What Is Intubation and Why Is It Needed? Insertion of a tube to protect the airway

By Cristiano Antonino On Aug 7, 2022

Intubation is the process of inserting a tube called an endotracheal tube (ET) into the mouth or nose and then into the airway (trachea) to hold it open

Once in place, the tube is connected to a ventilator, a machine that pushes air in and out of the lungs.

When that’s not accessible, healthcare providers will connect the tube to a bag that they squeeze to have the same effect.

There are several reasons why intubation is needed, but it is mainly used to support breathing during surgery or in an emergency.

Types of Intubation and Why They’re Done

There are two types of intubation: endotracheal intubation (in which the tub is inserted through the mouth) and nasotracheal intubation (in which the tube is put in through the nose).

Which type is used depends on why a patient needs to be intubated.

Endotracheal intubation is used in most emergency situations because the tube that gets placed through the mouth is larger and easier to insert than the one inserted through the nose.

Endotracheal intubation is used to:1

Keep the airway open to provide oxygen, medicine, or general anesthesia
Support breathing in people with pneumonia, emphysema, heart failure, collapsed lung, COVID-19, or severe trauma
Remove a blockage from the airway

Prevent fluid from getting into the lungs if a person has had a stroke, has overdosed, or has massive bleeding from the stomach or esophagus

Nasotracheal intubation is used to:2

Protect the airway if there is a threat of an obstruction
Give anesthesia for surgeries involving the mouth, head, or neck (including dental surgery)

Is Being on a Ventilator the Same as Being Intubated?

Intubation and ventilation go hand-in-hand, but they are distinct elements of the steps taken to help someone breathe.

Intubation is simply the process of placing the tube that protects the airway, keeping an open passageway to the lungs.

Ventilation is the process by which air is mechanically moved in and out of the lungs when someone is unable to do that—either well or at all—themselves. The machine (or bag) does the breathing for them until they can breathe on their own.3

Risks of Intubation

Most people experience only mild side effects like sore throat and hoarseness as a result of intubation.

Some people have no symptoms and never even realize they were intubated.

However, some of the risks of intubation can be serious, especially in people who need to be on a ventilator for a long period of time.

Common risks of intubation include:

Gagging or choking
Sore throat
Hoarseness
Bleeding
A hole in the esophagus or soft palate
Trauma to the teeth, mouth, sinuses, larynx (voice box), or trachea (windpipe)
Bacterial infections (such as aspiration pneumonia)
Damage to soft tissues with prolonged use

Inability to be weaned off a ventilator and needing to have a surgical procedure to insert a tube directly into the windpipe to assist with breathing (tracheostomy)4

Tracheal stenosis, or a narrowing of the trachea, is also possible.

Who Cannot Be Intubated?

Sometimes, a person cannot be intubated safely. In these situations, intubation is not advised.

A person might not be able to be intubated if they:

Have certain injuries to their neck and spine
Have blocked pharynx (the space behind the nose and mouth)
Have certain facial or head injuries (for example, a broken nose)5

Intubation Procedures

The process of intubation varies based on whether the tube needs to be inserted into the mouth or nose.

Adjustments are also made when children need to be intubated.

Endotracheal Intubation Steps

Before intubation, a person needs to be sedated if they are not already unconscious. From there, the steps of endotracheal intubation are as follows:
The person is laid flat on their back.
The provider positions themselves above the person’s head looking down at their feet.
The person’s mouth is opened and a guard can be inserted to protect their teeth.

With the help of a lighted instrument that also keeps the tongue out of the way, the provider gently guides the tube into the person’s throat and advances it into their airway.

A small balloon at the end of the tube is inflated to secure it in place and keep air from escaping.

The tube on the outside of the mouth is secured with tape.

The tube can then be connected to a ventilator or used to deliver anesthesia or medications.

The provider will check that the tube’s placement is correct with a stethoscope, a chest X-ray, and/or a tool called a capnograph that detects carbon dioxide as it’s exhaled from the lungs.6

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Nasotracheal Intubation Steps

The process of nasotracheal intubation is similar to endotracheal intubation, but the person may either be fully or partially sedated.2

Since nasal intubation is more often performed in a controlled environment, there can be other tools involved in the process.

For example, a provider can use a decongestant spray to prevent nosebleeds, a topical anesthetic to reduce pain, and a muscle relaxant to prevent gagging. Some providers will also widen the passage with a device called a nasal trumpet.2

Once the tube is fed into the nostril and enters the middle part of the throat, a fiberoptic scope (called a laryngoscope) helps guide the tube between the vocal cords and into the windpipe.

The tube is then inflated to secure it in the trachea and taped on the outside to keep it from moving.2

Intubating Children

The process of intubation is more or less the same for adults and children, aside from the size of the tube and some of the equipment that can be used.7

Newborns are hard to intubate because of their small size. The procedure is also more difficult in little ones because a baby’s tongue is proportionally larger and the passage into their windpipe is proportionately longer and less flexible.

Nasal intubation is the preferred method for newborns and infants, though it can take several attempts to properly place the tube.8

Feeding During Intubation

It is not possible to eat or take fluids by mouth while intubated.

If an intubated person needs to be on a ventilator for two or more days, tube feeding will typically start a day or two after the tube is put in.

This is referred to as enteral nutrition.9

A tube feeding can be delivered in one of two ways:

Orogastric (OG): A tube that passes through the mouth and into the stomach
Nasogastric tube (NG): A tube that passes through a nostril and into the stomach10

Medication, fluids, and nutrition can also be pushed through the tube using a large syringe or pump.

Nutrition can also be given through a needle in their arm (intravenously). This method is also known as total parenteral nutrition (TPA). TPA is an option for people with severe malnutrition and weight loss; people with a blockage in their intestines, and people with diseases that make tube feeding impossible.10

Tube Removal and Intubation Recovery

Extubation is the process of removing a tracheal tube. It is usually easier and faster to take the tube out than it is to put it in.

Extubation involves the following steps:

First, the tape that holds the tube in place is removed.
Next, the balloon that holds the tube in the airway is deflated and the tube is gently pulled out.

Once the tube is out, a person may have to work harder to breathe on their own, especially if they have been on a ventilator for a long time. They will be closely monitored during this period.

Coughing, hoarseness, and discomfort are common symptoms after extubation, but they tend to improve within a few days.6