laryngotracheal complications of intubation...case - history •urgent aortic valve replacement and...
TRANSCRIPT
Laryngotracheal
Complications of
Intubation
Samuel A. Schechtman, MD
Clinical Assistant Professor of Anesthesiology
Director of Head and Neck Anesthesiology &
Airway Management
Disclosure Statement
NONE
Learning Objectives
• Laryngotracheal injuries following
intubation
• Anesthetic management
• Surgical treatment
• Tracheostomy and airway safety
practices
Lecture OutlineI. Case presentation
II. Background
III. Treatment of laryngotracheal
complications
• Posterior glottic stenosis
IV. Considerations post tracheostomy
Procedural ComplicationsI. Intubation
– Acute
• Nasal complications
• Oral cavity and oropharynx
• Laryngeal: mucosal injury, arytenoid subluxation/dislocation
– Chronic
• Laryngotracheal stenosis: glottic / posterior glottic, subglottic
• Vocal process granuloma
• Tracheal
II. Videolaryngoscopy
III. Airway exchange catheters
Uncommon Complications
From: Horellou MF, Mathe D, Feiss P: A hazard of
naso-tracheal intubation. Anaesthesia 33:73, 1978.
Case Presentation
• 59 yo ASA III, male with posterior
glottic stenosis (PGS) presenting for:
• Elective awake tracheostomy
• Microdirect laryngoscopy
• CO2 laser excision
• Steroid injection
• Mitomycin C application
Case - History• Urgent aortic valve replacement and mitral valve
repair 1 year prior
• Complicated post op course: 3 weeks of
endotracheal intubation
• Presented several months later with dysphonia,
dyspnea, & stridor
• Diagnosed with posterior glottic
stenosis (PGS)
Laryngeal Videostroboscopy
Posterior
Anterior
History of Laryngotracheal
Stenosis• 1858-1900: laryngotracheal stenosis associated with croup,
diphtheria, syphilis, leprosy, smallpox, measles, pertussis,
& blastomycosis
• 1900s: trauma to trachea and larynx identified as a
common cause
• 1900-1920s: Jackson associated stenosis with emergent
tracheotomies
• 1940s: Endotracheal intubation became most common
cause
Lefferts, 1890:
“The management of chronic
laryngeal stenosis, so varying in
it’s nature and indications for
treatment, will always require
patience, perseverance and
ingenuity”
Weiser et al. 2008.
• Estimated 234.2 million surgeries each year
worldwide
• Countries spending < US $100 per person on health
care: 295 per 100,000
• Those spending > US $1,000: 11,110 per 100,000
• Estimated > 30 million surgeries per year in the U.S.
Intubation Injury: Epidemiology
Domino et al. 1999.
• ASA Closed Claims database
– 1961-1996:
– 4460 claims
– 6% for airway injury (n=266)
– Most frequent sites of injury:
• Larynx (33%)
• Pharynx (19%)
• Esophagus (18%)
• Trachea (15%)
– Laryngeal injury (n=87)
• Vocal fold paralysis (n=30, 34%)
• Granuloma (n=15, 17%)
• Cricoarytenoid dislocation (n=7, 8%)
• Hematoma (n=3, 3%)
– Tracheal injury (n=39)
• Surgical tracheotomy (n=25, 64%)
• Tracheal perforation (n=13, 33%)
• Infection (n=1, 3%)
• 21 of 25 tracheostomies were emergent
4 for subglottic or tracheal stenosis
Epidemiology• Injuries to TMJ & larynx routine
intubation
• Injuries to the esophagus were more
severe
• Pharyngoesophageal perforation with:
- Difficult intubation
- Age > 60
- Female gender
Epidemiology
• “80% of laryngeal claims were
associated with routine (non-difficult)
tracheal intubation”
• “Most (85%) of laryngeal injuries
were associated with short-term
tracheal intubation”
Hua et al. 2012.
• American College of Surgeons National
Surgical Quality Improvement Program
(NSQIP) database
• 563,190 patients included (n = 1202 injured,
0.20%)
• Lip laceration / hematoma (61.4%)
• Tooth injury (26.1%)
• Tongue laceration (5.7%)
• Pharyngeal laceration (4.7%)
• Laryngeal laceration (2.1%)
• Increased risk with Mallampati III and
Mallampati IV
• Increased risk in patients > 80 years
• 1 in 500 for patients undergoing
major surgery
• 4.9 cases per million per year
using greater London population
Nouraei et al. 2007
• Retrospective cohort: Johns Hopkins University 34
patients
• Mean cost $4,080.09 annually
• Intubation-related stenosis significantly greater cost
- $5,286.56 intubation related
- $2,873.62 idiopathic
Yin et al. 2018.
