1. Complications of endotracheal intubation Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab.DCA, Dip. Software statistics, Phd (physio) Mahatma Gandhi Medical college and research institute, puducherry, India

2. The procedure has inherent problems Intubation is life saving

3. Complications Immediate Delayed Immediate or in between Physical or physiological

4. Some are inseparable

5. The number one and the most dangerous

6. Esophageal intubation How to know it ?? Sighting Feel of the bag Auscultation Chest expansion No borborygmi on epigastric auscultation Moisture

7. Steps to check Sternal pressure – escape of gases Chest Xray Cuff palpation at suprasternal notch Spontaneous – reservoir bag moves. Fibreoptic Ultrasound The gold standard is capnography

9. Sometimes it happens in esophageal intubation

10. The incidence of inadvertent esophageal tube placement was found to be 5.4%

11. “when in doubt, take it out”

12. Failed endotracheal intubation 1 in 250 cases in one study More in obstetrics Details ??

13. Endobronchial – 3. 7 % Emergency Laparoscopy Position change Types of tubes when the chin is depressed, the tube tip will move downwards and when the chin is lifted, the tube tip will move upwards.

14. Endobronchial intubation Ideally, ETT tip position should be below the interclavicular line and approximately 2 cm above the carina. This allows for tube tip movement when the neck is moved:

15. Endobronchial capnograph !! Clinical Bronchoscope Xray Capnography

16. Physiological Tracheal intubation causes a reflex increase in sympathetic activity that may result in hypertension, tachycardia and arrhythmia Factors 25 % rise possible Drugs Few seconds --- 1 minute --- 5 minutes

17. Percentage increase in IOP

18. Intracranial pressure Increases But ?? Significance with adequate drugs Don’t allow to cough after intubation

19. Bronchospasm A tube can stimulate a reflex Asthmatics H/O LRTI, light anaesthesia Tight bag – other causes

20. Water vapour The ETT bypasses the humidifying mechanisms in the nose and upper trachea. Inadequate humidification leads to drying of secretions, depressed ciliary motility and impaired mucous clearance Prone for infections

21. Trauma 86% of patients had occult or visible blood after extubation

22. Factors Experience or skill Repeated Difficult airway Tube size Use of stylets – going beyond Be gentle

23. Trauma Lips. teeth Dentures Cornea Pharynx Tongue Epistaxis Adenoidectomy Arytenoid injuries TM joint

24. airway injuries- incidence airway injuries accounted for 6%. The most frequent sites of injury were larynx (33%), pharynx (19%), and oesophagus (18%). Tracheal and oesophageal injuries were more frequent with difficult intubation Difficult intubation, age older than 60 yr and female gender were associated with claims for pharyngo-oesophageal perforation.- mediastinitis, sepsis – pnemothorax and emphysema

25. Possible sites

26. Arytenoid injuries May occur during passage of an ETT Left arytenoid is usually affected since intubation occurs from right side of mouth Patient will complain of hoarseness, throat discomfort, odynophagia, and cough Microlaryngoscopy and closed reduction should be performed early

27. Dental injury Incidence of dental injury ranges from 1:150 to 1:1000, The upper incisors are usually involved. Risk factors include preexisting poor dentition difficult laryngoscopy and intubation. When dental trauma occurs, the loose tooth should be recovered so that aspiration of tooth does not occur.

28. Airway foreign bodies Teeth Laryngoscope bulbs Tip of stylets

29. Edema and granulation

30. The incidence varies from 1: 800 to 1: 20000. Flaps of granulation tissue – Can move with inspiration/expiration – Inspiratory stridor – Not recommended to excise both sides – Most cases will resolve without any intervention once ETT is removed

31. Fibrous nodule Granuloma can transform into nodule in months

32. Subglottic edema Subglottic edema and stenosis Children Stridor

33. Intra op obstruction 1.Biting of the ETT. 2. Kinking of the ETT. 3. Obstruction by material in the lumen of the tube. This includes inspissated secretions, blood clots, nasal turbinates, adenoids or a variety of foreign bodies.

34. Intra op obstruction Defective spiral tubes. Impaction of the tip of the tube against the tracheal wall. Herniation of the cuff over the lumen of the tube. Compression of the lumen of the tube by the cuff may be caused by over inflation of the cuff.

