConsensus

EvidenceData are mixed. A Class II RCT (Caputo et al. 2017) in the ED found no difference in lowest SpO2. A Class III ICU trial also found no advantage. However, a Class III meta-analysis and a large registry study suggested a potential reduction in desaturation. The guideline notes AO has minimal or no risk.

For practiceGiven its low risk profile, applying apneic oxygenation via nasal cannula is a reasonable 'belt-and-suspenders' maneuver.

CaveatStudies used varying flow rates (15 L/min vs >50 L/min), which may explain the mixed results.

p. 4 · Critical Question 1: Patient Management Recommendations

for hypoxemic patients at low risk of aspiration undergoing emergency intubation, consider utilizing positive-pressure ventilation with a bag-valve mask (BVM) between induction and laryngoscopy.

Evidence ClassClass II (Casey et al 2019)

EvidenceThis is based on the PREOXI trial (Casey et al. 2019), a Class II multicenter RCT in ICUs. It found that BVM ventilation during the apneic period reduced severe hypoxemia (SpO2 <80%) to 11% compared to 23% in the no-ventilation group, without an increase in aspiration.

For practiceIn select, low-aspiration-risk hypoxemic patients, gentle BVM ventilation during the apneic period can prevent desaturation.

CaveatThis study was in ICU patients and should be applied cautiously in ED patients with higher aspiration risk (e.g., recent meal).

p. 7 · Critical Question 1: Brief Summary

for adult patients undergoing emergency intubation with difficult airway characteristics, consider using a bougie to improve first-attempt success.

Evidence ClassClass II (Driver et al 2018)

EvidenceThe BEAM trial (Driver et al. 2018), a Class II single-center ED RCT, found that among patients with at least one difficult airway characteristic, use of a bougie increased first-pass success without hypoxemia to 82% from 60% with a stylet.

For practiceIn a patient with a known or suspected difficult airway, using a bougie on the first attempt is a evidence-supported strategy to increase success.

CaveatA subsequent multicenter RCT (BOUGIE trial) did not replicate this finding in a general critically ill population, suggesting the benefit may be context- or operator-dependent.

p. 7 · Critical Question 1: Bougie and Stylet (derived from evidence)

for adult ED patients requiring intubation, avoid NIV for preoxygenation in patients with vomiting, decreased level of consciousness, or severe agitation.

Evidence ClassImplicitly based on clinical judgment/safety concerns

EvidenceThis is noted as a footnote to the Level B recommendation for NIV. It is based on established principles of airway management where the risk of aspiration from positive pressure ventilation in a patient with a full stomach or impaired airway reflexes is a primary concern.

For practiceScreen patients for these relative contraindications before initiating NIV for preoxygenation.

p. 4 · Critical Question 1: Patient Management Recommendations (footnote)

for adult ED patients requiring intubation, provide apneic oxygenation (AO) via high-flow nasal cannula (HFNC) or a standard nasal cannula.

Evidence ClassImplicitly based on studies reviewed for AO

EvidenceThis statement from the guideline's summary reflects the methods used in the reviewed AO trials. The guideline explicitly states that AO has 'minimal or no risk' and can be delivered via either standard or high-flow nasal cannula during induction and laryngoscopy.

For practiceIf performing apneic oxygenation, it can be done simply with a nasal cannula at 15L/min or with an available HFNC system.

p. 7 · Critical Question 1: Brief Summary

SOURCE GUIDELINE

Clinical Policy: Critical Issues in the Management of Adult Patients Requiring Endotracheal Intubation in the Emergency Department

ACEP

Year2025

TypeClinical Policy

JournalAnnals of Emergency Medicine

DOI10.1016/j.annemergmed.2025.04.003