DOI: http://dx.doi.org/10.18203/issn.2454-5929.ijohns20210163

A clinical study on laryngotracheal injuries following endotracheal intubation

Raveendra P. Gadag, Nidhi Mohan Sreedevi, Nikhila Kizhakkilott, Vijayalakshmi Muthuraj, Prajwal S. Dange, Manjunath Dandinarasaiah

Abstract


Background: Despite major advances in the design of endotracheal tubes and developments in the management of difficult airways, endotracheal intubation remains by far the most common cause of laryngotracheal injuries (LTI). These LTI are challenging to manage and are associated with significant morbidity and mortality. Hence, the present study was done to find out the incidence, types of LTI and to study the factors affecting the same.

Methods: A prospective study was conducted on patients who were intubated for more than 48 hours and admitted in medical intensive care units in a tertiary referral hospital, for a period of 1 year. All patients following extubation were evaluated for LTI by x-ray neck (antero-posterior and lateral view), rigid endoscopy and flexible naso-pharyngo-laryngoscopy.  

Results: Thirty patients were included in the study. Majority of the patients (56.6%) were found normal while 43.2% patients were having LTI following extubation in the form of bilateral vocal cord fixation, subglottic stenosis, granulation tissue in the posterior commissure and in the trachea. Majority of these patients were aged less than 45 years, with duration of intubation for more than 10 days, with tube size more than 7 mm. Organo-phosphourous (OP) poisoning was the etiology for LTI in 69.2% cases.

Conclusions: A high incidence of LTI especially in cases of OP poisoning warrants one to be cautious in managing these intubated patients. Those patients requiring prolonged intubation should be considered for other alternative airway managements like tracheostomy in addition to using low pressure, high volume cuffed tubes. Adequate training of the emergency personnel in the intubation technique and its subsequent care is important especially in a tertiary referral center.


Keywords


Endotracheal intubation, Flexible naso-pharyngo-laryngoscopy, Laryngotracheal injuries

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References


Sellery GR, Worth A, Greenway RE. Late complications of prolonged tracheal intubation. Canadian Anaesth Soc J. 1978;25:140-3.

Benjamin B. Prolonged intubation injuries of the larynx: endoscopic diagnosis, classification, and treatment. Ann Otol Rhinol Laryngol. 2018;127:492-507.

Rangachari V, Sundararajan I, Sumathi V, Kumar KK. Laryngeal sequelae following prolonged intubation: A prospective study. Indian J Crit Care Med. 2016:10.

Burns HP, Dayal VS, Scott A, van Nostrand AW, Bryce DP. Laryngotracheal trauma: observations on its pathogenesis and its prevention following prolonged orotracheal intubation in the adult. Laryngoscope. 1979;89:1316-25.

Sarafoleanu C. Laryngo-tracheal trauma. Problems in management. Pneumologia. 2005;54:119-22.

Weymuller EA Jr, Bishop MJ, Fink BR, Hibbard AW, Spelman FA. Quantification of intralaryngeal pressure exerted by endotracheal tubes. Ann Otol Rhinol Laryngol. 1983;92:444-7.

Steen JA, Lindholm CE, Brdlik GC, Foster CA. Tracheal tube forces on the posterior larynx: index of laryngeal loading. Crit Care Med. 1982;10:186-9.

Heidegger T, Starzyk L, Villiger C. Fiberoptic intubation and laryngeal morbidity: a randomized controlled trial. Anesthesiology. 2007;107:585-90.

Esteller-Moré E, Ibañez J, Matiñó E. Prognostic factors in laryngotracheal injury following intubation and/or tracheotomy in ICU patients. Eur Arch Otorhinolaryngol. 2005;262:880-3.

Frioui S, Khachnaoui F. Severe tracheal stenosis after prolonged intubation. Pan Afr Med J. 2017;28:247.

Greaney D, Russell J, Dawkins I, Healy M. A retrospective observational study of acquired subglottic stenosis using low-pressure, high-volume cuffed endotracheal tubes. Paediatr Anaesth. 2018;28:1136-41.

Deeb ZE, Williams JB, Campbell TE. Early diagnosis and treatment of laryngeal injuries from prolonged intubation in adults. Otolaryngol Head Neck Surg. 1999;120:25-9.

