Intubation Brain Injury

Oxygen is necessary for human life. Reduced oxygen or cutting off oxygen can lead to brain injury and death within just a few minutes. If an individual is not able to breathe or the oxygen supply is cut off, intervention may be required to keep the airway open to provide oxygen to the lungs. This can be done manually through intubation.

Intubation is a medical procedure to open airway access to the lungs. The process generally involves having a tube put down the patient’s throat. Intubation is often done in an emergency situation where the individual is not able to breathe on their own. Intubation can also be done during surgical procedures to maintain oxygen supply.

Improper intubation, failure to intubate, or delayed intubation can lead to serious injury or death. Unfortunately, many family members or people who died because of intubation negligence never find out that the death was preventable if the doctors or health care providers had maintained the proper standard of care. Injury or death caused by intubation accidents may be medical malpractice.

Intubation Practice and Procedure

Endotracheal intubation (EI) is a procedure performed on individuals who are unconscious or unable to breathe on their own. Tracheal intubation provides a secure airway for oxygen to enter the lungs and carbon dioxide to exit. The most common reasons for intubating a patient include emergency medical treatment and surgical procedures.

Intubation is invasive and generally requires the individual to be unconscious or under anesthesia because the natural reflexes of the body prevent a tube from being inserted into the throat.

Inserting the Tube

Stimulation of the upper airway causes reflexes including glottic closure, pharyngeal reflex, or laryngeal spasm, sometimes called the gag reflex. This is part of the process that allows food to go down the esophagus (food pipe) instead of the trachea (windpipe). In endotracheal intubation, the tube must be inserted into the trachea, not the esophagus. One of the devices used to do this is the laryngoscope.

A laryngoscope generally has a long flat or curved blade and a light source. The laryngoscope is inserted past the tongue to keep the tongue and epiglottis depressed and allow the user to look down into the throat. With a view of the tracheal opening, the plastic intubation tube can be inserted directly into the trachea. An inflated cuff can be used to secure the tube and prevent air from leaking out around the tube and prevent other substances from going into the lungs. This completed process provides an airway directly from outside the mouth to the lungs.

Oxygen Supply After Intubation

The intubation tube does not breathe for the lungs, if the lungs are unable to breath on their own, something else must be done to ensure the body is supplied with oxygen. Oxygen to the lungs to substitute breathing can be done with chest compressions (which has a limited capacity to provide a steady supply of oxygen and can cause internal injury), a bag that is manually or automatically pumped, or ventilator.

Intubation for Anesthesia

Many surgical procedures, including elective surgeries, may require the patient to be sedated, or “put to sleep,” during the surgery. This may be necessary to avoid pain and to keep the patient immobile during the surgery.

With general anesthesia, the anesthesiologist provides drugs that keep the patient stable while making them unconscious. Neuromuscular block agents also paralyze the individual temporarily. The anesthesiologist has to monitor the patient’s vital signs during the period they are sedated.

When the patient is anesthetized, they may be unable to breathe on their own and intubation provides an airway and oxygen supply to keep the patient alive and stable during the medical procedure when they cannot breathe on their own.

Using a laryngoscope, the anesthesiologist gets a clear view of the vocal cords and inserts the appropriately sized endotracheal tube into the lower portion of the trachea. The doctor should listen for lung sounds to make sure the tube is in the right place and secure the tube with an inflatable ring. This also helps keep fluids from getting into the lungs.

One of the reasons patients who are about to undergo surgery have to fast before the procedure is to reduce the chance of aspiration, or vomiting that allows stomach contents to enter the lungs, which can cause pulmonary edema, pneumonia, or other lung damage.

During the procedure, a ventilator is connected to the endotracheal tube to provide oxygen. After the procedure, as soon as the patient no longer needs an artificial airway, the endotracheal tube is removed (extubation). The patient should be monitored closely to make sure they are getting enough oxygen after the tube is removed.

Intubation in Emergency Medicine

Intubation can also occur in emergency medicine, including prehospital care. For example, if the paramedics respond to a car accident and find the injury victim is unconscious, they will do a rapid assessment to determine if the patient is breathing. If the patient is not breathing, they may conduct an emergency laryngoscopy and endotracheal intubation.

An injury victim may not be breathing because of a number of causes or factors, including unconsciousness or a blocked airway. Keeping the airway open and secure can maintain oxygen to the body long enough to perform other emergency procedures and transport the patient to an emergency department (ED) or hospital. Reasons for intubation in an emergency situation may include:

Choking on an object,
Trauma to the neck,
Drowning,
Strangulation,
Allergic reaction which causes the throat to swell shut,
Chemical inhalation or burns,
Epiglottitis,
Burn injuries or smoke inhalation,
Poisoning,
Severe asthma attack,
Drug overdose,
Traumatic brain injury (TBI),
Blood loss,
Chest trauma,
Alcohol poisoning,
Cardiac arrest,
Stroke, or
Seizure.

As part of an emergency assessment, paramedics or firefighters may conduct a respiratory assessment. This may include:

Talking to the patient if they are conscious,
Talking to witnesses to find out what happened,
Looking at the environment around the patient,
Looking for signs of breathing (raising and lowering of the chest),
Listening for breathing and lung sounds,
Checking for an obstructed airway (food or object in the throat),
Pulse oximetry to monitor oxygen saturation, and
Administering oxygen through a nasal cannula or mask.

