Intubation
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Intubation being practiced on a dummy (conventional technique using a laryngoscope)
In medicine, intubation is the placement of a tube into an external or internal orifice of the body. Although the term can refer to endoscopic procedures, it is most often used to denote tracheal intubation. In tracheal intubation, an endotracheal tube is passed through the nose or mouth, through the larynx, and into the trachea.
Tracheal intubation is performed in various medical conditions:
- in comatose or intoxicated patients who are unable to protect their airways. In such patients, the throat muscles may lose their tone so that the upper airways collapse and air can not pass to the lungs. Furthermore, protective airway reflexes such as coughing and swallowing, which serve to protect the lower airways against aspiration of secretions and foreign bodies, may be absent. With tracheal intubation, airway patency is restored and the lower airways can be protected from aspiration.
- in general anesthesia. In anesthetized patients spontaneous respiration may be decreased or absent due to the effect of anesthetics, opioids, or muscle relaxants. To enable mechanical ventilation, an endotracheal tube is often used, although there are alternative devices such as face masks or laryngeal mask airways.
- in diagnostic manipulations of the airways such as bronchoscopy.
- in endoscopic operative procedures to the airways such as laser therapy or stenting of the bronchi.
- in intensive care medicine for patients who require respiratory support.
- in emergency medicine, particularly for cardiopulmonary resuscitation.
There are various types of tracheal tubes for oral or nasal intubation. Tubes may be either flexible or preformed and relatively stiff. Most tubes have an inflatable cuff to seal the lower airways against air leakage and aspiration of secretions.
Techniques
Several techniques exist. Tracheal intubation can be performed by direct laryngoscopy (conventional technique), in which a laryngoscope is used to obtain a view of the glottis. A tube is then inserted under direct observation. This technique can only be employed if the patient is comatose (unconscious) or under general anesthesia.
Rapid Sequence Induction (RSI) is a variation of the standard technique for patients under anesthesia. It is performed when immediate definitive airway management through intubation is required, and especially when there is a risk of aspiration. For RSI, a short acting narcotic is administered followed shortly thereafter by a paralytic such as succinylcholine.
Another alternative is intubation of the awake patient under local anesthesia using a flexible endoscope. This technique is preferred if difficulties are anticipated, as it allows the patient to breathe spontaneously throughout the procedure, thus securing oxygenation even in the event of a failed intubation.
Some alternatives to intubation are
- Tracheotomy - a surgical technique, typically for patients who require long-term respiratory support
- needle cricothyrotomy - an emergency technique used when intubation is unsuccessful and tracheotomy is not an option, typically performed by paramedics. For a needle cricothyrotomy, a hollow needle is advanced through the skin of the neck and into the larynx to deliver oxygen into the airways. This is a last resort procedure that can only provide a minimum of oxygen to the patient; therefore intubation or tracheotomy must subsequently be performed.