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ANESTHESIA AND ANALGESIA . . . Current Researches VOL.53, NO. 2, MARCH-APRIL, 1974

The Complications of Tracheal Intubation: A New Clxsification With a Review of the Literatwe
VICTOR FARIA BLANC, M.D., F.R.C.P.(C) NORMAND A. G. TREMBLAY, M.D. Montreal, Quebec, Canada*

The literature on complications of tracheal intubation is reviewed and a new classification is proposed for these complications. Incidents and accidents (early or immediate complications) are arranged in three etiopathogenic classes and in topographic subclasses, the status of endotracheal intubation being divided into three distinct periods: I: the act of intubation; 11: the tube in place; 111: extubation. Sequelae (late complications) are classified according to clinicopathologic criteria. The etiologic factors of sequelae are divided into three groups: predisposing factors, adjuvant factors, and decisive or determinant factors. Possible prevention or remedy of many complications is presented.

complications of tracheal intubation were reviewed by Wyliel in 1950, by Fields’ in 1959,and by Lewis and Swerdlows in 1964. Why another review? What is new?


1. Chronologic:385whether occurring during laryngoscopy, when the tube is in place, or following extubation.

The widespread use of tracheal intubation in patients of all ages and of almost any medicosurgical status, the massive use of new synthetic disposable materials, the procedure of prolonged translaryngeal intubation, are hut some of the factors which prompted us to review and to reclassify this fundamental subject. In short, we felt that the accelerated change we have witnessed in this field was reason enough to reassess the complications of this common technic. Such revisions must be done as prophylaxis against the malady of “future shock in academic medicine.”

2. Topographic: whether lesions occur in eyes, lips, teeth, pharynx, larynx, and so on.

3. Etiopathogenic: grouped as traumatic, as neurogenic or reflex, as chemical, allergic, etc.
4. Pathologic: as defined by pathologists and by otolaryngologists.

5. Statistical: divided as common or rare.
6. Severity:4 according to the gravity of the complication, the degree of airway obstruction, whether the cause is remediable or not, etc.

7. Mixed: using two or more of the above criteria.
Since all these classifications are of some practical value, the choice among them remains arbitrary. From a didactic point of view, we propose the following classification:

CLASSIFICATION At least seven different criteria have been used to classify the complications of tracheal intubation:

‘*Departmentof Anesthesiology-Reanimation,University of Montreal and HBpital Sainte-Justine pour les Enfants, Montreal, Quebec, Canada. A bibliography of 198 additional citations is available from the authors on request. Paper received: 5/22/73 Accepted for publication: 7/31/73

laryngoscope bulb. phenol. tooth.% I .) . soda lime powder) Laryngeal stridor (nasogastric tube) Glottic edema (allergy t o topical anesthetics or lubricants) Pharmacochemical Increased intraocular pressure Bronchospasni Hypotension Cardiac a r r e s t (succinylcholine. Ruptured cuff and tracheal bleeding Endobronchial aspirationG Respiratory obstruction Rupture of trachea Emphysema. tongue. pneumothorax Difficult or impossible extubation Respiratory obstruction Tracheal injury due to damage by armored tube 5 Retrobulbar hemorrhage Retropharyngeal dissection Subcutaneous. gastric content) Swallowed tube Esophageal intubation (stomach distention) Endobronchial intubation (hypoxemia) Reflex Laryngovagal Laryngosympathetic Laryngospinal Bronchospasm (formaldehyde. etc. etc. mediastinal emphysema Perforation of the esophagus Endotracheobronchial aspiration (blood. TABLE 1 Classification of the Incidents and Accidents (Early or Immediate Complications) of Tracheal lntubation Period I I ( t u b e in p l a c e ) Period I l l ( e x t u b o t i o n ) E Period I ( i n t u b o t i o n ) m R W Traumatic o r mechanical F i r e in tracheal tube Fracture-luxation cervical column Trauma to glottis by inflated cuff Fracture-luxation cervical column (spinal injury) Eye trauma a 2 3 Y Epistaxis Teeth t r a u m a Trauma to lips.

