How an Endotracheal Tube Is Used

Understanding the purpose, procedure, and possible risks

Endotracheal tube with other intubation equipment

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An endotracheal tube is a flexible plastic tube that is placed through the mouth into the trachea (windpipe) to help a patient breathe. The endotracheal tube is then connected to a ventilator, which delivers oxygen to the lungs. The process of inserting the tube is called endotracheal intubation. There are many reasons why an endotracheal tube may be placed, including surgery with a general anesthetic, trauma, or serious illness. Learn about the procedure, potential risks and complications, and what you might expect.

Purpose

An endotracheal tube is placed when a patient is unable to breathe on her own; when it is necessary to sedate and "rest" someone who is very ill; or to protect the airway. The tube maintains the airway so that air can pass into and out of the lungs.

Uses

There are a number of indications for placement of an endotracheal tube that can be broken down into a few broad categories. These include:

  • General surgery: With general anesthesia, the muscles of the body including the diaphragm are paralyzed, and placing an endotracheal tube allows the ventilator to do the work of breathing.
  • Foreign body removal: If the trachea is obstructed by a foreign body that is aspirated (breathed in), an endotracheal tube may be placed to help with the removal of the foreign object.
  • To protect the airway against aspiration: If someone has a massive gastrointestinal bleed (bleeding in the esophagus, stomach, or upper intestine) or suffers a stroke, an endotracheal tube may be placed to help prevent the stomach contents from entering the airways. (If the stomach contents are accidentally breathed in, a person may develop aspiration pneumonia, a very serious and potentially life-threatening disease.)
  • To visualize the airway: If an abnormality of the larynx, trachea, or bronchi is suspected, such as a tumor or a congenital malformation (birth defect), an endotracheal tube may be placed to allow careful visualization of the airways.
  • After surgery: After surgery on the chest such as lung cancer surgery or heart surgery, an endotracheal tube connected to a ventilator may be left in place to help with breathing after surgery. In this case, a person may be "weaned" from the ventilator at some time during recovery.
  • To support breathing: If someone is having difficulty breathing due to pneumonia, a pneumothorax (collapse of a lung), respiratory failure or impending respiratory failure, heart failure, or unconsciousness due to an overdose, stroke, or brain injury, an endotracheal tube may be placed to support breathing. Some medical conditions (especially neurological conditions) can result in full or partial paralysis of the diaphragm and may require respiratory support. Examples include amyotrophic lateral sclerosis, Guillain-Barre syndrome, and botulism. The diaphragm may also become paralyzed due to damage or pressure on the phrenic nerve related to trauma or a tumor in the chest.
  • When sedation is required: If strong sedatives are needed, such as when a person is very ill, an endotracheal tube may be placed to assist with breathing until the sedatives can be discontinued.
  • In premature babies: Respiratory distress in premature babies often requires placement of an endotracheal tube and mechanical ventilation.
  • When a higher concentration of oxygen is needed: Endotracheal tube placement and mechanical ventilation allows for the delivery of higher concentrations of oxygen than found in room air.

Before the Procedure

If you will be having surgery with a general anesthetic, quitting smoking even a day or two before the surgery can lower your risk of complications.

Endotracheal tubes are flexible tubes that can be made from a number of different materials. Though latex tubes are not commonly used, it's important to let your doctor know if you have a latex allergy.

Sizes

Endotracheal tubes come in a number of different sizes ranging from 2.0 millimeters to 10.5 millimeters in diameter. In general, a 7.0 to 7.5 mm diameter tube is often used for females and an 8.0 to 9.0 mm diameter tube for men. Newborns often require a 3.0 mm to 3.5 mm tube, with a 2.5 to 3.0 mm tube used for premature infants.

In an emergency, doctors often guess at the right size, while in the operating room the size is often chosen based on age and body weight.

Single and double lumen tubes are available, with single lumen tubes often used for lung surgery so that one lung can be ventilated during surgery on the other lung.