35. Obstruction

36. Trachea is deformed

37. Kink

38. Eccentric inflation of the cuff

39. Some treatment options Passing a fiberscope down the tube may facilitate diagnosis. Altering the patient's head position or deflation of the cuff may relieve the obstruction. examination with a gloved finger or by direct vision using a laryngoscope. Passing a suction catheter or stylet down the tube may be helpful. Digital pressure at the site of the kink may relieve the obstruction. A kink in a small tube can sometimes be remedied by placing a larger tube over the small tube

40. Swallow the tube There are a number of case reports of a tracheal tube being lost in the esophagus, usually during newborn resuscitation Rarely in adults also

41. Tube catches fire When a fire in the airway occurs, the flow of oxygen must be immediately stopped, saline poured on the ETT trachea extubated. Surgery is stopped, the trachea is reintubated and the patient given humidified oxygen

42. Leak Cuff OK Macgill Position of cuff Inflation system ?? Biting Laser beam

43. When it leaks ?? Use pharyngeal packing to control the leak. increase the fresh gas flow Fill the cuff with a mixture of lidocaine and saline Attach a mechanism for maintaining a continuous gas infusion into the inflation tube. Place a supraglottic device such as an LMA over the tube, and seal the proximal end Replace the tracheal tube.-- tube exchanger.

44. Unintended Extubation Nightmare Ryles tube, adhesive, position change, cuff position, connectors Prevention LMA in lateral position

45. Infection A high incidence of sinusitis and otitis during and following nasotracheal intubation During long-term intubation, nosocomial sinusitis and pneumonia – same between oral and nasal intubation Laryngitis, tracheitis have been reported

46. Postoperative Sore Throat Females Large tubes Prone position Long duration Sore throat is a minor side effect that should resolve within 72 hours Inhalational steroid gargling with sodium azulene sulfonate Inflate the cuff with NS lignocaine Less cuff pressure Temporary hoarseness ---may persist for more than 1 week ??

47. British Journal of Anaesthesia 103 (3): 452–5 (2009) Hoarseness was observed in 49% of patients on the day of surgery 29%, 11%, and 0.8% on 1, 3, and 7 postoperative days, respectively

48. Neurological Trigeminal, lingual, buccal, and hypoglossal nerve palsies have been reported following short-term intubation Vocal cord paralysis and paresis have been reported after tracheal intubation despite the intubation being atraumatic and the site of the surgery remote from the head and neck Recurrent nerve injury can be prevented by avoidance of overinflation of the ETT cuff

49. Vocal cord paralysis 24 out of 31247 patients reported vocal cord paralysis. 0.077 % incidence Nerve damage and microcirculatory defect 70 years, diabetes, > 3 hours duration

50. Posterior glottic stenosis Forms when scar contracts after wide ulceration with no intact median strip of mucosa Vocal cords unable to abduct Glottis remains partly closed Inspiratory stridor Voice is usually unaffected Treatment: deep vertical division with laser or 11 blade down to level of cricoid

51. Posterior glottic stenosis

52. Pressure injuries The microcirculation of the mucosa and muco perichondrium is interrupted when pressure from the ETT exceeds capillary pressure Ischemia → Necrosis → Edema, → Hyperemia, → Ulceration, → Erosion

53. Pressure problem

54. Sites

55. Factors Extrinsic factors – Diameter of ETT – Duration of intubation – Traumatic or multiple intubations Patient factors – Poor tissue perfusion (i.e. sepsis, organ failure, etc) – Abnormal larynx – Wound healing, keloid Movement – During ventilator use – During suctioning – During coughing – During transport

56. Long term problems Tracheomalacia Tracheomalacia is a process characterized by flaccidity of the supporting tracheal cartilage, widening of the posterior membranous wall, and reduced anterior-posterior airway caliber. cause tracheal collapse, especially during times of increased airflow, such as coughing, crying, or feeding

57. Tracheal stenosis Tracheal stenosis following prolonged intubation is a relatively rare but a serious problem Ischemia → necrosis of mucosa → continued Ischemia → tracheal ring destruction with fibrosis → Tracheal stenosis Beware 25 mm Hg balloon bronchoplasty.

58. Summary

62. Thank you all