Greer et al. 2016.
2018. Annals of Otology, Rhinology, and
Laryngology.
Factors in Intubation Injury
• Abnormal larynx
• Emergency intubation
• Impairment of mucocilliary clearing
• Gastric aspiration
• Bacterial infection
• Acute or chronic disease states
• Duration of intubation
• Endotracheal tube size
• Endotracheal tube cuff pressure
Specific Injuries
• Tongues of granulation tissue
• Ulcerated troughs
• Healed furrows
• Healed fibrous nodule
• Intubation granuloma
• Interarytenoid adhesion
• Posterior glottic stenosis
• Subglottic stenosis
• Ductal retention cysts
• Vocal fold paralysis
• Arytenoid dislocation
Mulholland MW, Doherty GM, Hogikyan ND, Fung K. "Complications of
Intubation, Tracheotomy, and Tracheal Surgery". In: Complications in
surgery. Philadelphia: Lippincott Williams & Wilkins; 2006.
Keys to Prevention
• Endotracheal tube (ETT) choice
• Treatment of reflux
• Minimize secretions
• Antibiotic treatment with
tracheostomy
• Minimize intubation time
• Manage comorbidities
Prevention (back to basics)• Monitor ETT cuff pressures
• Caution with blind procedures (AFOI, AECs) –
McLean et al. 2013.
• Optimize intubating conditions
• Neuromuscular blockade (Pacheco-Lopez et
al. 2014)
• Positioning
• Lubricated ETT
Laryngotracheal Anatomy
• Larynx - vital component of respiratory system
– Swallowing
– Breathing coordination
– Intrathoracic pressure regulation
– Vocalization
• Laryngotracheal stenosis
– Anterior or posterior glottic stenosis (PGS)
– Subglottic stenosis or tracheal stenosis
(SGS/TS)
Anatomy of posterior glottis
• Posterior 1/3 of vocal folds
• Posterior commissure and
interarytenoid muscle
• Cricoid lamina
• Cricoarytenoid joints
• Arytenoids
• Overlying mucosae
Posterior glottis susceptibility• Anatomy
– Posterior & subglottis: respiratory vs
squamous epithelium
• ETTs displaced by base of tongue onto
posterior glottis
• Proliferative fibrotic process
• Arytenoid contracture, possible ankylosis
Impairment of glottic airflow
Perfectly positioned ETT
Right in the posterior glottis
PGS: Development
Initial mucosal ulceration and inflammation (A)
Posterior laryngeal granulation tissue (B)
Contracts the arytenoids forcing the vocal folds into a
bilateral midline position (C)
From Hillel et al. 2016
Posterior Glottic Stenosis
Posterior vocal folds
Vocal processes of the arytenoids
Interarytenoid region
Cricoarytenoid Joints
- Mulholland MW, Doherty GM, Hogikyan ND, Fung K. "Complications of Intubation, Tracheotomy, and Tracheal
Surgery". In: Complications in surgery. Philadelphia: Lippincott Williams & Wilkins; 2006.
- Bogdasarian RS, Olson NR. Posterior glottic laryngeal stenosis. Otolaryngol Head Neck Surg 1980;88:765–
772.
- Dedo HH, Sooy CD. Endoscopic laser repair of posterior glottic, subglottic and tracheal stenosis by division or
micro-trapdoor flap. Laryngoscope. 1984 Apr;94(4):445-50.
SGS & PGS – Location Matters
Hatcher et al. 2015.
Surgical Management Goals
• Balance airway & voice
• ↑Airway → ↓voice
• Tracheostomy placement may
be best
• No surgery can correct fixed
cricoarytenoid joints
• PGS can permanently alter QOL
Hatcher et al. 2015.
PGS: Risk Factors
• 28 PGS patients (14 ♂, 14 ♀) ≥ 24hrs intubated in
ICU
• PGS risk factors included:
- Ischemic condition (374% ↑ OR)
- Diabetes (888% ↑ OR)
- Length of intubation (21% ↑ OR/day)
- ETT (≥ 8)Hillel et al. 2016.
