Breathing Support

When a person is seriously ill they often need breathing support. This page describes the treatments used to support breathing, which will depend on how ill the person is and any medical problems they have.

Oxygen masks

An oxygen mask is used to give extra oxygen to people who need it. Different oxygen masks are used to give different amounts of extra oxygen. All the masks have an oval-shaped plastic cup that fits over a person’s mouth and nose. The mask is kept in place by elastic straps.

How does it work?

The oxygen mask is connected to cylinders that give oxygen or air through a short tube. The type of mask used will be decided by the intensive care team. The team may change the mask used as the person’s condition changes. To help monitor the person’s breathing, an oxygen saturation monitor will usually be attached to their finger or ear. An oxygen saturation monitor checks how much oxygen is in the blood. See Equipment page for details on the monitor.

Are there any problems?

The most common problem with using an oxygen mask is dry mouth. This is easily overcome by drinking small amounts of water, or rinsing out the mouth if the person in the Intensive Care Unit (ICU) is unable to take oral fluids. However, this may not be possible for some.

Nasal prongs

Nasal prongs are devices with two prongs that sit just inside the nose. They are used when only a small amount of oxygen is needed.

How does it work?

The prongs are connected to an oxygen or air source using a short piece of tubing. The intensive care team closely check to see whether enough oxygen is being given. To help monitor the person’s breathing, an oxygen saturation monitor will usually be attached to their finger or ear. See Equipment page for details on the monitor.

Are there any problems?

The most common problems are a dry or itchy nose and minor soreness behind the ears. If there are problems, please let the staff know.

High flow nasal cannula

The high flow nasal cannula is similar to nasal prongs but is used for people who are having more difficulty in breathing, as it is able to supply more oxygen.

How does it work?

The device has short, soft prongs that sit just inside the nose. The prongs are connected to specialised tubes, which are connected to:

  • a heated water bath
  • a source of oxygen.

The intensive care team closely check to see whther enough oxygen is being given. To help monitor the person’s breathing, an oxygen saturation monitor will usually be attached to their finger or ear. See Equipment page for details on the monitor.

Are there any complications?

The most common problems are a dry or itchy nose, and minor soreness behind the ears. If there are problems, please let the staff know.

Ventilators

Ventilators are commonly known as breathing machines. This is because they help people to breathe for themselves, or they can take over breathing completely. Some people also call them ‘life support machines’, although this is not quite true.

Types of ventilation

Depending upon their illness and current state, seriously ill people may receive one of two types of ventilation: non-invasive or invasive.

monitor screen showing numbers and graphs

Non-invasive ventilation

Non-invasive ventilation (NIV) is where the person is attached to the ventilator using one of these masks:

  • nasal-oral mask (covers nose and mouth)
  • nasal mask (covers nose only)
  • full face mask (covers whole face)
  • helmet (covers entire head).

NIV can only be used when the person is awake enough so that they can breathe for themselves and their airway is fine.

NIV is delivered two ways:

  1. CPAP (continuous positive airway pressure) – this supports breathing by applying pressure at the end of the breathing cycle (expiration). This ‘splints’ the airways open, which helps people with a severe lung infection. It also allows extra air to escape, which helps when the airways are tight, as in asthma. CPAP is used for many problems, including acute severe asthma, pneumonia and heart failure.
  2. BiPAP (BiLevel positive airway pressure) – this supports breathing by applying pressure throughout the breathing cycle. BiPAP has the same benefits as CPAP with the added benefit of applying pressure during inspiration (when breathing in). BiPAP is needed when the person may be too tired to take a large enough breath themselves. BiPAP is used for a range of problems, including pneumonia, worsening of chronic obstructive pulmonary disease or after a breathing tube has been removed.

People getting NIV are closely monitored by the intensive care team to check that they have the right amount of breathing support, and their condition is stabilising and improving. The monitoring includes checking breathing patterns and that they have the right amount of oxygen and carbon dioxide in their blood. See the Arterial blood gas on the Common blood tests page for more detail.

Some people find the masks uncomfortable or claustrophobic. Small amounts of anti-anxiety medicine may be given to ease this. Some people might find NIV gives them all the help they need, and will need invasive ventilation.

The most common problems with non-invasive ventilation are a dry mouth, a sore face from the pressure of the mask and extra gas in the stomach.

Invasive ventilation

Invasive ventilation is where the person is attached to the ventilator using an artificial airway, such as endotracheal tubes (placed into the windpipe (trachea) through the mouth or nose) or tracheostomies (procedure that creates an opening through the neck into the windpipe).

