Endotracheal Intubation

Endotracheal intubation is a lifesaving medical procedure where a healthcare provider inserts a breathing tube through your mouth or nose into your windpipe to help you breathe when you cannot do so on your own.

Table of contents

• What Is Endotracheal Intubation?
• When Is This Procedure Needed?
• Understanding the Airway Anatomy
• How the Procedure Is Performed
• How Long Does the Procedure Take?
• Speaking and Eating During Intubation
• How Common Is This Procedure?
• Risks and Complications
• What Happens After the Procedure

What Is Endotracheal Intubation?

Endotracheal intubation is a medical procedure in which a flexible plastic tube is placed into the trachea (windpipe) through the mouth or nose. The trachea is the tube that carries oxygen to your lungs. In most emergency situations, the tube is placed through the mouth^[1][2].

The tube keeps your trachea open so air can get through. It can connect to a machine that delivers air or oxygen with pressure, known as mechanical ventilation^[1]. This procedure is also known as airway intubation, tracheal intubation, or simply intubation^[1].

Airway intubation, Tracheal intubation, ETT (Endotracheal intubation)

When Is This Procedure Needed?

A healthcare provider may need to intubate you when a blockage or damage to your airways keeps you from breathing. Intubation is performed to keep the airway open in order to give oxygen, medicine, or anesthesia^[3].

Some conditions that can lead to intubation include^[1]:

• Injury or trauma to your abdomen, chest or neck that affects your airways
• Loss of consciousness (fainting) or a low level of consciousness, which can make you lose control of your airway
• Need for surgery that will make you unable to breathe on your own
• Respiratory failure (when your lungs cannot work properly on their own)
• Risk for breathing in an object or substances, like food, vomit or blood (a problem called aspiration)
• Something caught in your airway and blocking the flow of air (airway obstruction)
• Sudden loss of heart function (cardiac arrest)
• A temporary stop in breathing (apnea)

The procedure is also used to support breathing in certain illnesses, such as pneumonia, emphysema, heart failure, collapsed lung or severe trauma. It helps remove blockages from the airway and protects the lungs in people who are unable to protect their airway^[3].

Understanding the Airway Anatomy

• Oral cavity (mouth)
• Nose
• Pharynx (throat)
• Larynx (voice box)
• Vocal cords
• Trachea (windpipe)
• Epiglottis
• Cricoid cartilage
• Bronchi (lung airways)

The upper airway consists of the oral cavity and pharynx, including the nasopharynx, oropharynx, hypopharynx, and larynx. These structures humidify and warm the air^[2].

The trachea is soft and membranous on the back side with cartilaginous rings on the front. Adult tracheal diameters vary between 15 mm and 20 mm. At the fifth thoracic spine, the trachea splits into the right and left mainstem bronchi. The angle between the trachea and the left mainstem bronchus is more acute, making foreign object movement into the left side less likely^[2].

The larynx sits above the vocal cords. The cricoid cartilage is ring-shaped and sits below the cricothyroid membrane, which is an important landmark for emergency airway procedures. Identification of the cricoid cartilage and manipulation of the airway often helps providers see the vocal cords during intubation^[2].

How the Procedure Is Performed

Most intubation procedures happen in the hospital. Sometimes, emergency medical services personnel intubate people outside of a hospital setting^[1].

Whether you are awake (conscious) or not awake (unconscious), you will be given medicine to make it easier and more comfortable to insert the tube. You may also receive medicine to relax^[3].

During endotracheal intubation, healthcare providers will^[1]:

1. Insert an intravenous (IV) needle into your arm
2. Deliver medications through the IV so you fall asleep and don’t feel pain during the procedure (anesthesia)
3. Place an oxygen mask over your nose and mouth to give your body extra oxygen
4. Tilt your head back and insert a laryngoscope in your mouth (or your nose when necessary); a laryngoscope has a handle, lights and a dull blade, which help providers guide the tracheal tube
5. Move the laryngoscope toward the back of your mouth, avoiding your teeth
6. Raise the flap of tissue that hangs in the back of your mouth (epiglottis) to protect your voice box (larynx)
7. Advance the tip of the laryngoscope into your larynx and then into your trachea
8. Inflate a small balloon around the endotracheal tube to make sure it stays in place in your trachea and that all air from the tube reaches your lungs
9. Remove the laryngoscope
10. Place tape on the sides of your mouth or a strap around your head to keep the tracheal tube in place
11. Ensure that the tube is in the right place by taking an X-ray or squeezing air through a bag into the tube and listening for breath sounds

The healthcare provider will use a device called a laryngoscope to be able to view the vocal cords and the upper part of the windpipe. Once the tube is inserted, it passes through the windpipe and past the vocal cords to just above the spot where the trachea branches into the lungs^[3].

How Long Does the Procedure Take?

In an emergency, a healthcare provider can complete intubation in less than a minute^[1].

Speaking and Eating During Intubation

No. The endotracheal tube passes through your vocal cords, so you won’t be able to speak^[1].

You also can’t swallow while intubated, so you can’t eat or drink. Depending on how long you’ll need intubation, healthcare providers may give you a peripheral IV to provide liquid nutrition (enteral nutrition) or IV fluids. They may also deliver them through a separate slim tube^[1].

How Common Is This Procedure?

Intubation is a very common lifesaving procedure. Each year in the U.S., healthcare providers perform intubation approximately^[1]:

• 15 million times in operating room situations
• 650,000 times outside of the operating room, including 346,000 times in the emergency department

Risks and Complications

Risks include^[3]:

• Bleeding
• Infection
• Trauma to the voice box (larynx), thyroid gland, vocal cords and windpipe (trachea), or esophagus
• Puncture or tearing (perforation) of body parts in the chest cavity, leading to lung collapse

What Happens After the Procedure

The procedure is most often done in emergency situations, so there are no steps you can take to prepare beforehand^[3].

After the procedure, you will be in the hospital to monitor your breathing and your blood oxygen levels. You may be given oxygen or placed on a breathing machine. If you are awake, your provider may give you medicine to reduce your anxiety or discomfort^[3].

Once there is no longer a need for help with breathing or protection of the airway, the tracheal tube is removed. This is called extubation of the trachea^[6].

The outlook will depend on the reason the procedure needed to be done^[3].