Endotracheal Intubation I: Procedure

Endotracheal or ET intubation is a critical medical procedure used to secure a patient's airway, often in acute respiratory distress, apnea, upper airway obstruction, ineffective clearance of secretions, high risk for aspiration, or during general anesthesia.

The ET tube comprises various components, including a standard adaptor to attach a bag-valve-mask (BVM) or ventilator, a cuff, a pilot balloon, and radiopaque markings along its length to measure the insertion distance. The tube sizes usually range from 7.0 to 8.0 millimeters in internal diameter, with females typically requiring a 7.0 mm tube and males an 8.0 mm tube. A larger diameter tube can reduce breathing resistance, facilitate easier suction and removal of secretions, and enable bronchoscopy if needed.

Purpose

The primary purpose of endotracheal intubation is to establish and maintain a patent airway for individuals who cannot maintain an adequate airway independently. It includes patients with respiratory distress, those who are comatose, undergoing general anesthesia, or experiencing extensive edema of upper airway passages. It is also used to bypass an upper airway obstruction, prevent aspiration, permit connection to a mechanical ventilator, or facilitate the removal of tracheobronchial secretions.

Tubes

There are two main types of endotracheal tubes: orotracheal and nasotracheal. Although uncomfortable, orotracheal insertion is often preferred, especially in emergencies, due to its ease of insertion and ability to accommodate a larger tube, facilitating ventilation. Nasotracheal insertion, while better tolerated by patients, is more complex and requires a narrower tube.

Procedure

The procedure involves inserting the ET tube through the mouth or nose, passing it through the vocal cords, and into the trachea with the help of a laryngoscope or bronchoscope. Oral ET intubation is preferred because the airway can be secured rapidly. The tube can remain in place for up to two weeks and is connected to a ventilator for control of respirations and ventilation of the lungs.

In some cases, airway pressure release ventilation (APRV) promotes spontaneous breathing in ventilated patients by cycling between higher and lower Continuous Positive Airway Pressure (CPAP) pressure levels. It helps open the alveoli and promotes better gas exchange.

Nursing Management

Nursing management involves periodically monitoring vital signs, evaluating blood gas levels, observing the patient's response to respiratory support, and identifying complications associated with endotracheal intubation. Nurses aim to improve the patient's comfort by providing reassurance, facilitating communication, and delivering oral care to keep the mouth and lips free of crusts and mucus. Position changes every two hours are essential to prevent atelectasis, and humidification is necessary to keep the inspired air moist.

After removing the endotracheal tube, the patient is positioned in a high-Fowler's or semi-Fowler's stance to encourage maximum expansion of the chest and lungs. Nurses frequently observe the patient for signs of laryngeal edema and increased respiratory distress; emergency respiratory support equipment must always be available.