Module 3
Complications of Managing the Airway
Complications with Intubation
NASOTRACHEAL INTUBATION
Nasotracheal intubations are potentially
hazardous. In the presence of basilar skull fractures or certain
facial fractures (such as LeFort II or III fractures) the
endotracheal tube may be inadvertently introduced into the
cranial vault. A case of an uncomplicated nasotracheal
intubation in which asystole occurred after the tube was
introduced into the orbit has been reported.26
Substantial facial trauma and evidence of basilar skull
fractures are usually considered to be contraindications for
this technique. Nasotracheal tubes may also dissect backward and
run behind the posterior pharyngeal wall.
Nasal intubation may cause lacerations of
the nasal mucosa, hemorrhage, and epistaxis. Nosebleeds are
common but are relatively easy to prevent. It is paramount that
the nasal mucosa be vasoconstricted before instrumentation (0.5%
phenylephrine). To minimize the chance of nasal injury, a
small endotracheal tube that has been lubricated well and
presoaked in warm water (to increase its pliability) should be
used. Should epistaxis occur, it is recommended that the
endotracheal tube cuff be inflated and remain in the nostril to
tamponade the bleeding.
Additional complications caused by
nasotracheal intubation include dislodgement of nasal polyps or
turbinates, adenoidectomy, injury of the nasal septum, and
perforation of the priform recess or epiglottic vallecula.
In case of injury to the priform recess, damage of the internal
branch of the superior laryngeal nerve (which supplies the
epiglottis and soft tissue of pharynx and larynx) or superior
laryngeal vessels may occur. Delayed complications of
nasotracheal intubation are pharyngitis, rhinitis, and synechia
between the nasal septum and inferior turbinate bone.
Distortion of the nares can lead to the development of ischemia,
skin necrosis, or nasal adhesions.
Even in the absence of gross trauma, the
mechanical damage to the superficial epithelial layers caused by
nasal intubation results in mucociliary slowing and bacteremia.
Even short-term intubation has been reported to cause nasal
septal and retropharyngeal abscesses. Acute otitis media
has been reported to occur in 13% of nasally intubated neonates.27
Paranasal sinusitis has also been reported, most commonly with
nasal intubation for more than 5 days.
Fractures of the frontal part of the skull
base with cerebrospinal rhinorrhea, intranasal abscesses or
abscesses with intranasal expansion, choanalatresia,
hyperplastic tonsils, tendency to uncontrollable nasal bleeding
and coagulopathies are contraindications for nasotracheal
intubation.
ESOPHAGEAL INTUBATION
When visualization of the glottis is
difficult, the endotracheal tube may inadvertently be introduced
into the esophagus. Esophageal intubation is more common with
inexperienced practitioners but may also occur in experienced
hands. Intubating the esophagus is not disastrous, but failure
to detect and correct the condition is. A closed claims
analysis of adverse anesthetic events reported that 18% of
respiratory-related claims involved esophageal intubation.28
Preoxygenation can help alleviate this problem by allowing a
longer apneic period for endotracheal intubation and by delaying
the onset of hypoxemia.
End-tidal CO2 monitoring is
essential in confirming endotracheal placement of the
endotracheal tube. Capnography should be available
wherever intubation is performed. Fiberoptic bronchoscopy
is another safe method for confirming the proper position of an
endotracheal tube. All other signs, such as equal
bilateral breath sounds, symmetric bilateral chest wall
movement, epigastric auscultation and observation of tube
condensation, are potentially misleading.
Perforation of the esophagus and
retropharyngeal abscess has been reported on several
occasions.29
It is most likely to occur when inexperienced clinicians handle
emergency situations, when intubation is difficult, or in the
presence of esophageal pathology. Subcutaneous emphysema,
pneumothorax, fever, cellulitis, cyanosis, sore throat,
mediastinitis, empyema, pericarditis, and death can occur.
The mortality rate of mediastinitis is >50%.
BRONCHIAL INTUBATION
Bronchial intubation often occurs
and is sometimes difficult to identify. Asymmetric chest
expansion, unilateral presence of breath sounds (usually on the
right side), and arterial blood gas abnormalities are diagnostic
features. Bronchial intubation (most commonly right-sided)
is more common in infants and children because of the small
distance between the carina and the glottis. If bronchial
intubation goes undetected, it may lead to atelectasis, hypoxia,
and pulmonary edema. Fiberoptic bronchoscopy is the best
method for detecting the proper position of the endotracheal
tube.
The tip of the endotracheal tube may be
moved during flexion or extension of the patient’s head as the
patient is positioned for surgery. The tip of the
endotracheal tube can move an average of 3.8 cm (up to 6 cm)
toward the carina when the neck is moved from full extension to
full flexion. When inadvertent bronchial intubation is
discovered, the endotracheal tube should be withdrawn and the
lungs hyperinflated sufficiently to expand any atelectatic
areas.
Bronchial intubation is deliberately
achieved in thoracic surgery with double-lumen tubes.
Even in the best of hands, tracheobronchial injuries occur
during double-lumen intubation. Bronchial rupture is a very
serious complication. Using double-lumen tubes that are too
large may cause bronchial trauma.
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