What Is Intubation: Procedure and Why Is It Done?

Are you ready to learn about all about the Intubation procedure and intubating patient? If so, then you’re in the right place, because that is what this study guide is all about. 

As a Respiratory Therapist, this is a procedure that you will perform (or assist with) very often. That is why it’s extremely crucial that you develop a full understanding of the intubation procedure as a student. Not to mention, you will need to know this information for the TMC Exam as well. So if you’re ready, let’s go ahead and dive right in.

Intubation

What is Endotracheal Intubation?

Endotracheal intubation is an emergency medical procedure that is performed on patients with altered level of consciousness or an impaired breathing pattern.

By conducting this procedure, the healthcare provider can help maintain an open airway and prevent respiratory arrest. In addition, endotracheal intubation allows for continuous medical intervention while prolonging the life of the patient.

How does the Intubation Process Work?

An intubation is helpful because it provides a way to provide mechanical ventilatory support to the patient in order to keep them stable while the underlying cause is treated.

In a typical endotracheal intubation, patients are given anesthesia and a muscle relaxant in order to minimize discomfort and relax the muscles of the airways. During the procedure, a laryngoscope (device designed for visualization of the vocal cords) is used to hold the tongue aside.

A flexible plastic tube will then be inserted into the trachea through the patient’s mouth. The tube will be then secured by inflating the small cuff around it.

Pressure is often applied to the patient’s Adam’s apple to significantly lower the risk of aspiration of stomach contents. With that being said, we’ll discuss the intubation procedure in more detail later on in this guide — so keep reading. 

The process of endotracheal intubation is the same in patients of different age brackets. The only difference is in the size of the equipment used during the process of insertion.

Normally, pediatric patients require a much smaller ET tube than older adults, and inserting the tube may require skills and experience because ET tube placement in smaller airways needs a higher degree of precision.

In some cases, health care providers use a fiber optic scope, a device used to enhance/enlarge images, to allow better visualization and easy insertion during the process.

Indications for Intubation:

Endotracheal intubation helps maintain a patent airway. This procedure allows air/oxygen to pass freely to and from the patient’s lungs during respiration.

This emergency medical procedure is indicated for the following:

• To open the airways so that the patient can receive a sufficient amount of oxygen, prescribed medication, or anesthesia.
• To protect the patient’s lungs.
• To help patients who stopped breathing or those with impaired breathing pattern.
• It helps patients who require a mechanical ventilator achieve spontaneous breathing.
• It is indicated for patients with head injury who cannot breathe on their own.
• It is performed on patients who require sedation for a period of time to allow recovery from a debilitating medical injury or serious illness.

Aside from this, endotracheal intubation is beneficial for patients who are suffering from the following medical conditions:

• Collapsed lung
• Emphysema
• Heart failure
• Inhalation injury accompanied by severe inflammation of the vocal cords
• Intestinal or stomach bleeding
• Massive bleeding from the esophagus
• Overdose
• Hemorrhage
• Pneumonia
• Pulmonary Contusion
• Respiratory arrest
• Respiratory failure
• Stroke

What is an Endotracheal Tube?

An endotracheal (ET) tube is a flexible plastic tube that is inserted into the patient’s mouth into the trachea or windpipe to help sustain spontaneous breathing.

The ET tube is then connected to a ventilator or a bag valve mask (BVM) to provide patients with continuous oxygen delivery. The process of inserting an ET tube into the airways of the patient is known as endotracheal intubation.

The ET tube comes in various types and sizes. The size of the ET tube can be determined by the inner diameter (ID).

For example, if the ID is 8 mm, the tube size is also 8.

Also, ET tubes can either be cuffed or uncuffed. Cuffed ET tube requires an injection of pressurized air into the balloon to create a seal against the inside walls of the airway. On the other hand, an uncuffed ET tube is recommended for children less than 8 years old to prevent narrowing of the trachea.

What are the Steps of the Intubation Procedure?

