Intubation When Breathing Cannot Wait
Airway First. Always.
Why Is the Airway Everything?
The first rule of emergency medicine is simple. ABC. Airway. Breathing. Circulation. In that order. That sequence is not negotiable. If air is not moving, nothing else matters. Not the IV. Not the CT scan. Not even the blood pressure. Oxygen is the currency of life, and without it the brain begins to suffer within minutes.
A patient can have a pulse and still be in immediate danger. If the airway is blocked by swelling, blood, vomit, infection, or profound fatigue, oxygen cannot reach the lungs effectively. When that happens, organs begin to fail quickly. In those moments, protecting the airway becomes the priority above all else.
What Is Intubation, Really?
Intubation means placing a tube through the mouth, past the vocal cords, and into the trachea, the windpipe that leads to the lungs. The formal term is endotracheal intubation. The tube physically secures the airway, creating a protected pathway for oxygen to reach the lungs without obstruction.
It serves two essential functions. First, it prevents aspiration, which is stomach contents or secretions entering the lungs and causing severe pneumonia. Second, it allows mechanical ventilation. The tube connects to a ventilator that delivers oxygen, controls airflow, and supports or completely replaces natural breathing when the body cannot do it alone.
What Happens in the Room?
Imagine a patient who arrives unresponsive with a high fever and falling oxygen levels. Their breathing is shallow and ineffective. Their blood pressure is unstable. Oxygen by mask may help briefly, but if the lungs are filling with infection or the brain is no longer reliably driving respiration, more definitive action is required.
The room becomes focused, not frantic. Nurses prepare medications for sedation and neuromuscular blockade. Respiratory therapy stands ready. Using a laryngoscope, often with video assistance, we visualize the vocal cords and guide the tube precisely through them into the trachea. It is controlled urgency with deliberate movement.
What Does the Ventilator Actually Do?
After placement, we confirm the tube carefully using lung exam, end tidal carbon dioxide monitoring, and usually a chest X ray. The ventilator then assists or takes over breathing. It controls respiratory rate, tidal volume, oxygen concentration, and airway pressures. These settings are adjusted carefully to avoid complications such as barotrauma or volutrauma while giving injured lungs time to recover.
Just as important, intubation is not automatically permanent. A ventilator is a tool, not a sentence. Many patients require temporary support while pneumonia improves, sedation clears, or swelling decreases. When they can protect their airway and generate adequate spontaneous respirations, we remove the tube in a process called extubation. In many cases, that moment signals meaningful recovery.
Why Is the Decision So Deliberate?
Intubation is lifesaving, but it carries risk. Ventilator associated pneumonia, airway injury, drops in blood pressure during induction, and prolonged ICU stays are real considerations. Once a patient is intubated, getting them safely off the ventilator requires physiologic stability and thoughtful timing.
Experience teaches restraint. It is technically possible to intubate many patients. The harder skill is knowing when it is truly necessary. When we choose to secure the airway, it is because the benefits clearly outweigh the risks and because protecting oxygenation cannot wait.
THE BOTTOM LINE
• Airway comes first. Without oxygen, no organ system can function
• Intubation secures the airway and allows mechanical ventilation when breathing fails
• In many cases, a ventilator is temporary support while the body heals
Written by a Board-Certified Emergency Medicine Physician