Preparation

Before an endotracheal tube is placed, your jewelry should be removed, especially tongue piercings. People should not eat or drink before surgery for at least six hours to reduce the risk of aspiration during intubation.

During the Procedure

The procedure for placing an endotracheal tube will vary depending on whether a person is conscious or not. An endotracheal tube is often placed when a patient is unconscious. If a patient is conscious, medications are used to ease anxiety while the tube is placed and until it is removed.

Precise steps are usually used during intubation. First, the patient is preoxygenated with 100 percent oxygen (ideal is five minutes) to give the intubator more time to intubate. An oral airway may be used to keep the tongue of the way and reduce the chance that the patient will bite the ET tube.

During surgery, the anesthesiologist will want to make sure the patient is completely paralyzed before inserting the tube to reduce the chance of vomiting during placement and subsequent complications. With patients who are awake, and anti-nausea drug (antiemetic) may be used to decrease the gag reflex, and anesthesia may be used to numb the throat. In some cases, a nasogastric tube may need to be placed before intubation, especially if blood or vomit is present in the patient's mouth.

In the emergency department, doctors usually make sure they are prepared to perform a cricothyrotomy if intubation is not effective.

Intubation

During intubation, a physician usually stands at the head of the bed looking towards the patient's feet and with the patient lying flat. The positioning will vary depending on the setting and whether the procedure is being done with an adult or child. With children, a jaw thrust is often used.

The endotracheal tube with the assistance of a lighted laryngoscope (a type of laryngoscope called a Glidescope video laryngoscope is particularly helpful for people who are obese or if a patient is immobilized with a suspected injury to the cervical spine) is inserted through the mouth (or in some cases, the nose) after moving the tongue out of the way. The scope is then carefully threaded down between the vocal cords and into the lower trachea.

When it's thought that the endotracheal tube is in the proper location, the doctor will listen to the patient's lungs and upper abdomen to make sure that the endotracheal tube was not inadvertently inserted into the esophagus. Other signs that suggest the tube is in the proper position may include seeing chest movement with ventilation and fogging in the tube.

When a doctor is reasonably sure the tube is in position, a balloon cuff is inflated to keep the tube from moving out of place. (In infants, a balloon may not be needed). The tube is then taped to the patient's face.

Verifying Proper Placement

Once the tube is in place, it's important to verify that it is truly in the proper location to ventilate the patient's lungs. Improper positioning is particularly common in children, especially children who have experienced trauma.

In the field, paramedics have a special device that allows them to determine if the tube is in the correct position by a color change. In the hospital setting, a chest X-ray is often done to ensure good placement, though a 2016 review suggests that a chest X-ray alone is inadequate, as is pulse oximetry and physical examination.

In addition to directly visualizing the endotracheal tube pass between the vocal cords with a video laryngoscope, the authors of the study recommended an end-tidal carbon dioxide detector (capnography) in patient's that had good tissue perfusion, with continued monitoring to make sure the tube does not become displaced. In the setting of a cardiac arrest, they recommended using ultrasound imaging or an esophageal detector device.

After the Procedure

After the endotracheal tube is in place and a patient connected to a ventilator, health care providers will continue to monitor the tubing, settings, and provide breathing treatments and suctioning as needed. Careful attention to oral care will also be provided. Due to the location of the tube, patients who are conscious will be unable to talk while the tube is in place.

Feeding During Mechanical Ventilation

As with talking eating will also be impossible while the endotracheal tube is in place. When mechanical ventilation is needed for only a short period of time, intravenous fluids are usually adequate and can prevent dehydration. If the tube must be left in place for more than a few days, some type of feeding tubes will be needed to provide nutrition and access for oral medications. Options include a nasogastric tube, a G tube or PEG (PEG or percutaneous endoscopic gastrostomy is similar to a G tube but placed through the skin of the abdomen) or a J tube (jejunostomy tube). Rarely, a central line might be considered through which nutrition is provided (total parenteral nutrition).