The following are the correct steps of the intubation procedure:

1. Verify the doctor’s order.
2. Ask the family or relatives of the patient to sign an informed consent.
3. Prepare all necessary materials close at hand (assorted ET tube sizes, laryngoscope handle, blades, 10 ml syringe, water-soluble lubricant, tape, BVM, suction equipment, and stethoscope).
4. Wash hands and put on sterile gloves.
5. Check the endotracheal cuff for any signs of leaks.
6. Gently insert stylet into the ET tube.
7. Connect blade to battery base and check if flight is fully functioning. Make sure to have backup blades of different types and sizes close at hand.
8. Using BVM, preoxygenate the patient with 100% oxygen to prevent hypoxemia (low oxygen levels).
9. Administer sedatives or opioids as appropriate.
10. Ask an assistant to continuously apply cricoid pressure to prevent aspiration of gastric contents.
11. Assess for patient’s ability to mask ventilate.
12. Administer appropriate neuromuscular blockade (paralyzes affected skeletal muscles) for easy insertion.
13. Firmly hold the laryngoscope with your left hand.
14. Using the cross finger technique (thumb and index finger of a gloved hand on opposite rows of teeth) to open the patient’s mouth.
15. Gently insert the blade into the right side of the mouth of the patient, pushing the tongue to the left.
16. Advance the blade until it reaches the base of the tongue. The tip of the curved blade should be accurately secured in front of the epiglottis (flap in the throat) in the valecula (depression just behind the root of the tongue). Adjust the the tip of the straight blade so that it is under the epiglottis.
17. Lift the handle to visualize the vocal cords.
18. Using the stylet, grasp the ET tube.
19. Slowly insert the ET tube along the right side of the mouth until the cuff can no longer be seen.
20. Secure the ET tube in place by holding it firmly.
21. Withdraw the blade.
22. Remove the stylet.
23. Using the syringe, inflate the ET tube cuff with 5-10 ml of air to secure it in place.
24. Using the stethoscope, check for bilateral breath sounds and absence of breath sounds over the epigastrium (upper central region of the abdomen). If assessment indicates that the ET tube is not in the correct position, deflate the ET tube cuff using the syringe, remove the ET tube, resume mask ventilation with 100% oxygen, and then prepare to reinsert. If breath sounds cannot be heard on the left, deflate the ET tube cuff using the syringe, withdraw the ET tube 1-2 cm, and reassess for proper placement.
25. Palpate the visible dip in between the neck and the two collarbones (suprasternal notch) to feel for the ET cuff. If felt, it means that the ET tube is in proper position.
26. Assess for any abnormalities in the vital signs.
27. Secure the ET tube with a tape.
28. Connect the ET tube to the mechanical ventilator and observe for continuous rise and fall of the chest.
29. If necessary, use a portable chest X-ray to determine proper ET tube placement.
30. Clean and return used materials and then wash hands.

After the endotracheal tube is secured in place and the patient is connected to a mechanical ventilator, the health care provider will continue to monitor the condition of the patient, the tubing, and settings.

In addition, treatments, oral care, and suctioning are necessary in order to maintain a patent airway and sustain spontaneous breathing. Due to the location of the tube, it is important to keep in mind that conscious patients will not be able to speak while the ET tube is in place.

Orotracheal vs Nasotracheal Intubation

Orotracheal intubation involves the insertion of ET tube through the patient’s mouth and into the trachea. Unlike nasotracheal intubation, this type of intubation is performed more frequently.

Orotracheal intubation is indicated for the maintenance of a patent airway of critically ill patients with multisystem disease or injuries. In addition, it is also indicated for the control of the airway of patients undergoing general anesthesia.

