What Is Intubation and Why Is It Done?

What Happens During Intubation for Surgery

Elderly Hospital Patient
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Intubation is the process of inserting a tube, called an endotracheal tube (ET), through the mouth and then into the airway. This is done so that a patient can be placed on a ventilator to assist with breathing during anesthesia, sedation, or severe illness. The tube is then connected to a ventilator, which pushes air into the lungs to deliver a breath to the patient. 

This process is done because the patient cannot maintain their airway, cannot breathe on their own without assistance, or both.

This may be because they are being given anesthesia and will be unable to breathe on their own during surgery, or they may be too sick or injured to provide enough oxygen to the body without assistance.

How Intubation Is Usually Done

Prior to intubation the patient is typically sedated or not conscious due to illness or injury, which allows the mouth and airway to relax. The patient is typically flat on their back and the person inserting the tube is standing at the head of the bed, looking at the patient's feet. The patient's mouth is gently opened and using a lighted instrument to keep the tongue out of the way and to light the throat, the tube is gently guided into the throat and advanced into the airway.

There is a small balloon around the tube that is inflated to hold the tube in place and to keep air from escaping. Once this balloon is inflated, the tube is securely positioned in the airway and it is tied or taped in place at the mouth.

Successful placement is checked first by listening to the the lungs with a stethoscope and often verified with a chest x-ray. In the field, such as when 911 is activated and a breathing tube is placed by paramedics, a special device is used that changes color when the tube is placed correctly.

Risks of Intubation

While most surgery is very low risk, and intubation is equally low risk, there are some potential issues that can arise particularly when a patient must remain on the ventilator for an extended period of time.

Common risks include:

  1. Trauma to the teeth, mouth, tongue, and/or larynx
  2. Accidental intubation in the esophagus (food tube) instead of the trachea (air tube)
  3. Trauma to the trachea
  4. Bleeding
  5. Inability to be weaned from the ventilator, requiring tracheostomy.
  6. Aspirating (inhaling) vomit, saliva or other fluids while intubated
  7. Pneumonia, if aspiration occurs
  8. Sore throat
  9. Hoarseness
  10. Erosion of soft tissue (with prolonged intubation)

The medical team will assess and be aware of these potential risks, and do what they can to address them.

What Is Nasal Intubation?

In some cases, if the mouth or throat is being operated upon or has been injured, the breathing tube is threaded through the nose instead of the mouth, which is called a nasal intubation. The nasotracheal tube (NT) goes into the nose, down the back of the throat, and into the upper airway. This is done to keep the mouth empty and allow the surgery to be performed.

This type of intubation is less common, as it is typically easier to intubate using the larger mouth opening, and because it just isn't necessary for most procedures.

When Is Intubation Necessary?

Intubation is required when general anesthesia is given. The anesthesia drugs paralyze the muscles of the body, including the diaphragm, which makes it impossible to take a breath without a ventilator.

Most patients are extubated, meaning the breathing tube is removed, immediately after surgery. If they patient is very ill or having difficulty breathing on their own, they may remain on the ventilator a longer period of time.

After most procedure, a medication is given to reverse the effects of anesthesia, which allows the patient to wake quickly and begin breathing on their own. For some procedures, such as open heart procedures, the patient isn't given the medication to reverse anesthesia and will wake slowly on their own. These patients will need to remain on the ventilator until they are awake enough to protect their airway and take breaths on their own.

Intubation is also performed for respiratory failure. There are many reasons why a patient may be too ill to breathe well enough on their own. They may have an injury to the lungs, they might have severe pneumonia, or a breathing problem such as COPD. If a patient cannot take in enough oxygen on their own, a ventilator may be necessary until they are once again strong enough to breathe without assistance.

Pediatrics and Intubation

The process of intubation is the same with adults and children, aside from the size of the equipment that is used during the process. A small child requires a much smaller tube than an adult, and placing the tube may require a higher degree of precision because the airway is so much smaller. In some cases, a fiber optic scope, a tool that allows the person putting the breathing tube in to watch the process on a monitor, is used to make intubation easier.

While the actual process of placing the tube is essentially the same, preparing a child for surgery is very different than it is for adults. While an adult may have questions about insurance coverage, risks, benefits and recovery times, a child will require a different explanation of the process that is going to occur. Reassurance is necessary, and emotional preparation for surgery will vary depending on the patient's age.

Feeding During Intubation

A patient who will be on the ventilator for a procedure and then extubated when the procedure is completed will not requiring feeding, but may receive fluids through an IV. If a patient is expected to be ventilator dependent for two or more days, feeding will typically be started a day or two after intubation.

It isn't possible to take food or fluids by mouth while intubated, at least not the way it is typically done by taking a bite, chewing, then swallowing. 

To make it possible to safely take food, medication and fluids by mouth, a tube is inserted into the throat and down into the stomach. This tube is called an orogastric (OG) when it is inserted into the mouth, or a nasogastric tube (NG) when inserted into the nose and down into the throat. The medication, fluids, and tube feeding is then pushed through the tube and into the stomach using a large syringe or a pump.

For other patients, food, fluids, and medications must be given intravenously. IV feedings, called TPA or total parenteral nutrition, provides nutrition and calories directly into the bloodstream in liquid form. This type of feeding is typically avoided unless absolutely necessary, as food is best absorbed through the intestines.

Removing the Breathing Tube

The tube is far easier to remove than to place. When it is time for the tube to be removed. the ties or tape that hold it in place must first be removed. Then the balloon that holds the tube in the airway is deflated so that the tube can be gently pulled out. Once the tube is out, the patient will have to do the work of breathing on their own.

Do Not Intubate/Do Not Resuscitate

Some patients make their wishes known using an advanced directive, a document that clearly indicates their wishes for their healthcare. Some patients choose the "do not intubate" option, which means that they do not want to be placed on a ventilator to prolong their life. Do not resuscitate means the patient chooses not to have CPR.

The patient is in control of this choice, so they may choose to temporarily change this choice so that they may have surgery that requires a ventilator, but this is a binding legal document that cannot be changed by others under normal circumstances.

A Word From Verywell

The need to be intubated and placed on a ventilator is common with general anesthesia, which means most surgeries will require this type of care. While it is scary to consider being on a ventilator, most surgery patients are breathing on their own within minutes of the end of surgery. If you are concerned about being on a ventilator for surgery, be sure to discuss your concerns with your surgeon or the individual providing your anesthesia.

Source:

Endotracheal Intubation. Medline Plus. https://medlineplus.gov/ency/article/003449.htm​

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