Photo: Alice Blackmore
If you or your family member can’t breathe, not only is it terrifying, but it is a medical emergency. The critical care team needs to act fast and may not have time to explain the process or answer questions.
Let me join you in the waiting room and explain what may be going on behind the closed Intensive Care Unit (ICU) doors. First, who am I? I worked for fourteen years in a medical/surgical ICU and I have sat on both sides of the ICU doors. I am now a freelance writer for health articles, own a business called Insightful Nursing, and write nurse content and blogposts for families to help them understand in lay terms what happens in an ICU.
First of all, let me give you a simple explanation of the breathing process. I will start with an anatomy lesson.
Anatomy of breathing
If you opened your mouth and looked past your tongue and down your throat, you would see the long tube that stretches from your throat to your stomach called the esophagus. Every mouthful of food travels down this tube until it slides into the upper part of the stomach.
What you can’t see is another tube that lays on top of your esophagus. You might call it your windpipe, but the doctors and nurses call it a trachea. A small flap, called the epiglottis, acts as the door keeper to this tube, opening and closing each time you breath.
About four inches down, the trachea divides in two; with one side going to the right lung and the other going to the left lung. The point where it divides is called the carina. Your left lung has two lobes to leave space for your heart, and your right lung has three lobes.
When you breathe, air goes in through your nose and mouth, slides past the epiglottis, down the trachea, into the lungs, exchanges oxygen with carbon dioxide and reverses back up the trachea, through the epiglottis, past your nose and mouth, and back into the atmosphere.
Obviously, it is more complicated than this, but this is the terminology you need to know in order to understand what the medical team is telling you, and to ask questions.
Know your ABC’s
A = Airway, B = Breathing, C = Circulation
When there is an emergency, the medical team will first assess the airway by asking this question. Can air physically get through the epiglottis and into the lungs?
An example of this is when someone chokes on a piece of food. The person will die if the piece of food is not removed.
When the airway is not blocked, the medical team will next assess breathing. I will discuss this in more detail in this article.
If the airway is not blocked, and the person is breathing, the next point of assessment is circulation; how well blood is circulating through the body. Assessment tools will include getting a blood pressure and feeling for pulses in various parts of the body.
Now you understand what the medical team is doing and what they are looking for. So, let's back up and discuss breathing.
How do you know someone is having trouble breathing?
It may be difficult to assess if someone is breathing adequately. Here are a few symptoms to look for:
Sucking in at the "v" knotch at the base of the neck - called tracheal tug
Sucking in between the ribs with each breath - called intercostal retractions
When the belly pulls or sucks in under the base of the ribs - called subcostal retractions
Cannot talk in full sentences
Gasping for air
Blue tinge around the mouth
Please stop reading this article and call 911 or the emergency number for your country if you see a blue tinge around the lips or drooling. This is a medical emergency.
Let’s assume that you called 911 and the ambulance attendants have arrived. They put a small clip onto your family member’s finger and tell you that it’s an oxygen saturation probe, also know as an O2 Sat Probe.
What is an O2 Sat probe? It --
Measures oxygen levels of the blood circulating through your body
A typical child/adult will have an O2 saturation of 95% - 100%
An older adult may have an O2 saturation of 95%
Some adults with chronic lung diseases, such as cardiopulmonary lung disease (COPD) may have O2 Saturations of 88% - 93%
Some babies with heart issues may have a lower O2 Saturation
If the paramedics assess the oxygen saturation and decide that the patient needs oxygen, they will put a clear oxygen mask attached to an oxygen tank onto the persons face and secure it with an elastic behind the patients head. The paramedics control the amount of oxygen delivered to the patient by turning the regulator on the tank up and down. A normal oxygen delivery amount if someone is not having too much difficulty breathing would be 1-2 litres.
In some situations, the paramedics may use a more advanced breathing system, which will be discussed in a later blogpost.
The paramedic will transport the patient to the hospital for emergency care. Most often you are asked to sit in the waiting room so the medical team can assess your family member.
There are many reasons why someone might be having difficulty breathing. Here are some of them --
Chronic lung illness — such as COPD, interstitial lung disease, or asthma
Lung infection — such as pneumonia
Obstruction from choking or a partial choking
You now have a basic understanding of breathing, have been introduced to some medical equipment, and learned some basic medical terminology.
The doctor comes into the waiting room and hurriedly tells you that your family member needs intubation or they will die. They don’t have time to explain the procedure or answer your questions. However, I can explain it to you.
What is intubation?
Intubation is when a tube, called an endotracheal tube (ET Tube), is inserted via the mouth, past the throat, and through the epiglottis, stopping just short of the carina. Remember, we talked about the carina earlier in this blogpost?
After it is inserted, the tube is hooked to a ventilator, a machine that pushes air and oxygen through the tube and into the lungs at a regulated speed. A ventilator comes in different styles and sizes, but most are the size of an apartment refrigerator on wheels, topped by a screen that shows waveforms
Oxygen is fed into the ventilator and and turned up and down according to the patients oxygen saturation
Other words you will hear for intubation and ventilation are mechanical ventilation, and artificial respiration
The process of intubation
When someone is having difficulty breathing, they usually sit in a high fowler’s position, a fancy term to say they are sitting upright. This position helps them to breath more easily
A respiratory therapist will be called if they are not already present
The physician will order medications to sedate the patient and manage their pain
The nurse prepares the medications and brings them to the bedside to administer when the team is ready to proceed
The respiratory therapist (RT) prepares the equipment needed to intubate the patient
Once the patient is adequately sedated, the medical team lays them flat with their head tipped backwards to better open see the epiglottis
Using a tool called a laryngoscope, the physician or RT slides the ET tube down the throat and into the trachea
The RT/physician checks that the ET tube is in the correct place by listening with a stethoscope, checking for carbon dioxide, and a final confirmation by a chest x-ray
Once the physician is assured that your family member is stable, you will be invited to sit at the bedside
Five important things to know
Your family member is sedated and may not respond to you
Your family member cannot speak with an ET tube in their mouth
Assume your family member can hear you. Speak to them to let them know that you are present
You may be asked to leave again so the physician can insert a central line which will give better access to veins, or for other procedures
If you feel anxious, here are some coping strategies
I hope this blogpost has helped you to better understand what happens when your family member is intubated and ventilated.
The medical terminology I've shared should help you better understand the conversations that physicians and nurses will have with you
Feel free to leave comments and questions about questions you may have
My next blogpost will address the question: What Questions Should I Ask if the Doctor says “We Need to Intubate.”
Alvarado, A. D., Panakos, P. (2022). Endotracheal Tube Intubation Techniques. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK560730/
Bonvissuto, D. (2022). What are chest retractions? WebMD
Cunha, J. P. (2021). What Is a Good Oxygen Rate by Age? Lung & Disease Respiratory Center.
MedlinePlus. (2023) Endotracheal Intubation. National Library of Medicine.
Steris Healthcare. (2023). What are the types of fowler’s positions?
Sullivan, B. (2020). 5 Things to Know About Capnography. EMS1 by Lexipol.
Disclaimer: Anything written on this blog can be used for informational purposes only and should not be substituted for medical advice.