The following are the correct steps in performing orotracheal intubation:

1. Place the patient in the sniffing position, with a small cushion behind the head.
2. Ask an assistant to apply continuous cricoid pressure during the procedure to prevent aspiration of gastric contents.
3. Select a laryngoscope blade size that is appropriate for the patient.
4. Open the patient’s mouth using the cross finger technique.
5. Slowly insert the laryngoscope blade along the right side of the patient’s tongue. Lean back as you do this for better visualization.
6. Hold the ET tube in your fingers like a dart and slowly insert through the arytenoids (pair of cartilages at the back of the larynx) until it reaches the rings of the trachea.
7. Pull back the ET tube until its black stripe is at the corner of the mouth of the patient.
8. Remove the laryngoscope from the mouth of the patient.
9. Confirm correct placement of the ET tube.
10. Secure the tube with a tape once correct placement is determined.

Nasotracheal intubation, also known as blind intubation, involves the insertion of an ET tube through the nose and into the trachea. The procedure is performed without using a laryngoscope to view the opening of the glottis (consisting of the vocal cords and the opening between them).

This technique may be used without extending the head of the patient, therefore it is recommended for patients with spine injuries and clenched teeth.

Nasotracheal intubation is performed using the following steps:

1. Apply anesthesia to the nasal passages and posterior pharynx.
2. Select the appropriate ET tube size and test the balloon cuff by inflating it.
3. Lubricate the ET tube.
4. Select the nares with the largest pathway to the pharynx.
5. Slowly insert the ET tube over the superior surface of the hard palate.
6. Advance the ET tube further until you can hear the patient’s breath coming through the tube. Make sure to advance the ET tube during inhalation so that it will go through the trachea. If the placement is correct, the patient will exhibit coughing mechanism and will not be able to speak.
7. Once the tube is correctly placed in the trachea, connect it to the mechanical ventilator.

What Medications are used for Intubation?

Prior to endotracheal intubation, your doctor may administer the following medications to facilitate easy insertion and maximize the effectiveness of the procedure:

• Atropine – This drug works by increasing the heart rate while decreasing bronchial secretions.
• Vecuronium – A small dose of this neuromuscular blocker is given in order to prevent muscle twitching caused by full doses of succinylcholine.
• Succinylcholine – Relaxes the muscles of the airways to facilitate easy insertion of the ET tube.
• Benzocaine – A topical anesthetic used to reduce discomfort associated with endotracheal intubation.
• Etomidate – It is used to sedate patients during the process of intubation.

What Does Rapid Sequence Intubation Mean?

Rapid Sequence Intubation (RSI) is considered as the fastest and most effective airway management technique that makes use of induction agent and muscle relaxant to induce prompt unconsciousness and paralysis, allowing health care providers to insert ET tube with minimal delay.

RSI is indicated for patients with the following conditions:

• Airway burn
• Cervical spine injury (diaphragmatic paralysis)
• Combativeness
• Hypoventilation
• Hypoxia
• Impaired gag reflex
• Major trauma requiring multiple medical interventions
• Penetrating neck injury
• Prolonged transfer
• Swallowing difficulties

What are the Complications of Intubation?

Short-term complications associated with endotracheal intubation may include the following:

• Aspiration of contents of the mouth or stomach
• Bleeding
• Esophageal placement of the tube
• Injury to the mouth, teeth, tongue, thyroid gland, larynx, trachea, vocal cords, or esophagus.
• Lung collapse (pneumothorax)
• Temporary hoarseness

Long term complications that may occur over time include:

• Allergic reaction to anesthesia
• Breathing difficulties
• Difficulty speaking or swallowing
• Facial swelling
• Fluid buildup
• Pain in the neck
• Severe sore throat
• Spinal cord injuries
• Tracheal stenosis (narrowing of the trachea)
• Tracheoesophageal fistula (abnormal connection between the trachea and esophagus)
• Tracheomalacia (flaccidity of the supporting tracheal cartilage)
• Vocal cord paralysis

So now that you’ve all the way through our study guide on Intubation, that pretty much means that you are now an expert on the topic.

But just to be sure, you can go through the practice questions that are listed below in order to truly solidify this information into your brain. This will definitely help you once it comes test-time.