Orotracheal intubation is a medical procedure involving the insertion of a specialized tube through a patient’s mouth and into the trachea, also known as the windpipe. This flexible plastic endotracheal tube establishes a secure pathway directly to the lungs. It facilitates breathing for individuals unable to maintain an open airway or breathe adequately on their own.
Medical Reasons for Intubation
Intubation is common during general anesthesia for surgical procedures. The tube maintains an open airway, ensuring that patients receive oxygen and anesthetic gases consistently throughout the surgery. This allows the medical team to control breathing and prevent aspiration, where stomach contents might enter the lungs.
Beyond surgical settings, intubation is a frequent intervention in critical care for individuals experiencing respiratory failure. Conditions such as severe pneumonia, acute respiratory distress syndrome (ARDS), or exacerbations of chronic obstructive pulmonary disease (COPD) can severely impair a person’s ability to breathe effectively. In these cases, the endotracheal tube allows for mechanical ventilation, providing breathing support.
Intubation also protects the airway in unconscious patients. Individuals with a diminished level of consciousness, perhaps due to major trauma, a stroke, or a drug overdose, may lose the protective reflexes that prevent foreign material from entering the lungs. Placing an endotracheal tube secures the airway, safeguarding against aspiration of fluids like vomit or blood.
The Intubation Procedure
Before the procedure, medical staff prepare equipment, including the endotracheal tube, a laryngoscope for viewing the airway, and a suction device. The patient is positioned on their back, often with their head slightly elevated to align the oral, pharyngeal, and tracheal axes, which helps in visualizing the vocal cords.
To ensure the patient’s comfort and relaxation, sedative and paralytic medications are administered. These medications render the patient unconscious, preventing any pain or memory of the procedure and relaxing the muscles of the airway.
A healthcare provider uses a laryngoscope, a device with a light and a blade, to gently lift the tongue and soft tissues, allowing a direct view of the vocal cords. With the vocal cords visible, the lubricated endotracheal tube is carefully guided through the mouth and past the vocal cords into the trachea. The tube is advanced until its tip rests a few centimeters above the carina, the point where the trachea divides into the main bronchi.
Once the tube is in place, a small balloon, known as a cuff, located near the tip of the tube is inflated with air. Correct placement is confirmed through several methods: listening for equal breath sounds over both lungs with a stethoscope, observing condensation inside the tube with exhalation, and using a carbon dioxide detector to verify exhaled CO2. A chest X-ray can also confirm the tube’s final position.
Life Support While Intubated
After the endotracheal tube is securely positioned, it is connected to a mechanical ventilator. This machine takes over breathing, pushing air into and out of the lungs. The ventilator can be adjusted to deliver specific volumes of air at a set rate, ensuring adequate oxygen delivery and carbon dioxide removal.
The inflatable cuff on the endotracheal tube plays a significant role during mechanical ventilation. By sealing the airway, the cuff ensures that all the air delivered by the ventilator goes into the lungs and prevents air from escaping back up the trachea. It also helps protect the lungs from aspiration of oral secretions or stomach contents.
Patients who are intubated are kept sedated to minimize discomfort, anxiety, and to allow their body to rest and heal. Due to the tube passing through the vocal cords, intubated patients are unable to speak. Communication with less sedated patients may involve simple gestures, writing notes, or using communication boards.
While intubated, continuous care is provided by nurses and other medical professionals. This care includes regular suctioning of secretions from the airway to maintain tube patency and prevent blockages. Oral hygiene is also performed to reduce the risk of infections.
Potential Complications
Orotracheal intubation carries potential complications. During the insertion, minor trauma to the mouth, lips, or teeth can occur, such as chipped teeth or abrasions. A sore throat is a common, temporary after-effect.
A more serious, though rare, complication during the procedure is the accidental misplacement of the tube into the esophagus instead of the trachea. If not quickly identified, this can lead to inadequate ventilation and rapidly declining oxygen levels. Medical teams use multiple verification methods to immediately detect and correct such misplacements.
For patients who require intubation for an extended period, other complications may develop. Prolonged pressure from the endotracheal tube can sometimes cause injury to the vocal cords, leading to hoarseness or, in rare cases, more persistent vocal changes after the tube is removed. Scar tissue formation, known as tracheal stenosis, can also occur, narrowing the windpipe.
Another concern with prolonged intubation is the increased risk of ventilator-associated pneumonia (VAP). This lung infection occurs when bacteria enter the lungs through the breathing tube. Healthcare providers implement strict protocols, including head-of-bed elevation, regular oral care, and careful suctioning, to minimize the risk of VAP.
The Extubation Process
When a patient’s underlying condition improves and they are able to breathe more independently, the medical team will assess their readiness for extubation, which is the removal of the endotracheal tube. This assessment involves evaluating the patient’s ability to breathe on their own with minimal support from the ventilator and ensuring they are sufficiently awake and alert.
The extubation process begins by elevating the head of the patient’s bed to an upright position. Medical staff then use a suction device to clear any secretions from the patient’s mouth and from inside the endotracheal tube itself. After the tape or strap holding the tube in place is removed, the cuff at the end of the tube is deflated.
The healthcare provider will instruct the patient to take a deep breath and then cough or exhale as the tube is gently and quickly pulled out. Following extubation, it is common for patients to experience temporary side effects such as a hoarse voice, a sore throat, or mild difficulty swallowing, which usually resolve within a few days.