What is intubation?
Intubation is the process of inserting a tube into the trachea (windpipe) to help a patient breathe. This tube is called an endotracheal tube. Intubation is performed when a patient cannot breathe adequately on their own. The endotracheal tube is connected to a ventilator, which mechanically pushes air into and out of the lungs.
Intubation is typically done in the following situations:
- Respiratory failure – When the lungs are not exchanging oxygen and carbon dioxide effectively. This can happen due to conditions like pneumonia, COPD exacerbation, pulmonary edema, trauma, drug overdose etc.
- Airway protection – When the airway needs to be protected from aspiration. This includes patients with decreased consciousness due to drug overdose, seizures, traumatic brain injury etc.
- Surgery – To maintain ventilation and oxygenation during general anesthesia for surgery.
Intubation requires training and skill to correctly place the endotracheal tube. It is usually performed by physicians, paramedics, nurses or respiratory therapists. Medications are given to relax the muscles and lightly sedate the patient during the procedure. The patient’s breathing is temporarily stopped while the tube is inserted. Correct tube placement is confirmed by physical examination as well as by end-tidal CO2 monitoring.
Is intubation a form of life support?
Yes, intubation is considered a form of life support. Here’s why:
- Intubation takes over the critical function of breathing when a patient cannot do it adequately themselves. Breathing and oxygenation are essential to sustain life.
- It is an invasive intervention done only when a patient’s life is at risk due to compromised breathing. Noninvasive options like supplemental oxygen are tried first.
- The artificial ventilation provided via intubation can be life saving in conditions like respiratory failure, drug overdose, trauma etc.
- Patients requiring intubation are monitored in intensive care units just like those requiring other life supports like CPR or dialysis.
- Intubation requires continuous sedation and physical restraints to prevent the patient from dislodging the tube. This is because the tube is very uncomfortable when a patient is awake.
So in essence, intubation takes over the vital function of breathing to save a patient’s life when they are unable to breathe effectively on their own. That is why it is considered a type of life support or life sustaining treatment.
When is intubation used?
Intubation is used in the following situations:
Respiratory Failure
Intubation is commonly used in patients with respiratory failure when there is inadequate oxygen in the blood (hypoxia) or a buildup of carbon dioxide (hypercapnia). Conditions leading to respiratory failure include:
- Pneumonia
- COPD exacerbation
- Pulmonary edema
- Acute respiratory distress syndrome (ARDS)
- Pulmonary embolism
- Drug overdose
- Trauma
Supplemental oxygen alone may not be enough in these situations. Mechanical ventilation via an endotracheal tube is often required to rest the fatigued respiratory muscles and improve gas exchange.
Airway protection
Intubation may be required to protect the airway in patients with depressed consciousness who cannot protect their airway or manage secretions. This includes:
- Drug overdose
- Seizures
- Head injury
- Coma
- General anesthesia for surgery
Having an endotracheal tube helps prevent aspiration of gastric contents, secretions or blood into the lungs.
Other indications
Other situations where intubation may be required include:
- Severe asthma attack not responding to other treatments
- Life threatening trauma requiring emergency surgery
- Burns involving the airway
- Upper airway obstruction
So in summary, intubation is used when a patient’s oxygenation and/or airway protection are severely compromised and non-invasive methods cannot support respiration adequately. The need for intubation signifies that a patient’s life is at immediate risk without this intervention.
How long can intubation provide life support?
Patients can remain intubated and on mechanical ventilation for extended periods when necessary. The duration depends on the underlying disease process and reason for intubation.
Here is an overview of how long intubation can provide life support:
- Respiratory failure: Days to weeks. This allows time for the lungs to heal while being rested from the work of breathing.
- Coma or brain injury: Weeks to months. Allows time for neurologic recovery and consciousness to improve.
- Neuromuscular disorders: Weeks to indefinitely. Provides ventilation support when muscles are too weak to breathe adequately.
- Surgery: Hours to days. Usually needed only temporarily to get through the operative and immediate postoperative period.
- Drug overdose: Hours to days. Provides support while the toxins are metabolized.
Prolonged intubation is associated with risks like ventilator-associated pneumonia, narrowing of the airway and vocal cord injury. Patients who fail to wean off mechanical ventilation after prolonged intubation may require tracheostomy.
In certain incurable or end-stage diseases, intensive care specialists may decide to withdraw or withhold intubation and transition to comfort care. This decision depends on the patient’s prognosis and wishes.
Overall, modern intensive care enables intubation and ventilation to be continued for as long as necessary to save or sustain a patient’s life. But the risks and benefits have to be weighed, especially when the prognosis is poor.
