Intubation

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Intubation is the term used to describe the introduction of a tube into the windpipe through which a patient is artificially ventilated. It is always necessary when the patient cannot breathe independently, for example during surgery or resuscitation. The hose keeps the airways open, which would otherwise be blocked by a lack of muscle tension or reflexes. Read all about the intubation process, when it is used, and the risks.

What is intubation?

The aim of intubation is to ensure the function of the lungs in patients who cannot breathe independently. Intubation is also an important measure to ensure that stomach contents, saliva or foreign bodies do not get into the trachea. It also allows doctors to safely get anesthetic gases and medication into the lungs. Depending on the practitioner's experience and the medical circumstances, there are several procedures:

• Endotracheal intubation
• Intubation with a laryngeal mask
• Intubation with the laryngeal tube
• Fiberoptic intubation

Endotracheal intubation is most commonly used in hospitals. A plastic tube, the so-called tube, is inserted into the patient's windpipe. This is done either through the mouth or the nose. When the patient is able to breathe independently again, the tube is removed with the so-called extubation.

When do you perform intubation?

Intubation is performed in the following situations:

• Operations under general anesthesia
• coma
• mechanical resuscitation
• severe injuries or swellings in the face or throat with (threatened) obstruction of the airways
• Examination of the trachea and bronchi

Alternatively, in many cases, ventilation can also be provided through a face or larynx mask that is tightly closed over the mouth and nose. However, endotracheal intubation with a tube offers the best protection against inhalation of stomach contents, saliva and foreign bodies. The risk of this is particularly high with:

• ventilating patients who have recently eaten or drank.
• Surgery on the abdomen, chest, face and neck
• intubation during pregnancy
• resuscitation of a patient

What do you do with intubation?

Before the actual intubation, the patient inhales pure oxygen for about three to five minutes through a mask that sits close to the mouth and nose (hyperoxygenation). This enrichment of oxygen in the blood enables the time to complete intubation to be bridged better because the body builds up a small oxygen reserve. At the same time, the anesthetist injects the patient with painkillers and sleeping pills, as well as a drug to relax the muscles. As soon as this mixture works, the actual intubation can begin.

Endotracheal intubation

With endotracheal intubation, the patient's head is overstretched so that the access via the mouth and throat in the direction of the airways is as straight as possible. The anesthetist carefully inserts a metal spatula into the oral cavity, using which he presses down the tongue and prevents it from blocking access to the larynx. This gives him a good view of the larynx and vocal cords.

Intubation through the mouth

For intubation through the oral cavity (orotracheal intubation), the tube is now inserted directly into the mouth. The tube is carefully pushed several centimeters deep into the windpipe along the metal spatula between the vocal cords. At the end of the tube there is a small balloon, the so-called cuff, which is now inflated. This seals the windpipe completely. This is the only way to make artificial ventilation with positive pressure possible.

Intubation through the nose

Another option is to insert the ventilation tube over the nose (nasotracheal intubation). For this purpose, after the administration of decongestant nasal drops, a tube coated with lubricant is carefully pushed through a nostril until it is in the throat. If necessary, it can be directed from there into the windpipe using special forceps.

Correction of the correct position

To check whether the tube is really in the windpipe and not in the esophagus, air is blown into it with a resuscitator. At the same time, the doctor listens to the patient in the stomach region with a stethoscope. If a bubbling noise can be heard, the tube is in the esophagus and its position must be corrected immediately.

If nothing can be heard and the patient can be ventilated with the bag without great pressure, the chest should now raise and lower at the same time. Even with the stethoscope, you should be able to hear an even breathing sound across both sides of the chest. This is important to ensure that the tube has not advanced beyond the bifurcation of the trachea into one of the main bronchi. Then only one side of the lung, usually the right, would be ventilated.

In addition, the carbon dioxide content of the outflowing air can be checked with a special device. If the tube is in the lungs, it must be higher than that of the incoming air.

The metal spatula is removed and the outer end of the tube is attached to the cheek, mouth and nose with plaster strips so that it cannot slip. The intubated person is now connected to a ventilator via tubes.

Extubation

After the operation, the anesthetist removes the tube. First, the saliva in the throat is sucked off so that it cannot flow into the trachea during extubation. The balloon is then deflated and the tube withdrawn from the windpipe.

Intubation with laryngeal mask and laryngeal tube

Especially in emergencies or with certain injuries, the doctor does not necessarily have the option of overextending the cervical spine and working his way into the trachea with the intubation tube. The laryngeal mask was developed for such cases.In this case, the end of the tube is provided with a beveled, oval bead. The laryngeal mask is also inserted into the throat, but then remains in front of the larynx and seals it against the esophagus. Then the bulge of the "larynx mask" is inflated to enable ventilation with positive pressure.

Intubation with a laryngeal tube works on a similar principle. Here, too, the esophagus is blocked, but with a blind, rounded end of the tube. Further up, a second opening above the larynx allows gas exchange.

Fiberoptic intubation

If endotracheal intubation is difficult for anatomical reasons, it can be performed under vision. So-called fiber-optic intubation is used for this. For example, it may be necessary when the patient

• only has a small mouth opening
• has limited mobility of the cervical spine
• suffers from inflammation in the jaw or loose teeth
• has a large, immobile tongue

The difference to normal intubation is that the attending physician first paves the way through the nostril with a so-called bronchoscope. This thin and flexible instrument carries movable optics and a light source. After the patient is given a numbing nasal spray, the bronchoscope is inserted through the lower nasal passage. Once the doctor has made his way to the windpipe, the patient is anesthetized and the ventilation tube is pushed through the endoscope into the windpipe.

What are the risks of intubation?

Intubation can lead to various complications, especially in emergency situations. For example:

• Damage to teeth
• Damage to the mucous membrane in the nose, mouth, throat and windpipe, which can lead to bleeding
• Bruises or tears in the throat or lips
• Injuries to the larynx, especially the vocal cords)
• Overinflation of the lungs
• Inhalation of stomach contents
• Misalignment of the tube in the esophagus

In addition, if the anesthesia is inadequate in the upper airways, the mechanical irritation may trigger a number of reflexes:

• cough
• Vomit
• Tension of the larynx muscles
• Rise or fall in blood pressure
• Cardiac arrhythmias
• Apnea

Long-term intubation in particular can cause irritation and damage to the mucous membrane of the windpipe, mouth or nose.

What should I watch out for after intubation?

As soon as the anesthetist has ensured that the patient can breathe independently again, artificial ventilation is no longer necessary. The tube can be removed. The patient's breathing rate and heartbeat will continue to be monitored while the patient recovers from anesthesia and intubation.

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