What Is an Endotracheal Tube?

Purpose, Placement, and Possible Risks

An endotracheal tube, or ET tube, is a flexible plastic tube that is placed through the nose or mouth into the trachea, or windpipe, to help a patient breathe. In most emergency situations, it's placed through the mouth. The endotracheal tube is then connected to a ventilator, or breathing machine, that 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 or serious illness. This article explores the procedure and its uses, how to prepare for it, and potential risks and complications.

Intubation equipment sitting on a prep table
Sister Sarah / Getty Images

Uses

An endotracheal tube is placed when:

  • A patient is unable to breathe on their own
  • It is necessary to sedate and "rest" someone who is very ill
  • Someone's airway needs to be protected (i.e., there is an obstruction or risk of one)

It's often used during surgery and a variety of emergency situations. The tube maintains the airway so that air can pass into and out of the lungs.

Surgery

General anesthesia is commonly used for surgery to make the patient unconscious during the procedure. With it, the muscles of the body are temporarily paralyzed.

This includes the diaphragm, a dome-shaped muscle that plays an important role in breathing. Placing an endotracheal tube makes up for this, as it allows the ventilator to do the work of breathing while you're under anesthesia.

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 "weaned" from the ventilator, or slowly taken off of it, at some point during recovery.

Foreign Body Removal

If the trachea is obstructed by something that isn't supposed to be there—a wad of gum or a pen cap that's accidentally swallowed, for example—an endotracheal tube may be placed to help with the removal of the foreign body.

This type of obstruction happens when something is aspirated, or breathed in.

Airway Protection

An endotracheal tube may also be placed to help prevent stomach contents from entering the airways in cases of:

  • A massive bleed in the esophagus, stomach, or upper intestine
  • Stroke, when an artery that supplies the brain is blocked or leaks blood

This is important in helping prevent aspiration pneumonia, a very serious and potentially life-threatening condition caused by contents from the mouth or stomach ending up in the lungs.

To Visualize the Airway

If an abnormality of the trachea, larynx (voice box), or bronchi (airways that lead from trachea into the lungs) is suspected, an endotracheal tube may be placed to allow careful visualization of the airways.

An abnormality can be present at birth or develop later, such as with a tumor.

Breathing Support

An endotracheal tube may be placed to support breathing if someone is having difficulty breathing due to pneumonia, a collapsed lung (pneumothorax), respiratory failure or impending respiratory failure, or heart failure.

It may also be used if someone is unconsciousness due to an overdose, stroke, or brain injury.

Some medical conditions, especially nervous system conditions, can result in full or partial paralysis of the diaphragm and may require respiratory support.

Examples include:

The diaphragm may also become paralyzed due to damage or pressure on the phrenic nerves that begin at the neck and control the diaphragm. This can be related to trauma or a tumor in the chest.

Required Sedation

If strong sedatives to produce a calming effect and slow brain activity 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.

Respiratory Distress in Premature Babies

Respiratory distress in premature babies often requires placement of an endotracheal or nasoendotracheal (inserted through the nose) tube. This is paired with mechanical ventilation.

Oxygen Delivery

Endotracheal tube placement with mechanical ventilation allows for the delivery of higher concentrations of oxygen than found in one's environment.

This may be needed for those with conditions or severe illnesses that lead to dangerously low oxygen levels.

Types

Endotracheal tubes are flexible tubes that can be made from a number of different materials, such as polyvinyl chloride (PVC), rubber, or silicone.

Though latex tubes are not commonly used, it's important to let your healthcare provider know if you have a latex allergy.

Endotracheal tubes come in a number of different sizes ranging from 2.0 to 10.5 millimeters (mm) in diameter. In general, the largest are typically used for men and the smallest for premature infants.

Ultimately, though, a patient's age and body weight are the determining factors. In an emergency, when this information is not at the ready, healthcare providers often guess the right size tube to use.

An ET tube may have one or two channels within a tube, known as lumen. A double lumen ET tube is often used when it's necessary to ventilate each lung separately, such as in the case of lung or other chest surgeries.

If an endotracheal tube is already in place, an endobronchial blocker may be inserted into the tube. It has a small balloon attached to it that can be inflated to block one of the lungs.

How to Prepare

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.

