Complications of endotracheal intubation

Dr. S. Parthasarathy MD., DA., DNB, MD (Acu),

Dip. Diab.DCA, Dip. Software statistics, Phd (physio)

Mahatma Gandhi Medical college and research institute , puducherry , India

The procedure has inherent problems

•

Intubation is life saving

Complications

• Immediate • Delayed

• Immediate or in between

• Physical or physiological

Some are inseparable

• The number one and the most dangerous

Esophageal intubation

• How to know it ?? • Sighting • Feel of the bag • Auscultation • Chest expansion • No borborygmi on epigastric auscultation • Moisture

Steps to check

• Sternal pressure – escape of gases • Chest Xray • Cuff palpation at suprasternal notch • Spontaneous – reservoir bag moves.• Fibreoptic • Ultrasound • The gold standard is capnography

Sometimes it happens in esophageal intubation

The incidence of inadvertent esophageal tube placement was found to be 5.4%

“when in doubt, take it out”

Failed endotracheal intubation

• 1 in 250 cases in one study

• More in obstetrics

• Details ??

Endobronchial – 3. 7 %

• Emergency • Laparoscopy • Position change • Types of tubes • when the chin is depressed, the tube tip will

move downwards and when the chin is lifted, the tube tip will move upwards.

Endobronchial intubation

• Ideally, ETT tip position should be below the interclavicular line and approximately 2 cm above the carina. This allows for tube tip movement when the neck is moved:

Endobronchial capnograph !!

• Clinical • Bronchoscope • Xray • Capnography

Physiological

• Tracheal intubation causes a reflex increase in sympathetic activity that may result in hypertension, tachycardia and arrhythmia

• Factors • 25 % rise possible • Drugs • Few seconds --- 1 minute --- 5 minutes

Percentage increase in IOP

Intracranial pressure

• Increases

• But ?? Significance with adequate drugs

• Don’t allow to cough after intubation

Bronchospasm

• A tube can stimulate a reflex

• Asthmatics

• H/O LRTI , light anaesthesia

• Tight bag – other causes

Water vapour

• The ETT bypasses the humidifying mechanisms in the nose and upper trachea.

• Inadequate humidification leads to drying of

secretions, depressed ciliary motility and impaired

mucous clearance

• Prone for infections

Trauma86% of patients had occult or

visible blood after extubation

Factors

• Experience or skill • Repeated • Difficult airway • Tube size • Use of stylets – going beyond • Be gentle

Trauma

• Lips. teeth • Dentures• Cornea • Pharynx • Tongue • Epistaxis • Adenoidectomy • Arytenoid injuries • TM joint

airway injuries- incidence

• airway injuries accounted for 6%. • The most frequent sites of injury were larynx

(33%), pharynx (19%), and oesophagus (18%). • Tracheal and oesophageal injuries were more

frequent with difficult intubation• Difficult intubation, age older than 60 yr and

female gender were associated with claims for pharyngo-oesophageal perforation.- mediastinitis, sepsis –

pnemothorax and emphysema

Possible sites

Arytenoid injuries

• May occur during passage of an ETT

• Left arytenoid is usually affected since intubation occurs from right side of mouth

• Patient will complain of hoarseness, throat discomfort, odynophagia, and cough

• Microlaryngoscopy and closed reduction should be performed early

Dental injury• Incidence of dental injury ranges from 1:150 to

1:1000,

• The upper incisors are usually involved.

• Risk factors include preexisting poor dentition

• difficult laryngoscopy and intubation.

• When dental trauma occurs, the loose tooth should

be recovered so that aspiration of tooth does not

occur.

Airway foreign bodies

• Teeth • Laryngoscope bulbs• Tip of stylets

Edema and granulation

The incidence varies from 1: 800 to 1: 20000.

• Flaps of granulation tissue

– Can move with inspiration/expiration

– Inspiratory stridor

– Not recommended to excise both sides

– Most cases will resolve without any

intervention once ETT is removed

Fibrous nodule

Granuloma can transform into nodule in months

Subglottic edema

• Subglottic edema and stenosis • Children • Stridor

Intra op obstruction

• 1.Biting of the ETT.• 2. Kinking of the ETT.• 3. Obstruction by material in the lumen of the

tube. • This includes inspissated secretions, blood

clots, nasal turbinates, adenoids or a variety of foreign bodies.

Intra op obstruction

• Defective spiral tubes.

• Impaction of the tip of the tube against the tracheal

wall.

• Herniation of the cuff over the lumen of the tube.