Posterior Glottic Stenosis
• As high as 14% in patients intubated > 10 days
• Increased risk:
- Traumatic intubation
- Prolonged intubation
- Multiple management maneuvers - motion
- Large ETT size
- Local infection
• Can present with co-existing subglottic
stenosis
Other Etiologies of PGS
• Radiation
• Autoimmune disease
• External laryngeal trauma
• Caustic ingestion
PGS: Typical Presentation
• Complex patient & prolonged intubation
• Progressive dyspnea and noisy
breathing
• May be mistaken as COPD or asthma
• Inspiratory vs biphasic stridor- Mulholland MW, Doherty GM, Hogikyan ND, Fung K. "Complications of Intubation, Tracheotomy, and Tracheal Surgery".
In: Complications in surgery. Philadelphia: Lippincott Williams & Wilkins; 2006.
- Bogdasarian RS, Olson NR. Posterior glottic laryngeal stenosis. Otolaryngol Head Neck Surg 1980;88:765–772.
Cummings
- Dedo HH, Sooy CD. Endoscopic laser repair of posterior glottic, subglottic and tracheal stenosis by division or micro-
trapdoor flap. Laryngoscope. 1984 Apr;94(4):445-50.
Flexible Laryngoscopy - PGS
- Mulholland MW, Doherty GM, Hogikyan ND, Fung K. "Complications of Intubation, Tracheotomy, and Tracheal Surgery". In: Complications in
surgery. Philadelphia: Lippincott Williams & Wilkins; 2006.
- Flint PW, Cummings CW. Cummings otolaryngology: head and neck surgery. Philadelphia, PA: Elsevier, Saunders; 2015.
- Bogdasarian RS, Olson NR. Posterior glottic laryngeal stenosis. Otolaryngol Head Neck Surg 1980;88:765–772.
I: Vocal Process
Adhesion
II. Posterior
Commissure or
interarytenoid scar
III: Unilateral CA fixation IV: Bilateral CA fixation
Bogdasarian Grades of PGS
May mimic bilateral true vocal fold
paralysis, depending on degree of
CA joint fixation
Surgical Management
of Posterior Glottic
Stenosis
Preoperative Evaluation
• Subjective/objective impairment
• Goals of preoperative examination:
– Anatomic location(s)
– Dimensions
– Quality
– Vocal fold / cricoarytenoid joint mobility
- Mulholland MW, Doherty GM, Hogikyan ND, Fung K. "Complications of Intubation,
Tracheotomy, and Tracheal Surgery". In: Complications in surgery. Philadelphia:
Lippincott Williams & Wilkins; 2006.
- Flint PW, Cummings CW. Cummings otolaryngology: head and neck surgery.
Philadelphia, PA: Elsevier, Saunders; 2015.
Evaluation• Indirect laryngotracheoscopy/stroboscopy
• Direct laryngoscopy
• Laryngeal EMG
- Equivocal cases VF motion impairment
• CT Scan with 2 mm cuts +/- 3D renderings
- Mulholland MW, Doherty GM, Hogikyan ND, Fung K. "Complications of Intubation,
Tracheotomy, and Tracheal Surgery". In: Complications in surgery. Philadelphia:
Lippincott Williams & Wilkins; 2006.
- Flint PW, Cummings CW. Cummings otolaryngology: head and neck surgery.
Philadelphia, PA: Elsevier, Saunders; 2015.
Surgical Management• Elective: Non-critical lesions
• Urgent: Acute distress
SECURE AIRWAY
– Temporizing measures
• Elevate head of bed
• Cool humidified air
• Racemic epinephrine
• Corticosteroids
• Heliox
Mulholland MW, Doherty GM, Hogikyan ND, Fung K. "Complications of Intubation,
Tracheotomy, and Tracheal Surgery". In: Complications in surgery. Philadelphia:
Lippincott Williams & Wilkins; 2006.
Goals of Definitive Operations • Establish SAFE airway
• Eventual decannulation with
tracheostomy
• Preserve other laryngeal functions – Airway protection
– Phonation
– Swallowing- Mulholland MW, Doherty GM, Hogikyan ND, Fung K. "Complications of Intubation,
Tracheotomy, and Tracheal Surgery". In: Complications in surgery. Philadelphia:
Lippincott Williams & Wilkins; 2006.
