An endotracheal tube is a flexible plastic tube that is inserted through the mouth into the windpipe (windpipe) to help the patient breathe. The endotracheal tube is then connected to a ventilator that delivers oxygen to the lungs. The process of inserting a tube is called endotracheal intubation .
There are many reasons why an endotracheal tube may be inserted, including surgery under general anesthesia, injury, or serious illness. Learn about the procedure, possible risks and complications, and what to expect.
An endotracheal tube is installed when the patient cannot breathe on their own, when it is necessary to calm and "rest" a very ill person, or to protect the airway. The tube supports the airway, allowing air to move in and out of the lungs.
There are a number of indications for endotracheal tube placement, which can be divided into several broad categories. This includes:
General Surgery: Under general anesthesia , the muscles of the body, including the diaphragm , are paralyzed and the placement of an endotracheal tube allows the ventilator to do the work of breathing.
Foreign body removal: If the windpipe is blocked by a foreign body that is being aspirated (inhaled), an endotracheal tube may be inserted to assist with removal of the foreign body.
To protect the airways from aspiration: If someone has severe gastrointestinal bleeding (bleeding in the esophagus, stomach, or upper intestine) or has a stroke, an endotracheal tube may be inserted to prevent stomach contents from entering the airways. .
If stomach contents are accidentally inhaled, a person can develop aspiration pneumonia, a very serious and life-threatening illness.
Airway imaging: If an abnormality of the larynx, trachea, or bronchi is suspected, such as a tumor or congenital malformation (congenital malformation), an endotracheal tube may be placed to closely visualize the airway.
After surgery: After breast surgery, such as lung cancer surgery or heart surgery, the endotracheal tube connected to the ventilator can be left in place to facilitate breathing after surgery. In this case, the person may be "disconnected" from the ventilator at some point during recovery.
To support breathing : If someone is suffering from breathing difficulties due to pneumonia, pneumothorax (collapsed lung), respiratory failure or impending respiratory failure, heart failure, or loss of consciousness due to an overdose, stroke, or brain injury, a tube may be placed endotracheal. for respiratory support.
Some diseases (especially neurological ones) can cause complete or partial paralysis of the diaphragm and may require respiratory assistance. Examples include amyotrophic lateral sclerosis , Guillain-Barré syndrome, and botulism .
The diaphragm can also become paralyzed due to injury or pressure on the phrenic nerve associated with trauma or swelling to the chest.
When sedation is required: If strong sedatives are needed, for example when the person is very ill, an endotracheal tube can be inserted to facilitate breathing until sedation is removed.
In premature infants: Respiratory distress in premature infants often requires placement of an endotracheal tube and mechanical ventilation.
When a higher concentration of oxygen is required: Endotracheal tube placement and mechanical ventilation allow higher oxygen concentrations to be delivered than in ambient air.
Before the procedure
If you are having surgery under general anesthesia, stopping smoking even a day or two before surgery can reduce the risk of complications.
Endotracheal tubes are flexible tubes that can be made from a variety of materials. Although latex tubes are not commonly used, it is important to inform your doctor if you are allergic to latex.
Endotracheal tubes come in a variety of sizes from 2.0mm (mm) to 10.5mm in diameter. Typically tubes with a diameter of 7.0 to 7.5 mm are often used for women and 8.0 to 9.0 mm for men. Newborns often require a 3.0-3.5mm tube and premature babies often require 2.5-3.0mm.
In emergencies, healthcare professionals often guess the correct size, while in the operating room, size is often chosen based on age and body weight.
Single and double lumen tubes are available, and single lumen tubes are often used in lung surgery so that one lung can be ventilated during surgery on the other lung.
Jewelry, especially tongue piercings, must be removed before inserting an endotracheal tube. People should not eat or drink for at least six hours before surgery to reduce the risk of aspiration during intubation.
During the procedure
The procedure to insert an endotracheal tube will depend on whether the person is conscious or not. An endotracheal tube is often inserted when the patient is unconscious. If the patient is awake, medications are used to relieve anxiety during insertion of the tube and before removal.
Precise steps are usually used during intubation. First, the patient is preoxygenated. with 100% oxygen (ideal time is five minutes) to give the intubator more time to intubate. Oral airways can be used to avoid interfering with the tongue and reduce the likelihood of the patient biting the endotracheal tube.
During surgery, the anesthesiologist must ensure that the patient is completely paralyzed before inserting the tube to reduce the likelihood of vomiting during insertion and subsequent complications.
For awake patients, antiemetics (antiemetics) can be used to reduce the gag reflex, and anesthesia can be used to numb the throat. In some cases, a nasogastric tube may be required before intubation, especially if there is blood or vomit in the patient's mouth.
In the emergency department, healthcare providers usually check to see if they are ready to perform a cricothyrotomy if intubation is not effective.
During intubation, the healthcare provider usually stands at the head of the bed, looking at the patient's legs, and the patient lies down. The location will vary depending on the configuration and whether the procedure is with an adult or a child. In children, a jaw lunge is often used.
An endotracheal tube is inserted with a lighted laryngoscope (the Glidescope video laryngoscope is especially useful for obese people or if the patient is immobilized with suspected cervical spine injury) is inserted through the mouth (or, in some cases, through mouth). nose) after moving the tongue to the side.
The endoscope is then carefully inserted between the vocal cords in the lower windpipe. When the endotracheal tube is believed to be in the correct location, the doctor will listen to the patient's lungs and upper abdomen to make sure the endotracheal tube has not been accidentally inserted into the esophagus .
