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Airway Complications ofIntubation

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Complications of MechanicalVentilation

•Complications related to Intubation

•Mechanical complications related to presenceof ETT

•Ventilator induced lung injury

•Complications related to Oxygen

•Infectious complications of mechanicalventilation

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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 intotrachea

•Fixed Unrecognizable glottis

•Too small glottis or sub-glotticdiamete

Vulnerability to complications

•Fixed Full stocmach

•Hypovolemia

•Hypotension

•Hypoxemia

•Hypercarbia

•Agitation

•Age and sex

•Trauma

•Endobronchialintubation

•Esophagealintubation

•Severe hypoxia

•Severe hypotension

•Death

Environment

•No skilled help

•No specialized equipments

•Missing of defectiveequipment

•Poor positioning

Difficult Intubation

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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 entrappedbetween the endotracheal tube and the lowerteeth

•Pressure ulcers to the palate and oropharynx

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SkinAvulsion

TongueInjury

Lip Injury

Periorbitalherpes

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Maxillary Sinus and Middle EarEffusion

•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 thembecome infected

•Hearing impairment that may contributes tothe confusion and delirium in elderlypopulation

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Laryngeal Injuries

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

•Erosive ulcers of vocal cords (posteriorcommissures)

•Swelling and edema of the vocal cords

•Granulomas (7% in patients intubated for 4days or more)

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Vocal CordsUlcers

Granulomas

Vocal CordHematoma

Vocal CordEdema

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Pharyngo-laryngeal Dysfunction

•Post-extubation discomfort (40% regardless of theduration)

•Hoarsness : edema, injury, disarticulate

–52% in short-term intubation

–70% in patients with prolonged intubation

•Slowing of the reflex swallowing mechanism and riskof aspiration

–15.8% of patients who were intubated more than 4 days didnot have a gag reflex

•Silent aspiration: Ventilator Associated Pneumonia

–20% in young population

–36% in older population

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Tracheal Injuries

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http://www.hospitech.co.il/images/under-inflated_cuff.jpg

•Cuff pressure related tracheal mucosa ischemia

•Cuff pressure tracheal damage: tracheal ulceration, edema andsub-mucosal hemorrhage

•Tracheal dilatation: tracheomalacia

•Tracheal stenosis:

–At the site of the cuff (50%)

–At the site of the tracheostomy (35%)

–Unclear (15%)

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TrachealStenosis

Glottic Stenosis

GranulomaandUlceration

Tracheomalacia

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Unplanned Extubation

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

•Longer ICU and hospital stay

•Increased ICU and hospital mortality

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