What are the risks and complications of intubation?
Intubation is an invasive procedure and has potential risks and complications:
During intubation
- Hypoxia from prolonged intubation attempts
- Hypotension
- Esophageal intubation (placing tube in esophagus instead of trachea)
- Dental trauma
- Right mainstem bronchus intubation
- Cardiac arrest
During mechanical ventilation
- Ventilator-associated pneumonia
- Barotrauma from high ventilator pressures
- Oxygen toxicity
- Ventilator-induced lung injury
- Airway trauma
- Inability to wean leading to tracheostomy
Other risks
- Laryngeal injury
- Vocal cord dysfunction
- Subglottic stenosis
- Sinusitis
- Gastroesophageal reflux
- Depression and psychological issues
Proper patient monitoring and safety protocols minimize complications. But intubation has higher risks than non-invasive ventilation and is only used when absolutely necessary to save a patient’s life.
Outcome and survival rates for intubated patients
Outcomes after intubation depend on the underlying disease, reason for respiratory failure, comorbidities, age and other health factors.
Some studies looking at survival rates in intubated patients:
| Study | Patient Group | Survival Rate |
|---|---|---|
| Wu et al 2021 | Critically ill COVID-19 patients on mechanical ventilation | 53% at 28 days |
| Walkey et al 2012 | Critically ill patients with sepsis requiring mechanical ventilation | 50% at 28 days |
| Roch et al 2005 | Lung transplant patients requiring mechanical ventilation | 20% at 28 days |
| Esteban et al 2002 | Critically ill patients receiving mechanical ventilation for >12 hours | 44% at hospital discharge |
As evident, survival rates are variable and depend on factors like age, disease severity and underlying health status. Patients with reversible illnesses tend to have better outcomes than those with chronic end-stage diseases. Advancements in critical care have improved survival in intubated patients over the decades.
Quality of life after intubation
Patients who survive after prolonged intubation are at risk for:
- Cognitive dysfunction
- Depression and PTSD
- Swallowing difficulty (dysphagia)
- Hoarse voice or vocal cord paralysis
- Critical illness neuromuscular abnormalities
- Reduced functional ability and exercise capacity
- Post-intensive care syndrome
Early mobility, rehabilitation, nutritional support, and psychiatric help can improve recovery. But some patients may have long-term impairments in physical, cognitive and mental health after critical illness. Many intubated patients develop new disabilities or worsening of pre-existing conditions.
However, studies show that most survivors still rate their quality of life as satisfactory. The will to live allows many critically ill patients to adapt and cope even after profound illness requiring intubation.
Can intubation prolong death?
Yes, intubation can prolong the dying process in terminally ill patients by providing artificial life support. This fact raises difficult ethical issues.
Intubation should ideally be avoided with patients who are actively dying or have irreversible end-stage disease. It will only extend their suffering without cure. However, accurately predicting when death is imminent is difficult.
Some ways intubation can prolong death:
- Enables cardio-pulmonary resuscitation after cardiac arrest to temporarily restore circulation.
- Prolongs inevitable death in end-stage cancer, advanced dementia or other terminal diseases.
- Restores oxygenation in case of a reversible complication in an otherwise dying patient.
- Maintains vital functions when withdrawal of life sustaining treatment is prolonged.
Many critical care societies advise avoiding intubation in patients with poor prognosis unless consistent with their goals of care. Timely discussions about the use of intubation with patients and families is important in end-of-life care.
Alternatives to intubation
For patients who wish to avoid invasive or high intensity life support at end-of-life, the following alternatives may be considered instead of intubation:
Oxygen therapy
- Nasal cannula
- Face mask
- Non-rebreather mask
Non-invasive ventilation
- CPAP or BiPAP mask
- High flow nasal cannula
Medications for comfort
- Opioids for dyspnea
- Sedatives for anxiety
Other options
- Airway suctioning
- Nebulizer treatments
- Manual techniques like breath stacking
Though less effective than intubation, these measures focus on comfort and dignity. Involvement of palliative care specialists helps ensure patients receive optimal symptom management at end-of-life.
Conclusion
Intubation is considered a form of life support as it takes over the critical role of breathing to save lives in emergency situations. It can sustain life for days to months depending on the clinical scenario. While outcomes have improved over the decades, intubation is still associated with significant complications and morbidity. Avoiding intubation in end-stage patients prevents undue prolongation of the dying process. Where consistent with patient preferences, non-invasive alternatives provide compassionate care. With modern medicine’s capacity to prolong life, deliberations on intubation require weighing of ethical issues along with clinical criteria.