If the patient is not breathing then an emergency laryngoscopy and endotracheal intubation may be performed where the patient, after the patient is loaded on a stretcher, or even in an ambulance on the way to the hospital. Since the brain can begin to die after only a few minutes without oxygen, prehospital field intubation is a common procedure in emergency medicine.

Injuries Caused by Improper Intubation

Improper insertion of the tube can cause tissue damage, aspiration of stomach contents, or improper intubation to the esophagus. Tissue damage can be minor and cause soreness, neck pain, swelling, difficulty speaking, or make it difficult to swallow after the tube is removed and the patient can breathe on their own. However, some damage caused by improper intubation can be permanent. This may include vocal cord damage, endotracheal perforation, bronchial intubation, and nerve damage.

Improper intubation can also increase the risk of fluid or objects getting into the lungs. Vomit, saliva, or stomach contents that enter the lungs can cause an infection or pneumonia. Improper intubation may also cause pneumothorax, or a collapsed lung.

The most dangerous risk of an improper intubation is the failure to deliver oxygen to the body. Unrecognized and unintentional intubation of the esophagus is common. This is most common in a prehospital setting. An improper intubation into the esophagus provides no access to the lungs and the individual could continue to suffer anoxia, which could lead to brain damage and death. Misplaced intubations often result in the patient dying on their way to or shortly after arrival in the emergency room.

Delays in Intubation

Delays in intubation can be just as damaging as failure to intubate. Hypoxia is a decrease in blood oxygenation to the brain. A compromised airway can reduce oxygen to the brain, leading to hypoxic ischemia, which can result in brain damage or death.

Anoxia is a complete cut off of oxygen supply to the brain. When a person is not breathing, brain cells and neurons begin to suffer damage very quickly. Damage can begin after as little as one minute and permanent damage can follow after a few minutes. Oxygen can be provided, through assisted breathing, administering oxygen, bag and mask ventilation, or a mechanical ventilator.

When Intubation May Not Be Advised

Any delay in intubation can cause unnecessary damage. However, there may be reasons not to perform a field intubation in an emergency response. Contraindications may include severe trauma to the head, neck, or chest area that would prevent safe intubation.

Cervical spine injury that requires complete immobilization may also make endotracheal intubation more difficult. The scene of prehospital treatment may also be a reason to delay intubation, if the emergency providers are not in a safe or stable location to conduct an endotracheal intubation.

Lack of a clear visualization may also complicate intubation or increase the risk of an improper intubation. In intubation, assessment may include the Mallampati classification. This classifies a patient based on the ability to see the epiglottis, as follows:

Class I – Visualization of the soft palate, fauces, uvula, and pillars.
Class II – Visualization of the soft palate, fauces, uvula.
Class III – Visualization of the soft palate and base of the uvula. Anticipate moderate difficulty in intubation.
Class IV – Soft palate is not visible. Anticipate severe difficulty in intubation.

Failure to Intubate a Patient

Failure to intubate a patient can prevent providing an open airway to deliver oxygen to the lungs. Failure to intubate for a patient who is not breathing or has a compromised airway will cause a decrease in oxygen supply to the important organs of the body, including the lungs, heart, and brain.

Lack of oxygen to the brain can lead to anoxic brain injury. Brain cells begin to die within minutes of oxygen deprivation. After about 10 minutes, brain damage can be extensive and the patient has a reduced chance of recovery. After about 15 minutes without oxygen, recovery and survival may be impossible.

Treatment for a patient who is suffering anoxia is to prioritize a return of the oxygen supply to the brain. This would generally involve an invasive procedure to provide access to the lungs, including intubation. Other forms of intubation include:

Nasotracheal intubation
Tracheostomy
Continuous positive airway pressure (CPAP) mask

Once oxygen supply has returned to normal, healthcare providers can assess the extent of the damage. Cognitive tests and imaging can identify signs of brain cell death and brain damage, including:

Magnetic resonance imaging (MRI)
Ultrasonography (US)
Computed tomography (CT)

Treatment following intubation brain injury may depend on the extent of brain damage. If the oxygen deprivation period was limited, the patient may be able to recover some function. Treatment options generally involve therapy to help the victim manage their injuries, including:

Physical therapy
Speech therapy
Occupational therapy
Education

Long-term physical injuries after a brain injury can include weakness in the arms and legs, paralysis, spasticity, or rigidity disorders. Some of the permanent or long-term cognitive symptoms of an intubation brain injury can include:

Memory problems
Problems with judgment and impulse control
Difficulty recalling words
Behaving sexually at inappropriate times
Mood changes
Impaired motor skills
Depression
Anxiety
Dementia-like symptoms

Neonatal and Infant Intubation and Brain Injury

Neonates in intensive care may require intubation and ventilation. Intubation on a neonate or infant can be more complicated because of the size of the mouth, throat, and trachea opening. Positioning of the tube may also be more restricted because of the small size of the patient.

Infants with an endotracheal tube should have continuous cardiorespiratory monitoring, oxygen saturation, with regular blood pressure monitoring.

The consequences of an intubation injury in infants can include severe brain damage. This can cause life-long impairments, including:

Epilepsy
Cerebral palsy
Developmental delays
Cognitive impairment
Neurodevelopmental delay
Motor Function impairment