Endotracheal intubation is a life-saving medical procedure that involves placing a breathing tube through the mouth or nose into the windpipe, allowing healthcare providers to help patients breathe when they cannot do so on their own.

What Is Endotracheal Intubation?

Endotracheal intubation is a medical procedure in which a healthcare provider inserts a flexible plastic tube, called an endotracheal tube, through a patient’s mouth or nose and guides it down into the trachea, which is the windpipe that carries oxygen to the lungs. This tube keeps the airway open so that air can reach the lungs, and it can be connected to a machine that delivers oxygen or assists with breathing.^[1]

The procedure is also known by several other names, including airway intubation, tracheal intubation, and simply intubation. The tube itself passes through the vocal cords and rests in the trachea just above where the windpipe splits into two branches leading to each lung. A small balloon at the end of the tube is inflated once the tube is in place, which helps keep it secure and ensures that all the air from the tube reaches the lungs.^[1]

Most intubation procedures take place in hospitals, though emergency medical personnel can also perform intubation outside of hospital settings when necessary. The procedure is relatively quick—in emergency situations, a skilled healthcare provider can complete intubation in less than one minute.^[1]

How Common Is This Procedure?

Intubation is an extremely common and essential life-saving procedure performed millions of times each year. In the United States alone, healthcare providers perform intubation approximately 15 million times annually in operating rooms during surgical procedures. Outside of operating rooms, intubation is performed around 650,000 times per year, with about 346,000 of these procedures occurring in emergency departments.^[1]

The frequency with which this procedure is performed highlights its critical role in modern medical care. Whether someone needs surgery requiring general anesthesia or faces a medical emergency that compromises their ability to breathe, intubation provides a vital bridge that can mean the difference between life and death.

Why Would Someone Need Intubation?

Healthcare providers may need to intubate a patient when a blockage or damage to the airways prevents normal breathing. The fundamental purpose of intubation is to maintain an open airway and support breathing in patients who cannot adequately breathe on their own.^[3]

There are several specific reasons why intubation becomes necessary. During surgical procedures, patients receive general anesthesia that makes them unable to breathe independently, requiring intubation to maintain oxygen flow to their lungs. In medical emergencies, patients suffering from respiratory failure—when the lungs cannot properly exchange oxygen and carbon dioxide—need intubation to survive. This can occur due to severe illnesses such as pneumonia, emphysema, heart failure, or a collapsed lung.^[3]

Patients who have lost consciousness or have a significantly reduced level of consciousness may lose control of their airway, making intubation necessary to protect their breathing passages. Similarly, those at risk of aspiration—breathing in foreign materials like food, vomit, or blood—require intubation to protect their lungs from these dangerous substances. This is particularly important for people who have suffered certain types of strokes, drug overdoses, or massive bleeding from the esophagus or stomach.^[3]

Other conditions that may require intubation include injury or trauma affecting the abdomen, chest, or neck that impacts the airways; airway obstruction when something blocks the flow of air; cardiac arrest when the heart suddenly stops functioning; and temporary cessations of breathing known as apnea.^[1]

Understanding the Anatomy Involved

To understand how intubation works, it helps to know the basic anatomy of the airway. The upper airway consists of the mouth, nose, and throat regions. The throat is divided into several sections including the area behind the nose, behind the mouth, and the lower part of the throat that leads to the voice box. These structures warm and moisten the air we breathe.^[2]

The larynx, or voice box, sits at the top of the trachea and contains the vocal cords—two bands of tissue that vibrate to produce sound when we speak. Just above the vocal cords is a flap of tissue called the epiglottis, which normally covers the larynx when we swallow to prevent food and liquids from entering the airway.^[1]

The trachea itself is a tube that extends from the larynx down into the chest. It has cartilage rings on the front and sides that keep it from collapsing, while the back is soft and membranous. In adults, the trachea typically measures between 15 and 20 millimeters in diameter. At approximately the level of the fifth vertebra in the chest, the trachea divides into two main branches called the right and left mainstem bronchi, with each branch leading to one lung.^[2]

The angle between the trachea and the right mainstem bronchus is more gradual than the angle to the left bronchus. This anatomical difference is important because if an endotracheal tube is advanced too far down the trachea, it is more likely to slip into the right bronchus rather than the left.^[2]

How the Procedure Is Performed

The intubation procedure follows a carefully structured sequence of steps designed to safely place the tube while minimizing discomfort and risk to the patient. Understanding what happens during intubation can help reduce anxiety for patients or family members who may witness or undergo the procedure.

The process begins with administering medications. Healthcare providers insert an intravenous line into the patient’s arm and deliver medications through this line. These medications cause the patient to fall asleep and prevent pain during the procedure—a state called anesthesia. Additional medications may be given to relax the patient’s muscles, making it easier to insert the tube.^[1]

Before inserting the tube, providers place an oxygen mask over the patient’s nose and mouth to give the body extra oxygen. This step, called preoxygenation, is critical because it creates an oxygen reservoir in the lungs that allows continued oxygenation of the blood during the brief period when the patient is not breathing while the tube is being placed.^[12]

Once the patient is properly sedated and oxygenated, the healthcare provider tilts the patient’s head back into what is known as the “sniffing position” and inserts a device called a laryngoscope into the mouth or nose. The laryngoscope has a handle, lights, and a blade that helps the provider see inside the throat and guide the breathing tube into the correct position.^[1]

The provider carefully moves the laryngoscope toward the back of the mouth, taking care to avoid the teeth. They then lift the epiglottis to expose the larynx and advance the tip of the laryngoscope into the voice box and then into the trachea. Once the vocal cords are clearly visible, the endotracheal tube is carefully passed between them and into the trachea.^[1]

After the tube is in place, the small balloon or cuff around the tube is inflated to secure it in the trachea and ensure that all air from the tube reaches the lungs. The laryngoscope is then removed, and the tube is secured to the patient’s face using tape or a strap around the head to prevent it from moving.^[1]

The final crucial step is confirming that the tube is in the correct position. This can be done by taking a chest X-ray or by using a bag to squeeze air through the tube while listening with a stethoscope for breath sounds in both lungs. Providers may also use other devices that detect carbon dioxide coming from the tube, which confirms that it is in the trachea rather than the esophagus.^[1]

What Happens After Intubation?