Other signs that the tube is in the correct position may include movement of the chest during ventilation and fogging of the tube. When the healthcare professional is reasonably certain that the tube is in place, the balloon is inflated to prevent the tube from moving. (Babies may not need a balloon.) The tube is then glued to the patient's face.
Checking the correct location
Once the tube is in place, it is important to make sure it is in the correct place to ventilate the patient's lungs. Incorrect posture is especially common in children, especially children who have suffered trauma.
In the field, paramedics have a device that allows them to determine the correct position of the tube by changing color. In a hospital setting, chest X-rays are often taken to ensure correct placement, although a 2016 review suggests that chest X-rays alone are insufficient, as are pulse oximetry and physical exams .
In addition to direct visualization of the passage of the endotracheal tube between the vocal cords using a video laryngoscope, the study authors recommended a carbon dioxide detector at the end of expiration (capnography) in patients with good tissue perfusion with constant monitoring to ensure that the tube does not work. dont move.
For cardiac arrest, they recommended the use of ultrasound or an esophageal detector .
After the procedure
Once the endotracheal tube is in place and the patient is connected to the ventilator, healthcare professionals will continue to monitor the tube, adjust, and perform breathing and suctioning as needed. Special attention will also be paid to oral care. Due to the location of the tube, awake patients cannot speak while the tube is in place.
Feeding while ventilated
As with conversation, it will also not be possible to eat while the endotracheal tube is in place. When mechanical ventilation is necessary for only a short period of time, intravenous fluids are usually sufficient and can prevent dehydration.
If the tube needs to be left in for more than a few days, some type of feeding tube will be needed to ensure nutrition and access to oral medications.
Options include a nasogastric tube, a G or PEG tube (PEG or percutaneous endoscopic gastrostomy is similar to a G tube but is inserted through the skin of the abdomen), or a J tube (jejunostomy tube). In rare cases, the central line that provides nutrition (total parenteral nutrition) can be considered.
Complications and risks
Endotracheal tube placement is associated with short-term and long-term risks and complications. Short-term complications can include :
- Placement of an endotracheal tube in the esophagus. One of the most serious complications is the incorrect placement of the endotracheal tube in the esophagus. If it goes unnoticed, a lack of oxygen in the body can lead to brain damage, cardiac arrest, or death.
- Temporary hoarseness when removing the tube
- Injury to the mouth, teeth or dental structures, tongue, thyroid gland, vocal apparatus (larynx), vocal cords, trachea (windpipe), or esophagus. Dental injuries (especially of the upper incisors) occur in approximately one in every 3,000 intubations.
- Pneumothorax (collapse of the lung): If the endotracheal tube is advanced too far and only enters one bronchus (and therefore only ventilates one lung), insufficient ventilation or collapse of one lung may occur.
- Aspiration of the contents of the mouth or stomach during insertion, which in turn can lead to aspiration pneumonia .
- Continuous need for mechanical ventilation (see below)
- Atelectasis : Insufficient ventilation (respiratory rate that is too low) can cause the smallest airways, the alveoli , to collapse, leading to atelectasis (partial or complete collapse of the lung).
Long-term complications that may persist or arise later may include :
- Tracheal stenosis or narrowing of the windpipe: occurs most often in people who require prolonged intubation, and occurs once in about 1% of people intubated.
- Spinal cord injury
- Tracheoesophageal fistula (abnormal passage between the trachea and the esophagus)
- Vocal cord paralysis – a rare complication that can cause persistent hoarseness.
Endotracheal Tube Removal
Before removing the endotracheal tube (extubation) and stopping mechanical ventilation, doctors carefully examine the patient to predict whether he will be able to breathe on his own. This includes:
- Ability to breathe spontaneously : If the patient has been anesthetized during surgery, they are usually allowed to turn off the ventilator. If an endotracheal tube is inserted for another reason, several factors can be used to determine the timing, such as using arterial blood gases or observing peak expiratory flow.
- Level of consciousness : in general, a higher level of consciousness (more than eight on the Glasgow Coma Scale) predicts a higher probability that weaning will be successful.
If there is reason to believe that the tube can be removed, the tape holding the endotracheal tube to the face is removed, the cuff is deflated, and the tube is removed.
Inability to wean or difficulty weaning
For some people, it is not possible to turn off the fan. In this case, the patient may require a tracheostomy and a tracheostomy tube. In other cases, the person is likely to eventually shut down, but it is possible. Difficulty putting down the fan .
This can happen in people with chronic obstructive pulmonary disease (COPD) who have had surgery for lung cancer or other reasons. Patients are closely monitored for signs that extubation may be successful, and potential problems such as persistent air leakage are addressed.
Side effects after removal
Postoperative sore throat and hoarseness are common after surgery, but usually only last a day or two. Ventilation during surgery is a major risk factor for atelectasis, so it is important that patients cough after surgery and become mobile as soon as possible.
Get the word of drug information
There are many potential uses for endotracheal tube placement and mechanical ventilation. While it can be intimidating to learn about the procedure and the potential risks, this option has tremendous value in surgery, as well as in stabilizing critical individuals.
Frequently asked questions
Yes. If you are awake, you will be given medicine to help you relax during the procedure.
The size of the tube is highly dependent on gender and age; dimensions refer to the circumference of the pipe. Men are usually intubated with an 8.0 mm (mm) tube and women with a 7.0 mm tube. The formula is commonly used to determine the appropriate size for infants and children.