- Flint PW, Cummings CW. Cummings otolaryngology: head and neck surgery.
Philadelphia, PA: Elsevier, Saunders; 2015.
PGS: Surgical Management
• Difficult to manage
• Success difficult to predict
• No definitive therapy for
cricoarytenoid mobility after
fixation
Surgical Techniques
• Endoscopic laser excision and
adjuncts
• Posterior cricoid split with cartilage
grafting
– Open
– Endoscopic
• Arytenoidectomy for grade IV
CO2 Laser Excision• CO2 laser excision of synechiae/scar tissue
• Injection of Kenalog and topical mitomycin application
Meyer TK, Wolf J. Lysis of interarytenoid synechia (Type I Posterior Glottic Stenosis): vocal fold
mobility and airway results. Laryngoscope. 2011 Oct;121(10):2165-71.
Suspension Laryngoscopy
• May be difficult without
tracheostomy
• University of Michigan:
– High frequency high pressure jet
ventilation without tracheostomy
– Low threshold for tracheostomy
Flint PW, Cummings CW. Cummings otolaryngology: head and neck surgery.
Philadelphia, PA: Elsevier, Saunders; 2015.
Anesthetic Considerations
• Preoperative evaluation
• Awake tracheostomy is common
• Shared, unprotected airway
• Bed 90 degrees
• Total intravenous anesthesia with NMB
• COMMUNICATION AND TEAMWORK
From Abdelmalak B and Doyle JD (Eds). 2013.
Anesthetic Management: Ventilation Methods
High Frequency Jet
Ventilation (HFJV)
High Frequency Jet
Ventilation (HFJV)
Supraglottic Jet Ventilation
Subglottic Jet Ventilation
Microlaryngeal ETT &
Intermittent Apnea
• Adequate oxygenation/ventilation in
1512
• 623 ABGs
• Mean PaO2 133.8 mmHg
• Mean PaCO2 of 42.3 mmHg
• No barotrauma
• 312 laser treatment – no complication
Rezaie-Majd et al. 2006.
Knights et al. 2013.
Philips et al. 2018
• 46 patients - 70 procedures
• 29 obese
• Jet ventilation successful in 28/29 of obese cases
• No significant differences in chest rise, need for
intubation, and length of surgery or ventilation
A New Use for an Old
Technology
Transnasal Humidified Rapid
Insufflation Ventilatory
Exchange (THRIVE)
T - Tube
Accessed On-Line:
https://www.intechopen.com/books/en
doscopy/endoscopy-of-larynx-and-
trachea-with-rigid-laryngo-
tracheoscopes-under-superimposed-
high-frequency-j
Accessed On-Line:
https://www.bosmed.com/safe-t-
tubestm.html
Dhillon et al. 2018.
• Maintain airway clearance and support tracheal wall
• 13 patients with laryngotracheal stenosis and
aphonia/dysphonia
• Significant improvement in VRQOL after T tube placement
• Most common complication: granulation tissue
T - Tube Management
• Under GA
- Remove and an armored ETT placed
- Small 4.0 ETT placed through T - tube
- Connector from ETT fit into end of T - tube
• If ETT through T - tube, must be directed
downward
• Manipulations WITH surgical service
T – Tube Removal
• Clamp with a hemostat - pull with firm
pressure
• Only replaced with DL & bronchoscopy
• Standard tracheostomy tube used
temporarily
PGS Highlights
• Common and costly
• Complication of airway management
• Difficult to diagnose
• Challenging to treat
System Based Practices
McGrath et al. 2012.
National Tracheostomy Safety
Project (NTSP)• Several airway management specialties & governing
societies
• In England in 2009-2010:
- 5700 surgical tracheostomies
- 5000-8000 percutaneous tracheostomies
- 570 laryngectomies
• Guidelines developed for tracheostomy-related
emergencies:– Training
– Distinct bedside signs and algorithms
– Emergency equipment
Specialized Airway Algorithms
Tracheostomy Laryngectomy
NTSP
National Tracheostomy Safety Project – Accessed On-Line:
http://tracheostomy.org.uk/http://tracheostomy.org.uk/
Michigan Medicine MiChart
Difficult Airway Navigator
Summary
Intubation NOT WITHOUT RISK
Anesthetic considerations for
management of laryngotracheal
complications
Importance of airway risk assessment
and planning
Team communication
Optimizing safe airway
management
THANK YOU
????
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