Once a patient is intubated, they cannot speak because the tube passes through the vocal cords. They also cannot swallow, which means they cannot eat or drink in the normal way. Depending on how long intubation is needed, healthcare providers may give nutrition through an intravenous line or through a separate thin feeding tube.^[1]

Patients remain in the hospital where healthcare providers closely monitor their breathing and blood oxygen levels. The endotracheal tube may be connected to a mechanical ventilator—a machine that helps with breathing by delivering oxygen and air with controlled pressure. If the patient is awake while intubated, which can happen in some situations, providers may give medications to reduce anxiety and discomfort.^[3]

When the patient no longer needs help breathing or airway protection, the tube is removed in a process called extubation. The timing of extubation depends on the underlying reason for intubation and the patient’s overall condition and ability to breathe independently.^[6]

Understanding the Risks

While intubation is generally safe and often life-saving, like any medical procedure, it carries some risks. Understanding these potential complications helps patients and families make informed decisions about their care.

Potential risks include bleeding, which can occur if tissues in the mouth, throat, or airway are injured during tube placement. Infection is another possibility, as introducing any device into the body creates a potential pathway for bacteria or other microorganisms. The procedure can cause trauma to various structures including the voice box, thyroid gland, vocal cords, windpipe, or esophagus if the tube or laryngoscope inadvertently damages these delicate tissues.^[3]

In rare cases, there can be puncture or tearing of structures in the chest cavity, which may lead to a collapsed lung. This is an uncommon but serious complication that requires immediate medical attention.^[3]

It’s important to note that serious complications from endotracheal intubation are rare. Minor problems are more common and can include damage to teeth, a sore throat after the tube is removed, and temporary hoarseness due to irritation of the vocal cords.^[7]

Different Techniques and Equipment

Modern medicine offers several approaches to intubation, with providers selecting the most appropriate technique based on the patient’s anatomy, the urgency of the situation, and the provider’s expertise. The two most common approaches are direct laryngoscopy and video laryngoscopy.^[2]

Direct laryngoscopy is the traditional method where the provider uses a standard laryngoscope to directly visualize the vocal cords by looking down the patient’s throat. This technique has been used for many decades and remains highly effective. There are different types of laryngoscope blades, with the curved blade and straight blade being the most common options. Each has advantages in different situations and with different patient anatomies.^[2]

Video laryngoscopy is a newer technology that uses a camera at the tip of a specialized laryngoscope to display the view of the airway on a screen. This allows the provider to see around corners and can be especially helpful in patients with difficult anatomy. It also allows other team members to see what the person performing the intubation sees, which can be valuable for teaching and for coordinating care.^[2]

In addition to laryngoscopes, providers use various other equipment during intubation. A stylet is a semi-rigid wire that can be inserted into the endotracheal tube to give it shape and help guide it into the trachea. A device called a bougie—a thin, flexible introducer—can be particularly helpful in difficult intubations, allowing the provider to first guide this smaller device through the vocal cords and then slide the endotracheal tube over it.^[2]

Special Situations

Some situations require modified approaches to intubation. In true emergencies where a patient’s condition is rapidly deteriorating, providers may use a technique called rapid sequence intubation. This involves giving sedative and paralytic medications in quick succession to achieve optimal conditions for intubation as rapidly as possible.^[10]

When intubation through the mouth or nose is impossible—perhaps due to severe facial trauma or an obstruction—providers may need to perform a cricothyrotomy. This emergency surgical procedure involves making an incision in the neck to place a tube directly into the trachea below the obstruction.^[2]

A tracheotomy is a surgical procedure similar to cricothyrotomy but is usually performed in more controlled, non-emergency situations when providers anticipate that a patient will need prolonged airway support. Unlike temporary endotracheal intubation through the mouth or nose, a tracheotomy creates a more stable opening in the neck for long-term ventilation.^[6]

Intubation in Children

The airway anatomy in children differs from adults in several important ways, which affects how intubation is performed. Children have relatively larger tongues compared to the size of their mouth, a more flexible and U-shaped epiglottis, and a higher and more forward-positioned larynx. These differences mean that techniques effective in adults may need modification when intubating children.^[2]

The size of the endotracheal tube must be carefully selected based on the child’s age and size. Using a tube that is too large can cause damage to the delicate airway structures, while a tube that is too small may not provide adequate ventilation. Children also have smaller oxygen reserves and higher metabolic rates, which means they can experience dangerous drops in oxygen levels more quickly than adults during the procedure.^[12]

Recovery and Outcomes

The outlook after intubation depends primarily on the underlying reason why the procedure was necessary. For patients intubated for elective surgery, recovery is typically straightforward—they wake up after surgery with the tube already removed and may experience only minor throat soreness that resolves within a few days.^[3]

For patients intubated due to severe illness or injury, the recovery course depends on their ability to overcome the underlying condition. Some patients need ventilator support for only a few hours or days, while others with more serious conditions may require weeks of mechanical ventilation.

After the tube is removed, patients may notice that their voice sounds hoarse or their throat feels sore. These symptoms are normal and typically resolve on their own over several days. In rare cases, longer-term effects such as persistent hoarseness may occur if the vocal cords were injured during the procedure, though this is uncommon with careful technique.