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  • Writer's picturealicejblackmore

What Questions Should I Ask if the Doctor says “We Need to Intubate.”

Intubation of a patient is often done as an emergent procedure. This means that it is urgent, and a decision must be made quickly. There is often not much time for a long discussion or to ask questions. Please read the blogpost on intubation for further understanding on intubation and ventilation.


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In this blogpost, I will discuss questions you should ask the doctor if you are told that you or your family member needs to be intubated. Who am I? I am the Intensive Care Unit (ICU) nurse that has the time to sit down with you and explain what is going on behind the closed doors of the ICU. I have over fourteen years of experience in the Intensive Care Unit and am now a freelance writer and owner of Insightful Nursing. I am using my expertise to help people like you to navigate a world that is as foreign as getting off a plane in a different county where you do not know the language, transportation system, or even how to stay safe.


This blogpost will be focused on adult patients only. A future blogpost will consider the unique issues and concerns surrounding intubation of children.


So let’s get started. The first thing you need to know that intubation doesn’t fix anything.


Intubation doesn’t fix ...


Accidents where your chest is crushed

Brain injuries

Breathing problems such as Cardiopulmonary Obstructive Disease (COPD), an illness that is often secondary to a lifetime of smoking

Cancer

Asthma

Heart Attacks

Illnesses such as Meningitis

Pneumonia

Strokes


Intubation doesn’t fix any problems. It merely supports the patient’s breathing while the doctors figure out what is causing you/family member to have difficulty breathing.


Why is it urgent to make a decision?


When people struggle to breathe, they get exhausted and are unable to keep their oxygen saturation above 90%. If nothing is done, they will eventually get so tired that they will stop breathing and die.


However, this usually takes place over hours or even days. If a patient comes into the hospital with difficulty breathing, they will be given a facemark that supplies extra oxygen, usually set at 1 to 2 litres. Nurses will monitor their oxygen saturation and breathing. If their breathing becomes more labored and their oxygen saturation dips below 90%, their mask will be changed to a different mask that delivers more oxygen. During this time, the patient will be given medications to solve the underlying problem. This might be antibiotics to fight an infection, a diuretic or “water pill” to help the kidneys rid the body of extra fluid, or a steroid to decrease inflammation in the lungs caused by asthma.


If the medications cannot solve the problem fast enough or there is another underlying issue, the patient will become exhausted. During this period of time, the physician may have spoken with you or your family member about intubation. This is the best time to ask questions and decide on the direction you want to take.


It is scary to have trouble breathing, and even more frightening to watch someone you love struggle. Once exhaustion sets in, decisions about intubation must be made; and often quickly.


So, let's talk about some of the questions you might ask the physician.


Why is it necessary to intubate?


Someone may struggle to breathe for hours or even days. However, even though they may be receiving supplemental oxygen, they will get eventually get exhausted, their oxygen saturation will drop, and they will stop breathing and die.


Is there an alternate treatment?


Sometimes the doctor will offer a treatment called Bi-level Positive Airway Pressure (BIPAP). BIPAP is described as assisting breathing by using air pressure to keep the lungs open and that it doesn’t hurt.


Can I describe what BIPAP really looks and feels like? It consists of a mask attached by tubing to a small BIPAP machine, which is connected to supplemental oxygen. The mask fits tightly over the patients nose and mouth, about as snug as a full face snorkelling mask. No air can seep in or out. When the machine is turned on, it feels like a full face wind blowing air down your throat. It doesn’t hurt but it is uncomfortable and people with claustrophobia will sometimes panic. Limited sedation can be given as the patient must continue to breathe on their own. This mask needs to be left on for several hours at a time.


Not everyone can tolerate using a Bipap mask and it is only effective if the patient is compliant with this treatment. It doesn’t work well for someone with dementia who is unable to understand that they need to leave it on.


What is the benefit of intubation?


The benefit of being intubated and mechanically ventilated is comfort and management. Patients are given adequate sedation and pain medications to keep them comfortable during the intubation procedure and during the time they are on a ventilator.


Intubation also allows the critical care team to better manage the patients airway, and their breathing. They can set the parameters on the ventilator to sync with the patients breathing needs. The ventilator can completely breathe for the patient if they are heavily sedated, or provide assistance with patient initiated breaths.


Remember that intubation doesn’t fix underlying problems. It gives time for the critical care staff to figure out what treatments the patient needs to get better.


Are there any risks to intubation?


The risks for intubation include injury to the voice box because the endotracheal tube passes through the vocal cords and into the trachea. Other risks are bleeding and infection.


If the doctor or respiratory therapists anticipates a difficult intubation, they will call the anesthetist and have him bring his expertise and specialized equipment. The team works together for a successful intubation.


How long will they be intubated?


The length of time for intubation depends on the underlying issues the patient is dealing with. It could be a few minutes or hours if the patient is being intubated for a procedure. Intubation is done to protect the patients breathing when they are too sedated to breathe on their own. Or if they are being intubated for pneumonia, it might take a few days for the infection to clear up enough for the patient to breathe again on their own.


If the patient is going to need the breathing tube longer than two weeks, the physician will discuss a procedure called a tracheostomy. Why? Because the endotracheal tube can erode the vocal cords and cause damage. A tracheostomy is when a small hole is cut through the neck and into the trachea or windpipe. A small tube is placed through the opening which can be connected to the ventilator. When it is no longer needed, the tube is removed and the hole will heal on its own.



Will they be able to talk to me when they are intubated?


A patient cannot talk when they have a breathing tube/endotracheal tube inserted. They may be able to communicate with you by writing on a sheet of paper. However, remember that they are often heavily sedated and may be only able to squeeze your hand, or may not respond at all. Always assume that they can hear you.


Is intubation ever a wrong choice?


All of life is a pathway and medical decisions are often at a crossroad; choices that will lead down one path or another. When someone is intubated, you start down a new path with new choices that may not always lead back to the familiar path you used to be on. It is also a path that can be difficult to turn around and go back.

Intubation is an easy choice when the patient is young or to buy time for a fixable problem.


However, the decision becomes more difficult when the patient with end-stage cancer has pneumonia; or someone a senior suffering from dementia has a significant stroke.


First, may I empathize with you and offer you some coping strategies? Choosing the right medical path presents a challenging situation for all families everywhere. You love and respect your loved one and you want to make the right decision without knowing the future. Can I ask a few questions? Has your family member ever expressed their wishes? Will intubation give them more quality time? Was your senior family member in decline prior to their stroke? What is the critical care team telling you about the possible/probable outcome?


Remember that the decision to intubate is a fork in the road that leads down a new path, not a solution to the underlying problem.


In Conclusion


  • Intubation buys time to fix an underlying solution

  • Intubation can be a difficult decision

  • Ask questions about intubation

  • Consider alternate treatments

  • It’s okay to struggle with the decision


Did you find this blogpost helpful? Leave your comments and questions below.

My next blogpost will be on Sepsis.


References


ICU-USA. (n.d.) Bi-level Positive Airway Pressure (BIPAP).


Medline Plus. (2023). Endotracheal Intubation.


Medline Plus. (2023). Tracheostomy Care.




Disclaimer: Anything written on this blog can be used for informational purposes only and should not be substituted for medical advice.

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