Intubation

Intubation simply means placing an endotracheal tube into the trachea. There are broadly two purposes to this:

  1. Maintaining patency of the airway.
  2. Securing the airway: This refers to protecting the lungs from aspiration of contaminants. Most endotracheal tubes have a cuff near their tip which, when inflated, provides a seal between the ET tube and the tracheal wall, preventing leakage of e.g. gastric contents into the lung. This seal also allows for intermittent positive pressure ventilation (IPPV) of the lungs. Intubation is still the gold standard for securing an airway when compared to SADs

The wide range and variety of available endotracheal tubes, intubating aids, laryngoscopes, other devices designed to visualize the airway and glottis, anatomical routes, and of course patient characteristics, means a large number of techniques are used for intubation. In addition, clinicians might then also slightly modify these many technical approaches to suit their personal preferences and style. Consequently we end up with a myriad of techniques to place an ET tube into the trachea.

For a more systematic approach to intubation techniques we can ask some questions (not an exhaustive list):

Which anatomical route will the ET tube take to the trachea?

  • Oral: Oral intubation is the most common approach
  • Nasal: The nasal route is useful in a number of scenarios, for example for some types of head & neck surgery and awake fiberoptic intubation
  • Front of neck airway (FONA): This covers cricothyrotomy and tracheotomy access to the trachea
  • Sub-mental: A somewhat exotic rarely used approach to the airway through the floor of the mouth

 

Does the planned surgery require a special kind of ET tube?

  • NIM tube: This ET tube allows monitoring of the recurrent laryngeal nerve intraoperatively.
  • Laser tube: This is a specially coated ET tube designed not to burn when exposed to a laser beam
  • Microlaryngoscopy tube
  • RAE tubes (nasal and oral)
  • Armored/ re-inforced tube
  • ....

 

Do we expect difficult laryngoscopy?

 

Do we expect difficult bag-mask ventilation/ is it safe to induce general anesthesia before intubation?

  • Awake fiberoptic intubation
  • ..

 

Do we need lung isolation in addition to intubation?

  • Double lumen tubes
  • Bronchial blockers

 

Does the patient have a full stomach or a high regurgitation risk for other reasons?

  • (Modified) rapid sequence induction