You should not eat or drink before surgery for at least six hours beforehand to reduce the risk of aspiration during intubation.

Before an endotracheal tube is placed, your jewelry should be removed, especially tongue piercings.

Patients being intubated during an emergency obviously will not have prepared for this procedure. But in these cases, the benefits always outweigh the risks.

Procedure

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.

Before Placement

Precise steps are usually used during intubation. Before the tube is placed:

  • The patient is given oxygen for about five minutes prior to intubation to increase their oxygen stores. This is done so that they will still have oxygen available should tube placement take longer than expected.
  • If a patient is unconscious, an oral airway device that rests on the tongue may be used to keep the tongue out of the way so the tube can be placed more easily.
  • The anesthesiologist will make sure the patient is completely paralyzed to reduce the chance of vomiting during placement and subsequent complications. With patients who are awake, an 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 that is passed from the nose through the esophagus and into the stomach may need to be placed before intubation, especially if blood or vomit is present in the patient's mouth.

In the emergency department, healthcare providers usually make sure they are prepared to perform a cricothyrotomy if intubation is not effective. This procedure establishes an airway with an incision through a membrane in the neck to access the trachea.

Intubation

During intubation, a healthcare provider usually stands at the head of the gurney looking toward the patient's feet. The patient lies flat and pillows or other types of padding may be placed under their head and/or neck to support airway access. A jaw thrust, or grasping of the jaw, may be used.

A lighted scope (and sometimes one with video capabilities) is inserted through the mouth to allow for better view of the structures at the back of the throat. This helps the practitioner get a view of the endotracheal tube after it is inserted through the mouth (or nose) and pass between the vocal cords.

The tube is carefully threaded down further into the lower trachea.

Confirming Proper Placement

When it's thought that the ET tube is in the proper location, the healthcare provider listens to the patient's lungs and upper abdomen to make sure that the tube was not inadvertently inserted into the esophagus.

If the tube is not properly placed, it cannot ventilate the lungs. Improper positioning is particularly common in children, especially children with traumatic injuries.

Other signs that suggest the tube is in the proper position include seeing chest movement with ventilation and fogging in the tube.

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

A Second Check

In the field, paramedics may have a device that changes color as it detects carbon dioxide, which is expelled during exhalation. The color change helps them determine if the tube is in the correct position.

In hospitals, a chest X-ray is often done to confirm accurate placement. However, a 2016 review suggests that this alone is often inadequate. Researchers say the same about pulse oximetry (measure of oxygen level in the blood) and physical examination.

They instead recommend that practitioners use an end-tidal CO2 detector to measure exhaled concentrations of carbon dioxide whenever possible. In addition, they recommend continued monitoring to make sure the tube does not become displaced.

For patients in cardiac arrest, which means their heart stopped beating, monitoring can be more difficult. Movements of the patient and equipment may displace the tube. Ultrasound imaging or an esophageal detector device may be used for monitoring after the patient is stable.

After the Procedure

After the endotracheal tube is in place and a patient is connected to a ventilator, healthcare providers will continue to monitor the tubing and settings. They will also provide medications and suctioning of respiratory secretions as needed to maintain the airway.

Careful attention to oral care, such as with mouth rinse or tooth brushing, will also be provided to help reduce the risk of infection.

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 tube will be needed to provide nutrition and oral medications.

Feeding tube options include:

  • A nasogastric tube that carries nutrients from the nose to the stomach
  • A gastrostomy tube (G tube) that is inserted directly into the stomach through the abdominal wall
  • A percutaneous endoscopic gastrostomy (PEG tube)—a G tube inserted through the skin of the abdomen with the help of a lighted scope
  • A jejunostomy tube (J tube), which is inserted through the skin of abdomen into the small intestine
  • A central line, which, in rare cases, is inserted into a vein to deliver nutrients (known as total parenteral nutrition)

Removal and Recovery

Before removing an endotracheal tube (extubation) and stopping mechanical ventilation, healthcare providers carefully assess a patient to predict whether or not they will be able to breathe on their own.

This includes:

  • Ability to breathe spontaneously: If a patient 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. These can include arterial blood gasses, which is a measure of oxygen and carbon dioxide in an artery, and peak expiratory flow rate, or how quickly the lungs expel air during a breathing trial.
  • Level of consciousness: In general, a higher level of consciousness predicts a greater chance that weaning will be successful.

