Step-by-Step Guide to Intubation

Learn the procedures, steps, risks, and requirements involved with intubation.

When someone cannot breathe independently, intubation can help save their life. Intubation is when a healthcare provider inserts a breathing tube through the patient’s mouth or nose into the trachea. This keeps the trachea open, allowing air to get into the lungs. The tube connects to a machine for automated air delivery or a bag for manual air delivery.

This is endotracheal intubation, an essential skill used by Advance Practice Registered Nurses (APRNs) such as Nurse Anesthetists. (Read our article for an overview of some everyday nursing duties, including intubation.)

In this blog, let’s get into the details involved with learning and performing intubation.

What’s the Definition of Intubation?

Intubation is a medical procedure where a tube is inserted through a patient’s nose or mouth and then extended down into the trachea/windpipe. This is endotracheal intubation, allowing patients to breathe when they can’t on their own.

There are other types of intubations, as well.

What Are Different Types of Intubation?

There are several types of intubation. The differences depend on the tube’s location and the procedure’s goal.

Here are the most common types of intubation:

1. Endotracheal intubation — Described above, this involves the insertion of a plastic tube into the windpipe to help a person breathe. This is usually done when the patient is under general anesthesia or has suffered trauma to the airway.
2. Nasogastric intubation — Unlike intubation to help a patient breathe, this intubation uses a tube placed through the mouth or nose down into the stomach. The tube can remove air, provide nutrients, or deliver medication to the patient.
3. Fiberoptic intubation — A tube with a tiny camera on the end is inserted into the throat. This can examine the throat or assist with endotracheal intubation when the patient cannot extend their head to straighten the airway.

What Is the Difference Between Intubation and Tracheostomy?

People can incorrectly assume these two procedures are the same. While the goal is to bypass a damaged or non-functioning trachea and provide air into the lungs, the two procedures differ.

Intubation inserts a plastic tube into the airway through the mouth or nose. Air is delivered through the tube into the lungs through a ventilator or bag.

With tracheostomy, a surgeon creates an opening in the front of the patient’s neck. A tube is inserted through this hole, and the patient may breathe through it or get assistance from a ventilator. A tracheostomy could be the preferred approach when the patient has severe trauma to the airway or when there is an obstruction that blocks the safe placement of the tube. (Learn more about tracheostomy care.)

What Is the Difference Between Being Intubated and Being on a Ventilator?

While ventilators have received lots of attention over the past couple of years due to COVID, intubation and being on a ventilator are not the same. Intubation is placing a tube through the mouth or nose into the windpipe. That tube may be attached to a ventilator to deliver oxygen into the lungs or connect to a bag that a healthcare provider manually squeezes to push air into the lungs.

What is the Purpose of Intubation?

These are the primary purposes a patient could need intubation:

• To open the airway to deliver oxygen, anesthetic, or medicine
• To bypass a blockage in the airway
• To help a patient breathe if they have collapsed lungs, trauma, or heart failure
• To allow a doctor to see the inside of the airway
• To prevent a patient from inadvertently breathing liquid into the lungs

How Long Does It Take to Perform Intubation?

These are not complicated procedures. In emergencies, an EMT may perform intubation in just 30 seconds. Without unforeseen complications, the nurse or other provider intubation will take less than five minutes.

Who Performs Intubation?

Intubation is not typically performed by registered nurses (RNs), although some states allow this if the RN has completed special training. It is much more common for physicians, anesthesiologists, nurse anesthetists, and other advanced practice registered nurses (APRNs) to perform intubation. EMTs and paramedics also perform intubation.

What Training Is Required to Perform Intubation?

Each state has its requirements for who is allowed to perform intubation. APRNs and nurse anesthetists perform intubation, but registered nurses usually do not. The first step is for a nurse to earn a Bachelor of Science in Nursing (BSN). This can happen in as few as 32 months at Brookline College. From there, the nurse will take extra coursework to pursue a specialization to become a nurse anesthetist, for example.

What Is the Intubation Procedure?

Step-by-Step Guide

Intubation is an essential skill for an APRN or nurse anesthetist. Most intubation is done within a hospital, although emergencies can require the procedure at the site of an accident.

Here is the process for performing intubation:

1. The patient is sedated, usually through an IV.
2. An oxygen mask is placed over the nose and mouth to provide extra oxygen, then removed.
3. The healthcare provider stands at the end of the bed above the patient’s head.
4. The patient’s head is tilted back to open and straighten the neck and throat.
5. A laryngoscope shines light down the throat and flattens the tongue.
6. The tube is inserted and maneuvered past the epiglottis into the larynx and the trachea.
7. A small balloon is inflated around the endotracheal tube to ensure it stays in place. This also blocks air from escaping.
8. Now the tube is taped or tied in place at the mouth.
9. The tube’s function is tested by listening to lung activity with a stethoscope.
10. A chest x-ray can also verify things are functioning correctly.

In rare cases, intubation happens through the nose rather than the mouth. This may be the case in a throat injury or for surgery on the throat. The process is the same, with the insertion of the tube through the nose rather than the mouth.