Complications and Risks

There are both short-term and long-term risks and complications associated with endotracheal tube placement. Short-term complications may include:

  • Bleeding
  • Esophageal placement of the tube: One of the most serious complications is improper placement of the endotracheal tube into the esophagus. If this goes unnoticed, the lack of oxygen tot he body could result in brain damage, cardiac arrest, or death.
  • Temporary hoarseness when the tube is removed
  • Injury to the mouth, teeth or dental structures, tongue, thyroid gland, voice box (larynx), vocal cords, windpipe (trachea), or esophagus. Dental injuries (particularly to the upper incisors, occur in around one in 3000 intubations)
  • Infection
  • Pneumothorax (collapse of a lung): If the endotracheal tube is advanced too far such that it only enters one bronchi (and thus ventilates only one lung), inadequate ventilation may occur or collapse of one lung
  • Aspiration of contents of the mouth or stomach during placement which can, in turn, result in aspiration pneumonia
  • Persistent need for ventilatory support (see below)
  • Atelectasis: Inadequate ventilation (a respiratory rate that is too low) can result in collapse of the smallest of airways, the alveoli resulting in atelectasis (partial or complete collapse of a lung)

Long term complications that may persist or arise later on may include:

  • Tracheal stenosis, or narrowing of the trachea: Once occurring in around one percent of people who were intubated, it is most common in people who require prolonged intubation
  • Tracheomalacia
  • Spinal cord injuries
  • Tracheoesophageal fistual (an abnormal passageway between the trachea and esophagus)
  • Vocal cord paralysis: Rarely, vocal cord paralysis is a complication that can cause permanent hoarseness

Removing the Endotracheal Tube

Before removing an endotracheal tube (extubation) and stopping mechanical ventilation, doctors carefully assess a patient to predict whether or not he or she will be able to breathe on her own. This includes:

  • Assessing ability to breathe spontaneously: If patients have had anesthesia during surgery, they will usually be allowed to wean off of the ventilator. If an endotracheal tube is placed for another reason, different factors may be used to determine if it is time, such as using arterial blood gasses or looking at peak expiratory flow rate.
  • Assessing level of consciousness: In general, a higher level of consciousness (Glasgow coma scale over eight) predicts a greater chance that weaning will be successful.

If it's thought that the tube can be reasonable removed, the tape holding the endotracheal tube on the face is removed, the cuff is deflated, and the tube is pulled out.

Inability to Wean or Difficulty Weaning

For some people, weaning off of a ventilator will not be possible, When this is the case a patient may need a tracheostomy and tracheostomy tube.

Other times, it's likely that a person will be able to be taken off eventually but there is difficulty weaning from a ventilator. This may occur in people who have COPD, have had lung cancer surgery, or other reasons. Patients are carefully monitored for signs that extubation may be successful, and potential problems, such as a persistent air leak, are addressed.

Side Effects After Removal

A sore throat after surgery and hoarseness are common following surgery but usually last only a day or two. Being on a ventilator for surgery is a major risk factor for atelectasis, and having patients cough after surgery and become mobile as soon as possible is important.

A Word From Verywell

There are many potential uses for the placement of an endotracheal tube and mechanical ventilation. While it can be frightening to learn about the procedure and potential risks, this option has made a tremendous difference in surgery as well as the stabilization of critically people individuals.

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Article Sources

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial policy to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Chaudhry R. Botulism: a diagnostic challengeIndian J Med Res. 2011;134(1):10–12.

  2. Nimmagadda U, Salem MR, Crystal GJ. Preoxygenation: Physiologic Basis, Benefits, and Potential Risks. Anesth Analg. 2017;124(2):507-517.

  3. Kugler C, Stanzel F. Tracheomalacia. Thorac Surg Clin. 2014;24(1):51-58.

  4. Engels PT, Bagshaw SM, Meier M, Brindley PG. Tracheostomy: from insertion to decannulationCan J Surg. 2009;52(5):427–433.

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