• Compression of the lumen of the tube by the cuff

may be caused by over inflation of the cuff.

Obstruction

Trachea is deformed

Kink

Eccentric inflation of the cuff

Some treatment options

• Passing a fiberscope down the tube may facilitate diagnosis.

• Altering the patient's head position or deflation of the cuff may

relieve the obstruction. examination with a gloved finger or by

direct vision using a laryngoscope.

• Passing a suction catheter or stylet down the tube may be helpful.

• Digital pressure at the site of the kink may relieve the obstruction.

• A kink in a small tube can sometimes be remedied by placing a

larger tube over the small tube

Swallow the tube

• There are a number of case reports of a tracheal tube being lost in the esophagus, usually during newborn resuscitation

• Rarely in adults also

Tube catches fire

• When a fire in the airway occurs, the flow of

oxygen must be immediately stopped,

• saline poured on the ETT

• trachea extubated.

• Surgery is stopped, the trachea is reintubated

and the patient given humidified oxygen

Leak

• Cuff OK • Macgill • Position of cuff • Inflation system ?? • Biting • Laser beam

When it leaks ?? • Use pharyngeal packing to control the leak.

• increase the fresh gas flow

• Fill the cuff with a mixture of lidocaine and saline

• Attach a mechanism for maintaining a continuous gas

infusion into the inflation tube.

• Place a supraglottic device such as an LMA over the tube,

and seal the proximal end

• Replace the tracheal tube.-- tube exchanger.

Unintended Extubation

• Nightmare • Ryles tube, adhesive, position change, cuff

position, connectors • Prevention

• LMA in lateral position

Infection

• A high incidence of sinusitis and otitis during and following nasotracheal intubation

• During long-term intubation, • nosocomial sinusitis and pneumonia – same between

oral and nasal intubation

• Laryngitis , tracheitis have been reported

Postoperative Sore Throat

• Females • Large tubes • Prone position • Long duration• Sore throat is a minor

side effect that should resolve within 72 hours

• Inhalational steroid • gargling with sodium

azulene sulfonate • Inflate the cuff with

NS lignocaine • Less cuff pressure

Temporary hoarseness ---may persist for more than 1 week ??

British Journal of Anaesthesia 103 (3): 452–5 (2009)

• Hoarseness was observed in 49% of patients on the day of surgery

• 29%, 11%, and 0.8% on 1, 3, and 7 postoperative days, respectively

Neurological • Trigeminal, lingual, buccal, and hypoglossal nerve

palsies have been reported following short-term

intubation

• Vocal cord paralysis and paresis have been reported

after tracheal intubation despite the intubation being

atraumatic and the site of the surgery remote from

the head and neck

• Recurrent nerve injury can be prevented by avoidance

of overinflation of the ETT cuff

Vocal cord paralysis

• 24 out of 31247 patients reported vocal cord paralysis.

• 0.077 % incidence

• Nerve damage and microcirculatory defect

• 70 years, diabetes , > 3 hours duration

Posterior glottic stenosis • Forms when scar contracts after wide ulceration with no intact

median strip of mucosa

• Vocal cords unable to abduct

• Glottis remains partly closed

• Inspiratory stridor

• Voice is usually unaffected

• Treatment:

• deep vertical division with laser or 11 blade down to level

of cricoid

Posterior glottic stenosis

Pressure injuries

• The microcirculation of the mucosa and muco perichondrium is interrupted when pressure from the ETT exceeds capillary pressure

• Ischemia → Necrosis → Edema, → Hyperemia, → Ulceration, → Erosion

Pressure problem

Sites

Factors • Extrinsic factors– Diameter of ETT– Duration of intubation– Traumatic or multiple intubations

• Patient factors– Poor tissue perfusion (i.e. sepsis, organ failure, etc)– Abnormal larynx– Wound healing, keloid

• Movement– During ventilator use– During suctioning– During coughing– During transport

Long term problems

• Tracheomalacia• Tracheomalacia is a process characterized by flaccidity of the

supporting tracheal cartilage, widening of the posterior

membranous wall, and reduced anterior-posterior airway

caliber. cause tracheal collapse, especially during times of

increased airflow, such as coughing, crying, or feeding

Tracheal stenosis

• Tracheal stenosis following prolonged intubation is a relatively rare but a serious problem

• Ischemia → necrosis of mucosa → continued Ischemia → tracheal ring destruction with fibrosis → Tracheal stenosis

• Beware 25 mm Hg• balloon bronchoplasty.

Summary

Summary

Summary

• Thank you all