Walner D, Loewen M, Kimura R. Neonatal subglottic stenosis-incidence and trends. Laryngoscope. 2001;111:48-51.

Szigeti C, Baeuerle J, Mongan P. Arytenoid dislocation with lighted stylet intubation: case report and retrospective review. Anesth Analg. 1994;78:185-6.

Yamanaka H, Hayashi Y, Watanabe Y, Uematu H, Mashimo T. Prolonged hoarseness and arytenoid cartilage dislocation after tracheal intubation. Br J Anaesth. 2009;103:452-5.

Bishop MJ. Mechanisms of laryngotracheal injury following prolonged tracheal intubation. Chest. 1989; 96:185-6.

House CJ, Noordzij JP, Murgia B, Langmore S. Laryngeal injury from prolonged intubation: a prospective analysis of contributing factors. Laryngoscope. 2011;121:596-600.

Brodsky MB, Levy MJ, Jedlanek E, Pandian V, Blackford B, Price C, et al. Laryngeal injury and upper airway symptoms after oral endotracheal intubation with mechanical ventilation during critical care: a systematic review. Crit Care Med. 2018;46(12):2010-17.

Panda NK, Mann SB, Raja BA, Batra YK, Jindal SK. Fibreoptic assessment of post intubation laryngotracheal injuries. Indian J Chest Dis Allied Sci. 1996;38:241-7.

Mathew OP, Abu-Osba YK, Thach BT. Genioglossus muscle responses to upper airway pressure changes: afferent pathways. J Appl Physiol Respir Environ Exer Physiol. 1982;52:445-50.

Cavo JW Jr. True vocal cord paralysis following intubation. Laryngoscope. 1985;95:1352-9.

Colice GL. Resolution of laryngeal injury following translaryngeal intubation. Am Rev Respir Dis. 1992;145:361-4.

Kastanos N, Estopá Miró R, Marín Perez A, Xaubet Mir A, Agustí-Vidal A. Laryngotracheal injury due to endotracheal intubation: incidence, evolution, and predisposing factors. A prospective long-term study. Crit Care Med. 1983;11:362-7.

Hsu CL, Chen KY, Chang CH, Jerng JS, Yu CJ, Yang PC. Timing of tracheostomy as a determinant of weaning success in critically ill patients: a retrospective study. Crit Care. 2005;9:R46-52.

Ellis SF, Pollak AC, Hanson DG, Jiang JJ. Videolaryngoscopic evaluation of laryngeal intubation injury: incidence and predictive factors. Otolaryngol Head Neck Surg. 1996;114:729-31.

Jackson C. Contact ulcer granuloma and other laryngeal complications of endotracheal anesthesia. Anesthesiology. 1953;14:425-36.

Marston AP, White DR. Subglottic Stenosis. Clin Perinatol. 2018;45:787-804.

Kandakure VT, Mishra S, Lahane VJ. Management of post-traumatic laryngotracheal stenosis: our experience. Indian J Otolaryngol Head Neck Surg. 2015;67:255-60.

Schiff BA. The relationship between body mass, tracheal diameter, endotracheal tube size, and tracheal stenosis. Int Anesthesiol Clin. 2017;55:42-51.

Wackym P, Snow J. Ballenger’s Otorhinolary-ngology: Head and Neck surgery. USA: People’s Medical Publishing house; 2016.

Hawkins DB, Luxford M. Laryngeal stenosis from endotracheal intubation: a review of 58 cases. Ann Otol Rhinol Laryngol Suppl. 1980;80:454-8.

Whited RE. A prospective study of laryngotracheal sequelae in long-term intubation. Laryngoscope. 1984;94:367-77.

Papsidero H, Pashley N. Acquired stenosis of the upper airway in neonates. Ann Otol Rhinol Laryngol Suppl. 1980;89:512-4.

Hulse EJ, Haslam JD, Emmett SR, Woolley T. Organophosphorus nerve agent poisoning: managing the poisoned patient. Br J Anaesth. 2019;123:457-63.

Verma S, Smith M, Dailey S. Transnasal tracheoscopy. Laryngoscope. 2012;122:1326-30.