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

Being on a ventilator for surgery is a major risk factor for a collapsed lung. Patients are often asked to cough after surgery, which encourages deep breathing and clearing of anything that may have accumulated in the lungs.

They will also be asked to move around as soon as possible to help get muscles moving and reduce the risks of complications.

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 to have a neck incision to place a tracheostomy tube—one that is inserted into the trachea to facilitate breathing.

Those who are likely to be taken off eventually may still have difficulty weaning from a ventilator. This may occur in people who have lung diseases such as chronic obstructive pulmonary disease (COPD) or have had lung cancer surgery, for example.

These patients are carefully monitored for signs that extubation may be successful and to make sure potential problems, such as a persistent air leak around the cuff, are addressed.

Common Side Effects

A sore throat and hoarseness are common side effects after removal of an ET tube. These usually resolve within a few days.

Its estimated that temporary hoarseness for up to one week after the ET tube is removed occurs in about one-third to half of all patients. Hoarseness that persists longer than a week can happen, but it is estimated to occur less than 1% of the time.

Risks and Complications

Endotracheal intubation is often a life-saving procedure, but it carries serious risks and potential complications.

The complications are often associated with intubation that lasts more than seven days.

ET Tube Placement and Removal

Many complications of endotracheal tube intubation occur during placement or shortly after the endotracheal tube is removed.

These risks and complications can include:

  • Bleeding in or around the trachea
  • Infections, especially bacterial infections, that can lead to inflammation of the trachea or pneumonia
  • Injury to the mouth, teeth or dental structures, tongue, thyroid gland, larynx, vocal cords, trachea, or esophagus
  • Aspiration of contents of the mouth or stomach during placement which can, in turn, result in aspiration pneumonia
  • Lack of oxygen due to improper placement of the endotracheal tube into the esophagus; could result in brain damage, cardiac arrest, or death if unnoticed
  • Partial or full collapse of a lung if the endotracheal tube only enters one bronchus (and, thus, ventilates only one lung) or if there is inadequate ventilation
  • Neck and spinal cord damage (new or, especially in emergency situations, worsened existing injuries)

Prolonged Intubation

Prolonged intubation is a risk factor for many complications, including those that persist long term or arise days or weeks afterward.

These complications can include:

  • Sinusitis, or sinus infection, that causes inflammation of the air spaces around the nose and eyes
  • Tracheal stenosis, a narrowing of the trachea that can lead to shortness of breath and wheezing
  • Tracheomalacia, a structural weakness or softening of the rings of the trachea that can cause it to collapse, leading to breathing difficulties
  • Tracheoesophageal fistula, an abnormal passageway between the trachea and esophagus
  • Vocal cord paralysis, a rare complication that can cause permanent hoarseness

Summary

There are many potential uses for an endotracheal tube and mechanical ventilation. An ET tube can be an important way to keep an airway open or offer protection in many life-threatening emergencies or surgeries. It can also be a means to view or protect the airways.

The most common side effects of endotracheal intubation are hoarseness or sore throat afterwards that typically resolves within a few days. The risk of more serious complications increases if someone needs to be intubated for more than seven days.

Frequently Asked Questions

  • Can you be awake when an endotracheal tube is placed?

    Yes. If you are awake, you'll be given medication to help you relax during the procedure.

  • How long can a person be intubated with an endotracheal tube?

    The standard limit is three weeks. If a patient is unable to breathe on their own at that point, they likely will undergo a tracheostomy. However, some research suggests it may be beneficial to progress to a tracheostomy sooner to prevent damage to the vocal cords.

  • How does a healthcare provider decide what size endotracheal tube to use?

    Choice of tube size, which refers to the diameter of the tube, largely depends on a patient's sex and age. For children, providers typically rely on a formula to determine the right tube size.

  • How is an endotracheal tube different from a tracheostomy tube?

    An endotracheal tube is threaded through the mouth and down the throat into the lungs. A tracheostomy tube is placed through an incision in the neck into the trachea and is held in place by a collar.

  • Is endotracheal intubation the same as being on a ventilator?

    Intubation is the process of inserting an endotracheal tube into the trachea. If it's being done to assist breathing, the endotracheal tube is then connected to a ventilator.

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