204 ANESTHESIA AND ANALGESIA . Canada. 2. and a Staff Anesthesiologist at the HBpital Sainte-Justine pour les Enfants. Accidents are grave physiologic disturbances or lesions that can occur a t any instant of intubation. The most frequent and common incidents and accidents of tracheal intubation are more-or-lesswell described in anesthesiology VICTOR F.7 We further divide the status of endotracheal intubation into three distinct chronologic periods: 1. M. F. 1. Glottic e d e m a (supraglottic. Ulceration of the lips. ) and is finished when the tube is fixed. 13. I. laryngoscopy. mouth.D. Sequelae (late complications) : classified according to the clinicopathologic criteria (table 2). MARCH-APRIL. with explanations as to their prevention. BLANC.R.. QuBbec. Dr. (C). Paresis of the hypoglossal and/or lingual nerves 5. pharynx 6. Blanc held a 4-year Residency in Internal Medicine and in Anesthesiology at the HBpital Notre-Dame and at the Royal Victoria Hospital in Montreal. dysphagia 3. 14. Dr. Intermittent aphonia and recurrent sore throat 4 . 1974 . ODwyer. Oporto. Zncidents are transient disorders. They are often potential accidents and most frequently occur in the first period of intubation. etc. Stricture of the nostril 9. * . Montreal. does not mention complications. 11. Prolonged tracheal intubation is that oral or nasal translaryngeal intubation whose duration is equal to or longer than 24 hours.P. Incidents and accidents (early or immediate complications) : arranged in 3 etiopathogenic classes and in topographic subclasses (table 1).G. Tracheal stenosis 1. 3. No. and started his training in Anesthesiology at the Hospital Geral de Santo Antonio. is an Assistant Professor at the University of Montreal. Laryngeal ulcers Laryngeal granulomas and polyps Synechia of the vocal cords Laryngotracheal membranes and webs Laryngeal fibrosis 16. Traumatic laryngitis (dysphonia or aphonia) 7. INCIDENTS AND ACCIDENTS (EARLY OR IMMEDIATE COMPLICATIONS ) (table 1) The history of accidents from tracheal intubation is almost as old as that of intubation itself. described seven types of accidents with his technic of translaryngeal intubation in cases of croup. with the cuff inflated. First period (the act of intubation) : starts with preparatory maneuvers (hyperextension of the head. 3. subglottic. Current Researches VOL. Infections (laryngitis. sinusitis. Second period (tube in place) : the time during which the patient breathes through the tracheal tube. Blanc graduated in medicine from Oporto University Faculty of Medicine (Portugal). in 1887. respiratory t r a c t infection) 8. abscess. Sore jaw 2.53. 12. usually spontaneously reversible..C. Sore throat. After four years as Anesthesiologist a t the H6pital Avicenne of Rabat (Morocco). Although MacEwen. Third period (extubation): from the deflation of the cuff to the time when the patient resumes normal breathing through his upper airways. 11. TABLE 2 The Sequelae of Tracheal lntubation Sequelae are disorders or lesions that manifest themselves within minutes to months after extubation. who first introduced tracheal intubation for anesthesia in 1868. retroarytenoidal) Vocal cord paralysis 10. 15. Portugal.