Invasive ventilation is needed where the person has severe lung problems and/or is not awake enough to breathe properly.

The ICU team will choose the types of support suited to person’s situation.

In the past, it was common for people receiving invasive ventilation to be made unconscious by giving them high doses of sedatives. Through research, the ICU team now knows when it is okay for people to remain awake, so that they can still breathe and move.

Medical-induced comas are now reserved for those who are extremely ill, such as people with severe head injuries, adult respiratory distress syndrome or sepsis (infection in the blood that spreads to the whole body).

The ICU team closely monitors anyone receiving invasive ventialtion to check that they are as comfortable as possible. This includes giving medicines as needed, in particular pain relieving medicines (analgesia).

A person on invasive ventilation is cared for by one nurse at all times. This is because they need close observation as well as help with normal functions, such as feeding and hygiene. The observation includes ongoing monitoring of their heart rate and breathing, making sure the person is handling the breathing support okay and that the oxygen levels are okay. See the Arterial blood gas on the Common blood tests page for more detail.

The ICU doctors are also available to talk to. And a physiotherapist will see the person many times a day to give support to improve lung and physical function. This includes in-bed exercises. The physiotherapist also helps the nurse to get the person out of bed. Where possible, some people may even be walked while they are ventilated.

How long will the person be ventilated?

Ventilators are used until the person’s condition improves and they are able to use a lower level of breathing support. For most, ventilation is only needed for a few days, but if someone is seriously ill, they may be ventilated from weeks to months. If ventilation is needed for the long term, then a tracheostomy tube may be inserted. The most common problems with invasive ventilation are a sore throat from the breathing tube and pneumonia.

Click on the buttons for translated fact sheets about ventilators.

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Artificial airways (breathing tubes)

Endotracheal tube

An endotracheal tube is a long plastic tube used during invasive ventilation. The tube is inserted through the mouth, down through the throat and into the lungs. This process is called intubation. The outer end of the tube is then attached to special tubing, which is connected to a ventilator.

How does it work?

The breathing tube allows gases, including oxygen, to move from the breathing machine to the lungs and then back out again. The breathing tube is held in place with tape or a plastic device. Because the breathing tube passes through the vocal cords, the person will not be able to speak while the endotracheal tube is in position.

How long will it be used for?

Endotracheal tubes are used for only a short time until the person can breath on their own or just need a lower level of breathng support.

The removal of an endotracheal tube is called extubation. If the person needs a breathing tube for a long period, the doctor may want to put a tracheostomy tube in the person’s neck.

Click on the buttons for fact sheets on endotracheal tubes in community languages.

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Tracheostomy

A tracheostomy tube is a short tube placed in a person's trachea (windpipe) through the neck. This is done under general anaesthesia. It is often called a ‘trache’, pronounced ‘trackie’.

In intensive care, tracheostomy tubes may be used for people who:

  • are on a breathing machine for a long time (more than 10 days)
  • have problems swallowing correctly so that secretions such as saliva keep getting into their lung, this is known as aspiration
  • have serious problems with their windpipe, such as severe infection or damage.

How is it done?

A tracheostomy tube can be inserted in one of two ways:

  1. in an operating theatre by a surgeon
  2. in ICU by an intensive care doctor specifically trained in doing the procedure.

The choice and timing of procedure depends on a many things, including the person’s condition and availability of trained staff. The procedure involves making an opening through the neck into the trachea (windpipe), where the tracheostomy tube is inserted into and directed down towards the lungs.

The doctors will decide which is the best method, and they will discuss the possible problems when getting consent to do the procedure.

How does it work?

When a person has a tracheostomy tube, air passes through the tube into the patient’s lungs. Secretions from the upper airways (mouth, nose and throat) are stopped from getting into the lungs by a small cuff around the tube. The tracheostomy also allows medical staff to remove secretions, such as saliva, from the person’s lungs more easily.

In ICU, a small number of people may need a tracheostomy tube for a short while until their acute illness is over.

A tracheostomy can make it easier for the person to breathe. It also can make it easier for nurses to clean the person’s mouth. This is important because if a person is unconscious, they might have difficulty keeping their airway clear and swallowing properly.

Tracheostomy tubes stop air from passing through the voice box. This means the person is unable to speak. However, in these situations, a special trache tube might be used that can allow the person to speak.

Once the reasons for having the trache tube have resolved, the person will go through a weaning process and the tube will be removed. This weaning process is supervised by the ICU team.

