What's the Purpose of Intubation?

Intubation is the process of inserting a tube called an endotracheal tube (ET) into the mouth or nose and then into the airway (trachea) to hold it open. Once in place, the tube is connected to a machine called a ventilator (or a bag that gets squeezed, depending on availability) to push air in and out of the lungs.

There are several reasons why intubation is needed, but it is mainly used to support breathing during surgery or in an emergency.

This article goes over the different types of intubation, the intubation procedure, and the risks of being intubated.

What Is Intubation?

Intubation occurs when a tube is inserted into your trachea to help you breathe. Depending on why intubation is needed, it may or may not be serious. Intubation is commonly used for anesthesia in surgery and for airway management in more critical patient care.

In emergency situations and certain illnesses, being intubated means a form of life support. It can help keep the airway open and assist breathing.

Why You Might Need to Be Intubated

The reason someone is being intubated dictates which of the two types of intubation will be used.

Endotracheal intubation is when the tube is inserted through the mouth. It used in most emergency situations because the tube that gets placed through the mouth is larger and easier to insert than the one inserted through the nose.

Endotracheal intubation is used to:

• Keep the airway open to provide oxygen, medicine, or general anesthesia
• Support breathing in people with pneumonia, emphysema, heart failure, collapsed lung, COVID-19, or severe trauma
• Bypass a blocked portion of the airway
• Prevent fluid from getting into the lungs if a person has had a stroke, has overdosed, or has massive bleeding from the stomach or esophagus

Nasotracheal intubation is when the tube is put in through the nose. It is used to:

• Protect the airway while preventing further damage in some trauma patients
• Give anesthesia for surgeries involving the mouth, head, or neck (including dental surgery)

What to Expect When Intubated

Intubation is a common procedure. In the United States alone, at least 15 million intubations are performed in an operating room and another 650,000 are performed outside of an operating room each year.

The survival rate for intubation patients depends on the underlying reason for intubation as well as other factors, like age and overall health status.

For example, about half of all patients who needed to be intubated during the COVID-19 pandemic died in the ICU. Severe cases of COVID that required intubation as well as advanced age were two factors that contributed to mortality in these patients.

Here's what to expect if you need to be intubated:

Endotracheal Intubation

Before endotracheal intubation, a person usually needs to be sedated if they are not already unconscious. This means that you will be given medication to make you relaxed and sleepy. It helps make sure you don't accidentally pull out the tube. You also won't be able to eat or talk while intubated.

The next steps of endotracheal intubation are as follows:

1. The person is laid flat on their back.
2. The provider positions themselves above the person's head looking down at their feet.
3. The person's mouth is opened and a guard can be inserted to protect their teeth.
4. With the help of a lighted instrument that also keeps the tongue out of the way, the provider gently guides the ET tube into the person's throat and advances it into the airway.
5. A small balloon at the end of the tube is inflated to secure it in place and keep air from escaping.
6. The tube on the outside of the mouth is secured with tape.
7. The tube can then be connected to a ventilator or used to deliver anesthesia or medications.
8. The provider will check that the tube's placement is correct with a stethoscope, a chest X-ray, and/or a tool called a capnograph that detects carbon dioxide as it is exhaled from the lungs.

Nasotracheal Intubation

The process of nasotracheal intubation is similar to endotracheal intubation, but the person may either be fully or partially sedated.

Since nasal intubation is more often performed in a controlled environment, there can be other tools involved in the process.

For example, a provider can use topical vasoconstrictors, medications used to make blood vessels smaller, or special tips or catheters to reduce the chance of bleeding. Nosebleed (epistaxis) is the most common complication of nasotracheal intubation.

Once the tube is fed into the nostril and enters the middle part of the throat, a fiberoptic scope called a laryngoscope helps guide the tube between the vocal cords and into the windpipe.

The tube is inflated to secure it in the trachea and then taped on the outside to keep it from moving.

