Airway Complications of Intubation

Complications of Mechanical Ventilation

• Complications related to Intubation• Mechanical complications related to presence

of ETT• Ventilator induced lung injury• Complications related to Oxygen• Infectious complications of mechanical

ventilation

CompetenceConfidence

Unable to Open Mouth•Trismus•Small mouth•Peri-oral scarring•Fascial swealling

Unable to insert laryngoscope•Short neck•Large chest•Prominent upper incisors•Small mandible•Edema

Unable to see glottis•Fixed position of the head•Small jaw•Anterior larynx•Obstructed by blood or vomit

Unable to pass tube into trachea•Fixed Unrecognizable glottis•Too small glottis or sub-glottic diamete

Vulnerability to complications•Fixed Full stocmach•Hypovolemia•Hypotension•Hypoxemia•Hypercarbia•Agitation•Age and sex

•Trauma•Endobronchial intubation•Esophageal intubation•Severe hypoxia•Severe hypotension•Death

Environment•No skilled help•No specialized equipments•Missing of defective equipment•Poor positioning

Difficult Intubation

Injuries to Face, Lips and Oro-pharynx

• Trauma to the lips and cheeks from tube ties• Peri-oral herpes• Injuries to the tongue especially if entrapped

between the endotracheal tube and the lower teeth

• Pressure ulcers to the palate and oropharynx

Maxillary Sinus and Middle Ear Effusion

• Maxillary effusion – 20% in patients intubated for > 7 days.– 47% when the gastric tube is placed nasally– 95%

• Secondarily infected maxillary effusion (45-71% of effusions)

• Middle ear effusion (29%) with 22% of them become infected

• Hearing impairment that may contributes to the confusion and delirium in elderly population

Laryngeal Injuries

• Some degree of glottic injury is seen in 94% of patients intubated for 4 days or longer

• Erosive ulcers of vocal cords (posterior commissures)

• Swelling and edema of the vocal cords• Granulomas (7% in patients intubated for 4

days or more)

Pharyngo-laryngeal Dysfunction

• Post-extubation discomfort (40% regardless of the duration)• Hoarsness : edema, injury, disarticulate

– 52% in short-term intubation– 70% in patients with prolonged intubation

• Slowing of the reflex swallowing mechanism and risk of aspiration– 15.8% of patients who were intubated more than 4 days did not

have a gag reflex

• Silent aspiration: Ventilator Associated Pneumonia– 20% in young population– 36% in older population

Tracheal Injuries• Cuff pressure related tracheal mucosa ischemia• Cuff pressure tracheal damage: tracheal ulceration, edema and

sub-mucosal hemorrhage• Tracheal dilatation: tracheomalacia• Tracheal stenosis:

– At the site of the cuff (50%)– At the site of the tracheostomy (35%)– Unclear (15%)

Unplanned Extubation

• Self extubation (8%) and accidental extubation (1%)

• Longer ICU and hospital stay• Increased ICU and hospital mortality

THANK YOU

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