The most common method of intubation is ‘endotracheal’ intubation, which can take place
- orotracheally: the tube enters through the patient’s mouth (most common method);
- rhinotracheally: the tube enters through the patient’s nose (less common method).
Intubation: when is it used?
The main purpose of all types of intubation is to allow the breathing of a person who, for various reasons, is unable to breathe independently, which puts the patient’s life at risk.
Another objective of intubation is to protect the airway from possible inhalation of gastric material.
Intubation is performed in many medical conditions, such as:
- in coma patients;
- under general anaesthesia;
- in bronchoscopy;
- in endoscopic operative airway procedures such as laser therapy or the introduction of a stent into the bronchi;
- in resuscitation on patients requiring respiratory support (e.g. in cases of severe Covid 19 infection);
- in emergency medicine, particularly during cardiopulmonary resuscitation.
Alternatives to intubation
There are some alternatives to intubation, but they are undoubtedly more invasive and certainly not risk-free, for example
- tracheotomy: this is a surgical procedure usually used on patients requiring long-term respiratory support; read more: Tracheotomy possibility of speaking, duration, consequences, when it is done
- cricothyrotomy: is an emergency technique used when intubation is not possible and tracheotomy is impossible.
Types of tubes used in intubation
There are various types of endotracheal tubes for oral or nasal intubation; there are flexible ones or semi-rigid ones, with a specific shape and therefore relatively more rigid.
Most tubes have in common that they have an inflatable margin to seal the lower airway, which does not allow air to escape or secretions to be aspirated.
Intubation: why is it done during anaesthesia?
Intubation is done by the anaesthesiologist during a general anaesthesia, since – to bring about anaesthesia – the patient is given drugs that inhibit his breathing: the patient is not able to breathe independently and the endotracheal tube, connected to an automatic respirator, allows the subject to breathe correctly during surgery.
In operations of short duration (up to 15 minutes) breathing is supported with a face mask, the tracheal tube is used if the operation lasts longer.
Will I feel pain?
Intubation is always performed after the patient has been put to sleep, so you will not feel any pain caused by it.
After the procedure you will not remember either the placement of the tube or its removal (i.e. extubation) from the airway when the procedure is over. Slight discomfort in the throat is possible, and quite frequent, after extubation.
Throat pain after intubation: is it normal?
As just mentioned, after a patient has undergone intubation, he or she may experience some unpleasant symptoms, including:
- sore throat
- sensation of a foreign body in the throat;
- difficulty swallowing solids and liquids;
- discomfort when making sounds;
These symptoms, although annoying, are fairly frequent and not serious, and they tend to disappear quickly, usually within a maximum of two days.
If the pain persists and is frankly unbearable, seek advice from your doctor.
Tracheal intubation can be performed using various techniques.
- Traditional technique: consists of a direct laryngoscopy in which a laryngoscope is used to visualise the glottis below the epiglottis. A tube is then inserted with a direct view. This technique is performed in patients who are comatose (unconscious) or under general anaesthesia, or when they have received local or specific anaesthesia of the upper airway structures (e.g. using a local anaesthetic such as lidocaine).
- Rapid sequence induction (RSI) (crash induction) is a variant of the standard procedure on patients under anaesthesia. It is performed when immediate and definitive airway treatment through intubation is required, and particularly when there is an increased risk of inhalation of gastric secretions (aspiration) that would almost inevitably lead to pneumonia ab ingestis. For RSI, a short-term sedative such as etomidate, propofol, thiopentone or midazolam is administered, followed shortly by a depolarising paralysing drug such as succinylcholine or rocuronium.
- Endoscope technique: an alternative to intubation of the conscious (or lightly sedated) patient under local anaesthesia is the use of a flexible endoscope or similar (e.g. using a video-laryngoscope). This technique is preferred when difficulties are anticipated, as it allows the patient to breathe spontaneously, thus ensuring ventilation and oxygenation even in the event of a failed intubation.
Does intubation present risks and complications?
Intubation can cause damage to teeth, especially in the case of previously damaged teeth or difficult anatomical relationships.
In addition to the frequent annoying throat symptoms seen above, in rarer cases intubation can cause more serious damage to the tissues it passes through, even leading to haemorrhaging.
Intubation may present some unforeseen problems, especially in cases of unforeseen difficult intubation, which is rare but possible, where the patient’s anatomical features make correct positioning of the tube in the airway more problematic.
Fortunately, in these cases, the doctor has tools at his disposal to help him limit the risks to the patient as much as possible, such as videolaryngoscopes and fiberscopes, which make up for the unforeseen or anticipated intubation difficulties encountered.
More schematically, the early and late risks are as follows:
- dental injury
- throat pain;
- oedema of the glottic structures;
- phonatory difficulties;
- tracheal perforation;
- cardiovascular arrest from vagal stimulation.
- tracheal injury
- chordal decubitus;
- decubitus buccal structures, pharynx, hypopharynx;