Absolutely, licensed respiratory therapists are not only capable, but also specially trained to perform intubation. They play a crucial role in emergency response teams precisely because of their expertise in establishing an artificial airway for patients who cannot breathe independently. This skill is a fundamental component of a respiratory therapist's scope of practice, empowering them to act swiftly and efficiently in critical moments to safeguard patient health
The proficiency of respiratory therapists in intubation extends across a wide range of clinical circumstances. Their comprehensive training encompasses advanced methodologies and adherence to best practices, ensuring they are thoroughly equipped to manage the intricate process of inserting artificial airways. Furthermore, research and comparative studies affirm that respiratory therapists exhibit a level of adeptness in successful intubations that parallels that of their physician counterparts (source: Pubmed).
What is intubation?
Intubation is a procedure performed to establish an artificial airway in a patient. An artificial airway may need to be placed in emergent situations and prior to surgery so a patient can be hooked up to a mechanical ventilator. This allows trained healthcare professionals to control a person’s breathing and provide oxygenation when they aren’t able to themselves.
When Does a Patient Need to Be Intubated?
A patient may need to be intubated for many reasons, the most common being:
- Respiratory failure
- Cardiac arrest
- Decreased level of consciousness
- Airway obstruction
- Severe hypoxemia
- Inability to protect airway
- Risk of aspiration
- Surgical procedure with general anesthesia
- Severe respiratory distress
- Hemodynamic instability
- Injury to airway
Intubating a patient allows medical staff to oxygenate and ventilate a patient with a ventilator when the patient is unable to effectively do it themselves.
What Happens During Intubation?
Before a patient is intubated, several steps are necessary to ensure a smooth and safe procedure:
- A verbal or written order must come from a physician to intubate the patient
- Medications for pain, sedation, and sometimes paralyzation must be ready to administer
- A respiratory therapist must gather all the proper supplies to insert an artificial airway
- Support staff must be ready and present to aid in the procedure
- A mechanical ventilator needs to be available
Once all the preparation is complete, an RT will stand at the head of the bed with a tool called a laryngoscope that allows them to see the patient’s airway and vocal chords. A registered nurse administers the proper medications so the patient is completely comfortable and asleep. The airway (also called an endotracheal tube) is inserted and the patient is connected to a ventilator that will breathe for them via positive pressure ventilation.
What Equipment Is Needed for Intubation?
For a successful intubation, the proper equipment should be prepared (with backups available!) including:
- Endotracheal tubes (including a size down)
- Stylet
- Lubrication jelly
- Bag-valve mask connected to oxygen that’s turned on
- Suction with a Yankauer tip suction catheter
- Colorimetric CO2 detector
- Laryngoscope handle and blade
- Tape or tube holder
- 10ml syringe
- Magill forceps
- Stethoscope
- Personal protective equipment (PPE)
- Ventilator
In most cases, the respiratory therapist prepares all the equipment for the procedure. An RT is responsible for making sure equipment is tested, not expired, and functional prior to intubating a patient.
Different Intubation Techniques
Various techniques and approaches can be used to place an endotracheal tube including:
- Direct laryngoscopy: This is the traditional and most commonly taught method of intubation. A laryngoscope is used to directly visualize the larynx, and the endotracheal tube is then guided into the trachea.
- Video Laryngoscopy: This technique uses a video laryngoscope. The video feed allows the doctor or RT to view the laryngeal structures on a screen, which can provide a better view in difficult intubation situations.
- Fiberoptic Bronchoscopy (FOB): This is especially useful for patients with challenging anatomy or cervical spine issues that prevent neck movement. A flexible bronchoscope equipped with a fiberoptic camera is navigated through the vocal cords, and the endotracheal tube is then advanced over it.
- Rapid Sequence Intubation (RSI): This is a method where specific drugs are administered in quick succession to induce unconsciousness and paralysis. It’s done to facilitate intubation in emergency situations, minimizing the time and risks of aspiration or airway trauma.
- Bougie-assisted Intubation: A bougie is a long, flexible tool that can be used to navigate difficult airway anatomy. Once the bougie's tip is positioned in the trachea, an endotracheal tube is advanced over it.
Depending on the hospital’s protocol, a respiratory therapist may be able to perform some, but not all, of these techniques independently.
Can Nurses Intubate?
Every state has their own set of guidelines when it comes to nursing scope of practice. Additionally, each medical facility has policies and protocols in place about who can intubate. Most states allow registered nurses to intubate, though it’s generally not needed when physicians and respiratory therapists are present.
Nurse anesthetists and nurse practitioners often intubate in hospital settings like the operating room or neonatal intensive care unit.
In the field, paramedics or flight nurses may be trained to handle intubations in emergent situations. Sometimes special airways are used in place of endotracheal tubes that are easier and safer to insert, like laryngeal mask airways (LMA).
What Else Can Respiratory Therapists Do?
Intubation is just one skill RTs are trained to do during school and on the job. Respiratory therapists have a diverse skill set that makes them critical to the patient care team.
Additional job duties of respiratory therapists:
- Assessing patients
- Administering aerosolized medications via nebulization
- Administering oxygen therapy via nasal cannula, non-rebreather, simple mask, and more advanced oxygen devices
- Performing lung expansion therapy
- Drawing and performing arterial blood gas (ABG) analysis
- Operating and maintaining respiratory equipment
- Responding to emergencies like code blue and rapid response alerts
- Assisting with bronchoscopies and other procedures
- Transporting critically ill patients
- Managing patients on mechanical ventilators
- Conducting pulmonary function tests (PFTs)
- Managing tracheostomies
- Suctioning airways
- Documenting therapy and treatment
- Inserting arterial lines or other invasive lines
- Educating patients and families about respiratory diseases and care
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