Endotracheal intubation

The endotracheal intubation is used for ventilation of unconscious or anesthetized patients in rescue and accident medicine as well as in anesthesia. An endotracheal tube is used, which is inserted through the mouth or nose into the windpipe. Incorrect implementation of the intubation can lead to complications.

What is endotracheal intubation?

Endotracheal intubation is the standard method for artificial ventilation of emergency and anesthetized patients. This method is also called intubation for short. The basis of this procedure is based on the introduction of an endotracheal tube through the nose or mouth into the windpipe (trachea).

It is passed between the vocal folds of the larynx. The endotracheal tube consists of a plastic tube for the oxygen supply. Usually it still contains a so-called cuff, which is inflated to prevent foreign bodies from being aspirated into the lungs.

There are tubes with two lumina (double lumen tube). You are able to ventilate both lungs separately. If intubation is difficult, alternatives to endotracheal intubation in the form of laryngeal masks, laryngeal tubes and combination tubes are used.

Function, effect & goals

Endotracheal intubation is used in patients who are unable to breathe independently due to illness, inadequate reflexes or anesthesia. Intubation prevents obstruction of the upper airway and the aspiration of foreign objects into the lungs.

It works by inserting a 20 to 30 cm long tube (hollow plastic tube) through the mouth or nose via the larynx into the trachea (windpipe). A connector for the ventilator is attached to the end of the hose on the mouth side. At the other end, the hose is slightly beveled. Just in front of this is a so-called cuff. This cuff can be inflated as a balloon and ensures that the windpipe is blocked from the nasopharynx to prevent foreign bodies such as blood, vomit or other from being inhaled.

When the balloon is inflated, the gaps between the tube and the wall of the trachea close. Before inserting the tube, the patient is placed in the so-called Jackson position. The head is high and the neck is hyperextended. This creates the best view of the glottis through the mouth. With the help of a laryngoscope blade, the epiglottis is drawn caudally and upwards. The tube is pulled through the vocal folds until it has crossed the cuff. The cuff is then inflated and the patient listened to.

If everything is correct, ventilation can be continued. Endotracheal intubation is used in a variety of situations. For example, in patients with cardiovascular arrest, anesthetized patients or patients with severe poisoning, the protective reflexes no longer function when breathing. Your ventilation is urgently needed. Even patients with inadequate breathing often need artificial respiration. In addition, artificial ventilation is often necessary for bronchoscopies, endoscopic operations on the respiratory tract, injuries to the upper respiratory tract or allergies to insect bites.

Different endotracheal tubes are also used depending on the area of ​​application. There are flexible or rigid tubes. Most tubes have an inflatable cuff. However, this does not apply to everyone. If the cuff is left on the mucous membrane for too long, it can lead to necrosis, so that cuffs are often not used for long-term ventilation. A cuff is also not used in children because their mucous membrane swells so quickly that the seal of the trachea is already secured.

A spiral tube does not kink easily and is therefore often used in goiter operations. Endotracheal intubation requires a lot of experience and is therefore difficult to use for many doctors. For this reason, many clinics have a special resuscitation team.

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Risks, side effects & dangers

When performing endotracheal intubation, a variety of complications can arise, especially since many doctors lack experience in this area. A frequent complication is the misintubation of the esophagus, which can even be fatal. The stomach is ventilated instead of the lungs.

If the error is not recognized in time, the patient will die of suffocation. Therefore, it is now standard practice to carry out monitoring to avoid this incorrect intubation. So-called aspiration is also feared. Foreign bodies such as blood or stomach contents enter the lungs via the windpipe. If there is an increased risk of this aspiration, a special form of induction of anesthesia (Rapid Sequence Induction) is carried out, which accelerates the induction of anesthesia. Another complication is injury to the vocal cords.

If the tube is pushed forward too far, there is a risk that only one lung will be ventilated. This incorrect intubation can be quickly determined by listening. Correction is made quickly by pulling back the tube. Long-term ventilation can have negative effects on the tracheal mucosa. The pressure on the mucous membrane can cause necrosis and ulcers. Therefore, the cuff pressure in intensive care units must be constantly monitored.

In rare cases it can happen that the teeth break out of the upper jaw. A reflex cardiac arrest or respiratory arrest due to the irritation of the parasympathetic nervous system of the autonomic nervous system is also very rarely possible. In addition, if the anesthesia is inadequate during intubation, vomiting can occur. For this reason, it is important that the patient fasts before a scheduled anesthetic.