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

http://shanahq.com/

@SamSchechtman

@shanasociety

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

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

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–

- 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

• 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,

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,

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,

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.

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

• 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)

Fisher & Paykel Healthcare

Optiflow THRIVE

https://www.fphcare.com/

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

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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Laryngotracheal Complications of Intubation...Case - History •Urgent aortic valve replacement and...

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