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Intubation

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In medicine, intubation is the placement of a tube into an external or internal orifice of the body. Although the term can refer to endoscopicprocedures, it is most often used to denote tracheal intubation. Tracheal intubation is placing a tube into the trachea. The most common tracheal intubation is orotracheal intubation. In orotracheal intubation, an endotracheal tubeis passed through the mouth, through the larynx, and into the trachea.

Tracheal intubation is performed in various medical conditions:

in comatoseor intoxicated patients who are unable to protect their airways. In such patients, the throat muscles may lose their tone so that the upper airways obstruct or collapse and air can not easily enter into the lungs. Furthermore, protective airway reflexes such as coughing and swallowing, which serve to protect the airways against aspirationof 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 lasertherapy or stentingof the bronchi.
in intensive care medicinefor 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 laryngoscopeis used to obtain a view of the glottis. A tube is then inserted under direct vision. This technique can usually only be employed if the patient is comatose (unconscious), under general anesthesia, or has received local or topical anesthesia to the upper airway structures (e.g., using a local anesthetic drug such as lidocaine).

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 sedativesuch as etomidate, propofol, thiopental or midazolamis normally administered, followed shortly thereafter by a paralytic such as succinylcholineor rocuronium.

Another alternative is intubation of the awake patient under local anesthesiausing a flexible endoscopeor by other means (e.g., using a GlideScope video laryngoscope). This technique is preferred if difficulties are anticipated, as it allows the patient to breathe spontaneously throughout the procedure, thus ensuring ventilation and 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 (usually through the cricothyroid membrane) and into the larynx to deliver oxygeninto the airways under pressure. This is a dangerous last resort procedure that can only provide a minimum of oxygen to the patient; therefore intubation or tracheotomy must subsequently be performed.

Intubation

Techniques

See also