Is sedation required for intubation?

Unless the patient is already unconscious or if there is a rare medical reason to avoid sedation, patients are typically sedated for intubation.

Intubation is a medical procedure used by doctors to keep the airway open or safe during a medical emergency or a surgical procedure. 

What is Intubation Used For?

Intubation is used:

• During surgery under general anesthesia 
• If there is an injury or illness that causes difficulty breathing
  • Swelling of the face or throat
  • Severe allergic reactions
  • Trauma to the neck
  • Burns to the face, mouth, and/or airway
• If a patient is unconscious or uncooperative and unable to keep their airway clear 
  • Overdoses
  • Stroke
  • To prevent aspiration (inhalation of vomit, blood, or other secretions into the lungs)
• To increase the amount of oxygen intake (due to low blood oxygen or respiratory failure)
  • Severe asthma
  • Chronic obstructive pulmonary disease (COPD)
  • Pneumonia
  • Congestive heart failure (CHF)
  • Blood clots in the lungs (pulmonary embolism)
  • Toxic exposures, such as to carbon monoxide or cyanide
  • Septic shock

To perform intubation:

• The patient is placed on cardiac and oxygen monitors lying on their back, face-up
• Pre-oxygenation is done when possible 
• High-flow oxygen is usually administered by mask or nasal cannula prior to the procedure
• Medications are administered to sedate the patient and paralyze the muscles of the airway
• The head is tilted slightly back
• The mouth, throat, and pharynx are cleared of any debris or secretions
• A scope with a light is inserted past the teeth and tongue into the back of the throat to locate the voice box (larynx) which is where the part of the airway that connects to the lungs begins
• An endotracheal tube is guided along with the lighted scope and placed in between the vocal cords in the trachea
• A small airway cuff (a small balloon at the end of the endotracheal tube) is inflated so the tube stays in place inside the trachea
• The endotracheal tube is connected to oxygen via a ventilator
• Once the tube is in place, the doctor will check that it’s in the right position and is assisting the patient in breathing correctly

Unless the patient is already unconscious or if there is a rare medical reason to avoid sedation, patients are typically sedated for intubation. 

Intubating patients who are not sedated is difficult and can be dangerous. The patient’s gag reflex can cause movement of the airway and regurgitation of vomit or secretions into the airway causing complications. The vocal cords can also spasm during a non-sedated intubation causing damage to the cords and complicating the procedure. 

Medications used in tracheal intubation include:

• Pre-treatment medications that are administered 2-3 minutes prior to induction and paralysis. Use the mnemonic LOAD: 
  • Lidocaine
  • Opioid analgesics (i.e. (fentanyl)
  • Atropine
  • Defasciculating agents (i.e. vecuronium)
• Sedatives/induction agents 
  • Ketamine (Ketalar)
  • Etomidate (Amidate) 
  • Propofol (Diprivan) 
  • Midazolam (Versed) 
• Paralytics 
  • Rocuronium (Zemuron)
  • Succinylcholine (Anectine)

Complications of intubation include:

• Dental damage such as chipped or broken teeth
• Lip, gum, or inner cheek cuts 
• Sore throat
• Difficulty talking or breathing following the procedure
• Pain in the lungs
• Lung collapse
• Pneumonia or another lung infection
• Aspiration (inhalation of vomit, blood, or other secretions into the lungs)

In the extremely rare case, intubation is unsuccessful, the patient may need an emergency procedure called a cricothyroidotomy, in which a smaller airway tube is placed into the neck through the cricoid membrane (near the “Adam’s apple”).  

Risk factors for complications from intubation include:

• Obesity
• Lung disease
• Neck or spine injury 
• Large teeth
• Poor dental condition
• Sleep apnea
• Smoking
• Recent eating or drinking