Virtual Disaster Medicine

Training Center (VDMTC)

Module 3

Complications of Managing the Airway

Complications with Infraglottic Procedures

Infraglottic airway access is the last step in the ASA airway management algorithm.¹⁴  In cases in which endotracheal intubation is impossible and the patient’s condition deteriorates into a ‘cannot ventilate, cannot intubate’ situation,  lifesaving steps must be immediately undertaken. Despite possible (and severe) complications, there are no contraindications for infraglottic procedures in these critical situations.  The most severe complication is failure to establish an airway before brain damage or death results.

TRANSLARYNGEAL AIRWAY

Retrograde wire intubation is an excellent technique for securing a difficult airway.  The procedure takes some time to perform and should not be considered under emergency circumstances unless the practitioner is extremely experienced in the technique.  Bleeding may occur at the site of the tracheal puncture. Cases of severe hemoptysis with resultant hypoxia, cardiopulmonary arrest, dysrhythmias and death following retrograde wire intubation have been reported.   Subcutaneous emphysema localized to the area of the transtracheal needle puncture is common.  In severe cases pneumomediastinum and pneumothorax may occur.²¹  Laryngospasm may result from irritation by the retrograde wire unless the vocal cords are anesthetized or relaxed.  Other, less common complications include esophageal perforation, tracheal hematoma, laryngeal edema, infection, tracheitis, tracheal fistula, trigeminal nerve injury, and vocal cord damage.³²

In both the surgical cricothyroidotomy (using a scalpel) and the needle cricothyroidotomy (using a needle-set) procedures, the cricothyroid membrane requires penetration.  Acute complications are bleeding (especially during surgical cricothyroidotomy), misplacement of the tube (especially after needle cricothyroidotomy) and barotrauma.  Subcutaneous emphysema, pneumothorax, pneumomediastinum and pneumopericardium tube malposition or failure of airway access, wound infection, displaced cartilage fractures and laryngotracheal separation may occur during this technique.

Granulation tissue around the tracheostomy site, subglottic stenosis, massive laryngeal mucosa trauma, endolaryngeal hematoma and laceration, vocal cord paralysis, hoarseness, and thyroid cartilage fracture with dysphasia are direct long-term complications. All emergency translaryngeal airways should be eventually changed to a formal tracheostomy.  Subglottic stenosis is a delayed complication, especially in children.

TRANSTRACHEAL AIRWAY

Transtracheal jet ventilation (TTJV) is accomplished by introducing a small percutaneous catheter into the trachea and insufflating the respiratory tract with high-pressure oxygen over a jet ventilator or a hand jet device.  Although this technique may be helpful in critical situations, life-threatening problems are associated with its use.

If the TTJV catheter is displaced from the trachea, subcutaneous emphysema, hypoventilation, pneumomediastinum, pneumothorax, severe abdominal distention, or death may result.  Oxygen delivered through a transtracheal catheter must be able to escape the lungs freely or over-distention and pulmonary rupture may occur.  In cases of total airway obstruction, the risk for pneumothorax is greatly increased because gas cannot escape from the lungs.  Strong consideration should be given to placing a second transtracheal ‘egress’ catheter in these circumstances or simply avoiding this technique altogether.  Laryngospasm can also impede the outward flow of oxygen from the trachea.  Inadvertent placement of a gas delivery line into the gastrointestinal tract may also result in complications (gastric rupture, esophageal perforations, bleeding, hematoma, and hemoptysis).  Damage to the tracheal mucosa may occur in patients who are managed with long-term TTJV, especially if the gas is not humidified.

Although percutaneous dilatational tracheostomy (PCDT) is not usually recommended for emergency use, it appears to be suitable for emergency situations in skilled hands.  Many different sets are available.  Bleeding, subcutaneous and mediastinal emphysema, pneumothorax, airway obstruction, aspiration, infection, accidental extubation and death are early complications.  Delayed complications are tracheal stenosis, scars, hoarseness, tracheoesophageal and tracheocutaneous fistulae.

Minitracheostomy occasionally results in excess bleeding into the airway, necessitating progression to a full surgical tracheostomy.  Air embolism, subcutaneous emphysema, pneumomediastinum and tension pneumothorax may occur.

Subglottic stenosis is a complication of long-term intubation.  This is much more difficult to repair and frequently results in permanent speech impairment or laryngeal damage.  A tracheostomy tube can cause tracheal erosion, particularly into the esophagus (tracheoesophageal fistula) or the brachiocephalic artery.  Accidental extubation and dislodgement of the cannula occur occasionally, most commonly in the early postoperative period. Infection, mediastinal sepsis, tracheal stenosis and tracheomalacia are rare late complications.