What Is Recovery Like After Intubation?

There isn’t any recovery while the breathing tube is in place. However, when the physician deems it safe to remove the breathing tube, a process known as extubation, there will likely be some soreness afterward. Patients can also have some difficulty swallowing, but this is usually fleeting.

The process of extubation is as follows:

1. Remove the tape or strap holding the tube in place.
2. Use a suction device to remove any debris in the airway.
3. Deflate the balloon anchoring the tube.
4. Have the patient take a deep breath and then cough or exhale simultaneously as the tube is pulled out of the throat.
5. Provide some crushed ice, if the patient desires, to aid any throat discomfort.

What Equipment is Needed for Intubation?

The primary equipment for intubation is the breathing tube and a laryngoscope to help keep the tongue depressed and out of the way during tube insertion. Here is a list of equipment that intubation may use:

• Endotracheal tube — This is the tube that delivers the air. It is fitted with an inflatable cuff that helps keep the tube in place. The cuff/balloon also prevents gases from leaking past the cuff.
• Laryngoscope — The metal or plastic tool has a handle on one end and a curved blade on the other with a tiny light that shines forward. The blade holds down the tongue while the light allows the healthcare provider to see the epiglottis at the back of the throat.
• Oral airway — This device fits the shape of the tongue and is placed in the mouth to keep the airway clear.
• Nasal airway — This device keeps the nasopharyngeal airway clear if intubation is done through the nose.
• Stylet — This thin rod or wire may be placed inside the tube, as this helps to manipulate the tube during insertion.
• Syringe — A syringe inflates the cuff.
• Suction catheter — A catheter removes any built-up secretions.
• Carbon dioxide detector — This device confirms the tube is in the correct place in the throat by measuring exhaled carbon dioxide,
• Bag-valve-mask — This mask is used to give patients extra oxygen before intubation.
• Nasal cannula — This two-pronged tube fits into the nostrils to provide supplemental oxygen.

What Are the Risks Involved with Intubation?

Intubation is a potentially lifesaving procedure when a patient’s breathing is blocked. It is a standard procedure and generally safe, but some risks are involved.

• Aspiration — If a patient inhales blood, vomit, or other fluid while intubated, this is aspiration. Aspiration can lead to pneumonia.
• Improper intubation — The breathing tube inadvertently enters the bronchi (tubes that connect to the lungs) or the esophagus (the food tube).
• Injury — The mouth, teeth, tongue, vocal cords, and trachea are damaged during intubation.
• Infection — Sinus infections are the most typical infection risk with intubation.

It is common for patients to have hoarseness and soreness in their throats after intubation. This passes within a couple of hours.

Pro Tips for Mastering the Art of Intubation?

The key to successful intubation is practice. Whether a paramedic or a nurse anesthetist, practicing intubation on a mannequin is a way to master this critical skill.

Here are a few other tips for becoming proficient in intubation:

• Advancing the blade — Once the patient’s mouth is suctioned, introduce the laryngoscope blade very slowly. You will eventually see the epiglottis as you move it down the tongue. If using a curved blade, insert the tip into the vallecula (located just above the epiglottis). With a straight blade, advance the tip just past the epiglottis. Then, gently lift the blade forward. Think of aiming at the patient’s left foot.
• BURP — If you have trouble seeing/finding the vocal cords, apply “backward, upward, rightward pressure” (BURP) to the lower third of the thyroid cartilage. This can allow you to better view the confirming landmarks in the airway. To do this, hold the laryngoscope in your left hand. Next, place the middle finger of your right hand just below the thyroid cartilage. Gently pull it toward the patient’s right ear.
• Check the CO² levels — You’ll need to confirm the tube is placed correctly through what is known as “waveform capnography.” Each breath produces a waveform and a numeric value of the amount of carbon dioxide exhaled with each breath. Look for a reading in the 30s or 40s on the quantitative capnometer.
• Macintosh blade — Some providers prefer this blade. Insert it on the far-right side of a wide-open mouth. Turn the blade handle 90 degrees, so the handle is flat and points to the patient’s left ear. Next, advance the Macintosh blade to the epiglottis and rotate it back to horizontal.
• Don’t bend your wrist — Be sure to lift the laryngoscope blade rather than bending your left wrist. If you lift the handle up and away (think to the upper corner of the room), the jaw will lift with the tongue and epiglottis following closely. Now your path into the airway will be clear.

A Lifesaving Skill

Intubation can be the difference between life and death for a patient, so APRNs and nurse anesthetists must be adept at performing this procedure. Extensive practice with intubation makes you more comfortable identifying the correct structures you’re seeing to avoid accidentally entering the tube into the esophagus or either of the two bronchi.

This practice and training are a part of the training necessary for an RN to become an APRN or nurse anesthetist.

Make the Move into Nursing

Not all nurses perform intubation, but the procedure is one of the tools necessary as training progresses and a nurse chooses to specialize. However, one thing common to every nursing career is the satisfaction of knowing you are helping people every day. That’s not something you can say in every career!

Are you interested in making a move into nursing? The profession needs people like you. Go here to learn about your options for Nursing Programs.