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

Competence Confidence 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

Skin Avulsion Tongue Injury Lip Injury Periorbital herpes

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)

Vocal Cords Ulcers Granulomas Vocal Cord Hematoma Vocal Cord Edema

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%)

Tracheal Stenosis Glottic Stenosis Granuloma and Ulceration Tracheomalacia

Unplanned Extubation Self extubation (8%) and accidental extubation (1%) Longer ICU and hospital stay Increased ICU and hospital mortality

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