Intubation and Mechanical Ventilation

Definition

Mechanical ventilation is a method used to help people who have breathing disorders and cannot move enough air in and out of their lungs without help.

The first step in mechanical ventilation is called intubation. This is the process of inserting one end of a tube, called an endotracheal tube, into your airway. The tube is passed through your mouth (with an orotracheal tube) or nose (with a nasotracheal tube) and then through your throat and your vocal cords into your windpipe, called the trachea.

Endotracheal Intubation

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The trachea divides into two smaller airways (called bronchi) that enter your lungs. If there is severe damage to the upper airway that makes passage of an endotracheal tube difficult or impossible, a tracheotomy (inserting the tube through a surgical incision in the neck into the trachea) may be necessary.

The other end of the tube is attached to a mechanical ventilator. A ventilator is a specially designed pump that moves air in and out of the lungs and helps people breathe. This procedure allows oxygen and carbon dioxide gases to pass freely. The ventilator has special controls that regulate the mixture of oxygen and air that is delivered, as well as the rate and amount of air with each breath.

Parts of the Body InvolvedMouthThroatTracheaLungs Reasons for ProcedureIntubation and mechanical ventilation can be life-saving for people who have conditions that affect their breathing. When gas exchange isnt functioning correctly, it may cause the levels of oxygen in the blood to be too low or the levels of carbon dioxide to be too high. Serious health effects or even death may occur when this happens. Some conditions that can require intubation and mechanical ventilation include: Respiratory failure or respiratory arrest Severe exacerbations of emphysema , chronic obstructive pulmonary disease (COPD) , or asthma After cardiac arrestAirway obstructionTraumatic injuries, especially if to the head, neck, and chestComaNeed for prolonged ventilatory supportNeed to protect airway from aspiration of stomach contents, if gag reflex is compromisedNeed to remove secretions from lungs in cases of severe lung injuryPrior to surgery or other medical procedure Risk Factors for Complications During the Procedure Risk factors that may increase the chance of complications during intubation and mechanical ventilation include:
Neck or cervical spine injuryPre-existing lung disease, such as emphysemaPoor condition of teethPresence of large amount of secretions in the mouth or tracheaRecent mealSevere upper airway obstruction which does permit passage of endotracheal tubeDehydration (may lead to low blood pressure after procedure) What to Expect Prior to Procedure In the days leading up to your procedure: Do not start taking any new medication without consulting your doctor.The night before, eat a light meal; do not eat or drink anything after midnight.Consult with your doctor for any other special instructions. AnesthesiaIf you are going to be awake during the intubation procedure, a local anesthetic is used to numb your throat where the tube will pass. The anesthetic is in the form of a spray or a gargle. You may also receive a muscle relaxant to prevent you from gagging when the tube is inserted.In addition, you may be given a sedative prior to the procedure since many patients have difficulty tolerating the procedure while fully awake. Further sedation may be necessary if the procedure is being performed prior to surgery or if there is a need for prolonged mechanical ventilation. Description of the ProcedureYou will wear an oxygen mask for 2-3 minutes before the procedure begins. This ensures that you have enough oxygen in your system during the procedure.
The doctor uses a tool called a laryngoscope to perform the intubation. The laryngoscope has a handle, a light, and a blade. It helps guide the endotracheal tube to its proper position.The doctor tilts your head back slightly to make it easier to insert the laryngoscope. It is inserted through your mouth and down into your throat. Then the tip of the endotracheal tube is advanced down into the trachea.Once the endotracheal tube is in position, the doctor removes the laryngoscope and the tube remains. The tube is taped to the corner of your mouth.The endotracheal tube is then attached to a ventilator machine, which moves air in and out of your lungs.In some cases, the tube is inserted through the nose instead of the mouth. After Procedure A portable chest x-ray is taken immediately after intubation to make sure the tip of the tube is positioned in the middle of your trachea. The doctor listens to your lungs to make sure that they are being inflated.The level of gases in your blood is measured to make sure that the ventilation is working.You will not be able to eat, drink, or talk until the endotracheal tube is removed. How Long Will It Take?The process of intubation and connecting to a ventilator usually takes less than five minutes.
Will It Hurt?The anesthesia will prevent you from feeling pain during the procedure. However, the tube can be uncomfortable and it may make you cough. It may also cause irritation to your voice box and trachea. Some patients will be given intravenous sedation so that they are not fully conscious during (and after) the procedure. Possible Complications Potential complications of intubation and mechanical ventilation include: Damage to teeth, lips, or tongue when endotracheal tube is insertedDamage to trachea, resulting in pain, hoarseness, and sometimes difficulty breathing after the endotracheal tube is removedEsophageal intubation (when the tube is accidentally inserted into the esophagus, which leads to the stomach, instead of the trachea)Movement of the tube down into one of the bronchiLow blood pressurePneumoniaLung injuryCollapsed lung (pneumothorax)Infection Average Hospital StayThe length of hospital stay associated with intubation and mechanical ventilation depends on the reason for having the procedure. It may be just a few hours for someone having anesthesia as part of an outpatient operation, or much longer for someone who requires life support. Postoperative Care Your doctor will check how well you are breathing before removing the tube. You need to:
Be breathing on your own through the tube, without the ventilator attached. You may only be partially awake during this time.Have a satisfactory score on the Weaning Index, which measures how often you take a breath, how well you are oxygenating your blood, and how much air you breathe in and out. OutcomeThe tube will be removed once you can breathe on your own again. If you require mechanical ventilation for a prolonged period of time (more than a few weeks), a tracheotomy may be performed, and the airway tube inserted through your windpipe instead of your mouth (or nose). Call Your Doctor If Any of the Following Occurs You should contact your doctor if you have any of the following conditions: Difficulty breathingA tendency to breathe in your food or drinkA condition known as stridor, which causes you to make a musical sound when you breathe RESOURCES: American Lung Associationhttp://www.lungusa.org Asthma and Allergy Foundation of Americahttp://www.aafa.org National Lung Health Education Programhttp://www.nlhep.org CANADIAN RESOURCES: BC Health Guidehttp://www.bchealthguide.org/ The Canadian Lung Associationhttp://www.lung.ca References: Beers, MH, Fletcher AJ, Jones TV, et al. The Merck Manual of Medical Information: Second Home Edition . Whitehouse Station, NJ: Merck Research Laboratories; 2003.
Harrisons Principles of Internal Medicine . 16th ed. McGraw-Hill; 2005. Human respiratory system. American Lung Association website. Available at: http://www.lungusa.org . Accessed September 8, 2005. Mason RJ. Murray and Nadel's Textbook of Respiratory Medicine . 4th ed. WB Saunders; 2005. Roberts JR. Clinical Procedures in Emergency Medicine . 4th ed. WB Saunders; 2004. Last reviewed February 2008 by Ronald Nath, MDPlease be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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