Some people are discharged from ICU with a trache tube still in. When this happens, there is a special team of doctors, nurses, physiotherapists and speech pathologists who help the person – this may take from days to months.

Once the trache tube is removed, the hole will close over and the person will be able to breathe normally.

Procedures

Intubation

The insertion of a long breathing tube or artificial airway (endotracheal tube) into the windpipe through the mouth is called ‘intubation’. At times, the tube may be inserted through the nose instead of the mouth.

Purpose

Intubation is needed when someone is unable to breath for themselves or is having difficulties in breathing.

The tube will usually be attached to a breathing machine (ventilator). This equipment will take over some or all of the work of breathing until the person is able to breathe on their own.

What is done?

Intubation is generally a planned procedure and is done by a team of trained medical staff, normally headed by a doctor. This team works together to make sure that the procedure is done in a safe and timely way. Intubation procedures are similar across hospitals, where most people are given general anaesthetic so they are asleep during the procedure.

During the procedure, the person is laid flat and remains connected to a bedside monitor so the team can keep checking vital functions (heart rate, blood pressure, etc.). The person is given anaesthetic medicines through an intravenous cannula to put them to sleep. The doctor uses a laryngoscope to open up the mouth and see down the throat, and then passes the endotracheal tube through the mouth and into the trachea (windpipe).

The endotracheal tube has a cuff, or balloon, around its middle. This cuff is inflated to create a seal around the tube within the trachea. This stops the mouth secretions going into the lungs.

The medical team makes sure that the endotracheal tube is in the correct position. A chest x-ray is done to confirm this. Once checked, the tube is kept in place by using either white cotton tape, adhesive tape or a plastic device. The other end of the tube will then be attached to a ventilator.

What happens next?

Once the ICU team is sure the endotracheal tube is in the right place, a specific ventilation plan will be created to give the person the right level of breathing support. This plan will include the types of sedation used (to cause sleepiness) so that the person is able to tolerate the tube.

The person won’t be able to talk because the endotracheal tube stops air from moving through the voice box. But most will be able to respond in some way, so talking to them in a quiet way is a good idea. If the person is awake, the nurse will explain what is going on and reassure them.

Rarely, a person will be intubated because something is blocking their airways, such as swelling or infection. This person may not need a breathing machine (ventilator). Once the person’s condition improves, the tube will be removed (extubation).

What are the risks?

The most common problems happen when the breathing tube is placed incorrectly. This will be become quickly obvious when checking the vital signs, which is done by the doctor immediately after intubation.

Extubation

What is extubation?

Extubation means removing the endotracheal tube.

Purpose

Extubation is done when the person is able breathe on their own or just needs a lower level of breathing support.

Why is it done?

The person will have been ‘weaned’ from the ventilator. Weaning means to slowly lower the amount of breathing help, until the person in ICU is able to breathe properly themselves.
Weaning can happen slowly or quickly. When the doctors feel the person is ready, the person will be extubated.

During extubation, the person will be awake and remain attached to the bedside monitor. They will sit up if they can, and the breathing tube and mouth will be suctioned to remove any secretions. The cuff on the breathing tube will be let down and the tube withdrawn. The person may cough but this is temporary. Usually, an oxygen mask or nasal prongs will be applied to give oxygen support.

The person will be closely monitored to pick up any problems. Sometimes NIV or a high flow nasal cannula will be used. The person will have ongoing monitoring to make sure they are okay.

Sometimes the tube will be removed if it is known that the person is dying. This is to done to give the person dignity during this difficult time. If somebody in ICU dies and a coroner’s case arises, the airway must remain in.

What are the risks?

It is uncommon to have problems, but some people might have difficulty breathing once they are extubated. This can happen for many reasons, including airway swelling, weakness of breathing muscles and lung infection. If this happens, most people will be able to breathe properly again with treatment. Some might need non-invasive ventilation. A few people will need an endotracheal tube re-inserted and will need to be placed back on the ventilator (breathing machine).

After extubation, it is pretty common to have a sore throat and a harsh voice for a while. Lozenges can help with this.

Publication details

Breathing support, version 1, 2015. Kaye Rolls, CPO, ICCMU.

Disclaimer

The information on this page is general in nature and cannot reflect individual patient variation. It reflects Australian intensive care practice, which may differ from that in other countries. It is intended as a supplement to the more specific information provided by the doctors and nurses caring for your loved one. ICNSW attests to the accuracy of the information contained here but takes no responsibility for how it may apply to an individual patient. Please refer to the full disclaimer.