Feeding During Intubation

It is not possible to eat or take fluids by mouth while intubated. If an intubated person needs to be on a ventilator for two or more days, tube feeding will typically start a day or two after the tube is put in. This is referred to as enteral nutrition.

Nutrition, fluids, and medication can be delivered through the feeding tube, which is either passed through the mouth or nose and then into the stomach.

Total parenteral nutrition (TPA), when nutrition is given through a needle in the patient's arm, is an option for people with severe malnutrition and weight loss, people with a blockage in their intestines, and people with diseases that make tube feeding impossible.

Is Being on a Ventilator the Same as Being Intubated?

Intubation and ventilation go hand-in-hand, but they are distinct elements of the steps taken to help someone breathe.

Intubation is simply the process of placing the tube that protects the airway, keeping an open passageway to the lungs.

Ventilation is the process by which air is mechanically moved in and out of the lungs when someone is unable to do that—either well or at all—by themselves. The ventilator machine (or bag) does the breathing for them until they can breathe on their own.

While being awake on a ventilator is possible, people are usually sedated to help prevent anxiety or discomfort. When a person is placed on a ventilator, they can be given monitored anesthesia to induce "twilight sleep" or general anesthesia to put them fully asleep.

What Are the Risks of Intubation?

Most people experience only mild side effects like sore throat and hoarseness as a result of intubation. Some people have no symptoms and never even realize they were intubated.

However, there are some risks of intubation that can be serious, especially in people who need to be on a ventilator for a long period of time.

Common risks of intubation include:

• Gagging or choking
• Sore throat
• Hoarseness
• Bleeding
• A hole in the esophagus or soft palate
• Trauma to the teeth, mouth, sinuses, larynx (voice box), or trachea (windpipe)
• Bacterial infections (such as aspiration pneumonia)
• Damage to soft tissues with prolonged use
• Inability to be weaned off a ventilator and needing to have a surgical procedure to insert a tube directly into the windpipe to assist with breathing (tracheostomy)
  

Tracheal stenosis, or a narrowing of the trachea, is also possible.

Who Should Not Be Intubated?

Sometimes, a person cannot be intubated safely. In these situations, intubation is not advised.

A person might not be able to be intubated if they:

• Have certain injuries to their neck and spine
• Have a blocked pharynx (the space behind the nose and mouth)
• Have certain facial or head injuries (for example, a broken nose or jaw)

Intubating Children

The process of intubation is more or less the same for adults and children, aside from the size of the tube and some of the equipment that can be used.

Newborns are hard to intubate because of their small size. The procedure is also more difficult in little ones because a baby's tongue is proportionately larger and the passage into their windpipe is proportionately longer and less flexible.

Nasal intubation is the preferred method for newborns and infants, though it can take several attempts to properly place the tube.

How Is the Tracheal Tube Removed?

Extubation is the process of removing a tracheal tube. It is usually easier and faster to take the tube out than it is to put it in.

Extubation involves the following steps:

1. The tape that holds the tube in place is removed.
2. The balloon that holds the tube in the airway is deflated and the tube is gently pulled out.
3. Once the tube is out, a person may have to work harder to breathe on their own, especially if they have been on a ventilator for a long time. They will be closely monitored during this period.

What Is Recovery Like After Being Intubated?

Coughing, hoarseness, and discomfort are common symptoms after extubation, but they tend to improve within a few days. Some people may also experience difficulty swallowing or talking while the throat and voice box recover from inflammation and irritation.

If you continue to experience difficulty talking or swallowing within a few weeks of being intubated, contact your healthcare provider. Your provider may refer you to an otolaryngologist (ear, nose, and throat specialist) to help you recover fully.

Summary

Intubation is the insertion of a tube either through the mouth or nose and into the airway to aid with breathing, deliver anesthesia or medications, and bypass a blockage.

It is called endotracheal intubation when the tube is inserted into the mouth and nasogastric intubation when the tube is fed through a nostril. The procedure for both is largely the same.

There are risks associated with intubation, but the benefits of intubation generally outweigh the risks.