Intubating and extubating ventilated patients are not risk-free procedures. Both are associated with morbidity and mortality when performed on patients in the intensive care unit (ICU). Patients with an unstable respiratory or cardiovascular system are at a particularly high risk of life-threatening complications during intubation. Extubation represents another risk period, which, according to studies, has a 10 % failure rate and is linked with a poor prognosis. 

What Is Endotracheal Intubation? 

Endotracheal intubation is a lifesaving procedure routinely performed throughout hospitals in the United States and worldwide. The process involves guiding an endotracheal tube (ETT) into the mouth or nose and then the patient's trachea to keep the airway open and allow air to flow to the lungs. The two most common clinical scenarios when doctors intubate patients are during emergencies or before surgeries. 

Whether the intubation is for surgery or due to an emergency, it is important to note that not all intubated patients are ventilated. Once the endotracheal tube is successfully inserted into the windpipe, the clinician then hooks the tube to a device that delivers air. The device can be a bag to manually push air into the patient's airway or a ventilator that blows oxygen into the lungs. 

What Is Extubation? 

Extubation is the removal of the endotracheal tube. Although the process sounds simple, the preparation for extubation is a long process, which starts on the day of the patient's intubation and continues through the acute management of the primary issue which caused respiratory failure.

Two terms associated with extubation are weaning and liberation. Weaning means gradually transitioning a patient from full invasive ventilatory support to spontaneous ventilation with minimal support. Liberation, on the other hand, means the complete discontinuation of mechanical ventilation. 

Clinicians should assess ventilated ICU patients daily for readiness to wean by carefully weighing the benefits of early weaning against the risks of morbidity and mortality associated with failed extubation. 

Most Common Risks Of Intubation

Although intubations are lifesaving procedures, complications can occur, including: 

• Trauma to the teeth, mouth, sinuses, larynx (voice box), or trachea (windpipe)
• Bleeding
• Sore throat and hoarseness
• Gagging or choking
• Aspiration pneumonia
• Ventilator-associated pneumonia
• Blood pressure changes
• Inability to be weaned off a ventilator 
  

What Does The Intubation Process Entail? 

Thanks to the introduction of video laryngoscopy (VL) and modern extra-glottic devices, emergency airway management has improved over the years. However, the instruments used are only one of the factors in intubation success. Instead, the totality of the intubation process determines whether a clinician can successfully intubate a patient, including one with a potentially difficult airway. Besides the glottic view and anatomic obstacles in placing the tracheal tube, these factors include: 

• pre-intubation preparation
• operator experience
• correcting physiologic derangements
• availability of backup devices and personnel
  

Here are the steps of the intubation process:

• Sedate the patient before intubation (if not already unconscious).
• Lay the patient on his back.
• Open the patient's mouth and use a guard to protect the teeth.
• While keeping the tongue out of the way, guide the tube into the patient's throat and the airway. 
• Inflate the small balloon at the end of the tube to keep it in place and prevent the air from escaping. 
• Secure the tube on the outside of the mouth with tape. 
• Connect the tube to a ventilator or administer anesthesia or medication. 
• Ensure that the tube's placement is correct with a stethoscope, chest X-ray, or capnograph.
  

What Does The Extubation Process Entail? 

After the patient successfully passes the spontaneous breathing trial (SBT), the clinician should proceed with extubation. It is critical to ensure that all equipment is available for extubation management, including those needed when extubation does not go as planned. 

Here are the steps of the extubation process:

• Ensure the patient is in an upright sitting position.
• Suction the ETT and the oral cavity and remove all secretions above the ETT cuff. 
• When ready to remove the ETT, ask the patient to take a deep breath and exhale. During exhalation, deflate the cuff and gently remove the endotracheal tube. 
• After removing the ETT, suction the oral cavity and ask the patient to cough out all secretions.
• Place the patient on supplemental oxygen afterward and observe over the next few hours.
• Use frequent airway suction to prevent re-intubation.
  

Summary

Intubation and extubation are routine procedures, yet complications can occur. Clinicians frequently perform intubation for surgery or during medical emergencies. Considering the lifesaving nature of intubation, the benefits generally outweigh the risks. Physicians should strive for 100% first-pass success by considering the entire intubation process and ensuring the availability of necessary devices and personnel. Extubation should only be performed after carefully assessing the patient's readiness to wean. 

Have you heard of QuickSteer™ - the latest innovation in airway management designed to reduce overall intubation time and improve first-pass success rate in patients with difficult airways? 

Watch this video to see QuickSteer™ in action. 

Ready to learn more? Connect with a customer service team member by calling 763.330.2162 or emailing info@accessairways.com.

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