Aspiration of a thesia. connective tissue as phentolamine can prevent hypertension.of the total plasma catecholamines. arterial hypotension. tooth guards. overinflated cuff (protrudplications. blood clots.cervical column injuries due to positional changes. under light perfect intubation technic. First Period of Zntubation (the act of esthetized asthmatic patients.kinking of the tube (by the surgeon or his assistant. The mere presence of the tracheal tube seems to be the most common precipitating cause of bronchospasm in an1.-The patient is still threatened by cause subcutaneous and/or mediastinal emphysema. a capnia provides some protection. dents is well illustrated by Scott and BrechAcute sialadenopathy during induction of ner. in place). the incidence being maximal between 30 and tated in the presence of hypoxemia.cases to an increased noradrenaline fraction umn. Traumatic or Mechanical Cornplicatempted blind nasotracheal intubation can tions.Laryngotracheal stimulation ing. Such lesions are most easily clude tachycardia. The esophagus can also be per. render the anesthesiologist less Nevertheless. A careful case hisHyperoxemia with normocapnia or hypotory. Blanc and Tremblay 205 bradycardia. hemorrhage secondary to nasotracheal intu2. bronchus. Laryngoscopy can damage teeth. especially their opposites of sympathetic stimulation. overused can give rise to three different types of tube) . vomiting.tions. against the tracheal orifice during laryngoscopy and tracheal intubation of the tube. which include possibility of legal repercussions. hyper40 years of age and decreasing with the ex. plane 2) as well thoramtomy and bronchotomy. during tracheal intubation. second period of tracheal intubation is the Tracheal tubes can be swallowed and lead possibility of respiratory obstruction due to: to major surgery. accidental extubation. tachyarrhythmias. textbooks. Noble and Derrick noted that likely to suffer from “legal complications. Traumatic or Mechanical Complica. . against such reflexes.arterial hypertension as frequent complicanesses or malformations of the cervical col. The Secondperiod of Zntubation (tube bation in a woman with a maxillary tumor. The hypertensive-hyperdynamic state umn (Morquio’s syndrome). b.” 60 percent of the arrhythmias in their study The value of the preanesthetic history and occurred before laryngoscopy and intubaexamination in the prevention of rare acci. diseases). collapse of a weak.laryngeal nerve block. by changing the position of the rence in small babies. bronchospasm. which ining agents. acute made in patients with congenital weak. with the Laryngospinal reflexes. which give rise to free piece of ruptured cuff lodging in a spasm of the glottis. or too light a plane of general anesperience of the performer. tube bevel lying against either the tracheal or the bronchial wall.-Reckless mobilization maneuvers of Bradycardia. bucking. and associates report tooth damage in 37 All such reflexes are most readily precipipatients out of 5387 tracheal intubations. Tooth and as by topical anesthesia or bilateral superior gingival protectors for endotracheal intuba. dried lubricant. . when muscle tone is abolished by curarizLaryngosympathetic reflexes.tion. bradyarrhythmia. .patient’s head) . and artethe head can produce serious lesions (fracture-luxation of the cervical column with rial hypotension are reportedly rarer than spinal compression or section). cardiac arrhythmias. Laryngovagal reflexes. . an equally pertinent examination. a very disagreeable occur.tion in goats as well as in humans. in patients with during laryngoscopy may be related in some fractures or dislocations of the cervical col. in the elderly as in patients with path. tion have been described. Hoydo coughing. herniating. as the use of general anesthesia. Perforation of the pyriform fossa in ata.capnia. who report an extensive retrobulbar anesthesia has been reported. Protection is given by deeper gendislodged tooth can lead to the need of eral anesthesia (stage 111. porosis. excessive reflexes: dried secretions. Neurogenic or Reflexly Caused Corn. tions. ologic fragility of the cervical spine (osteoAtropinization can prevent bradycardia. Yet the dominant feature of the forated.Complications . Laryngospasm intubation). can be produced by laryngotracheal intubaa. lytic bone tumors. We cite the rarer ones and describe in some detail those that appear to us to merit particular attention. apnea.

extubation must be slow and careful. In these circumstances. tend to cause glottic edema. should obstruction occur. Lindholm? reports that 6 patients out of 225 under prolonged tracheal intubation had respiratory obstruction on extubation. a. Obviously. b. . 4 of them requiring tracheostomy. Entrapped air may have to be released by puncture through the cricothyroid membrane. pack forgotten after extu- -Pharyngeal bation. MARCH-APRIL. membranous part of the trachea is very friable and susceptible to tearing in the elderly. The Third Period of Zntubation (extubation). Armored tubes do not always prevent respiratory obstruction and/or other severe complications.--The same problems as described for the first period of tracheal intubation can occur here. from the carina. Such a grave accident leads to hemorrhage and hypoventilation associated with emphysema and/or pneumothorax. -Excessively vocal cords. cuff inflation is better avoided. An identical situation is possible in Morquio’s disease with malformation of the tracheal cartilages. 2. -Flaccidity of the larynx-the most frequent cause of congenital respiratory distress in the newborn. --Inflated cuff separated from the endotracheal tube and left in the trachea. as some lubricants.? b. ration even in the presence of an inflated cuffed tube: contrast media slipped past the inflated cuff in 18 out of 90 intubated patients. Boyd tells of an antistatic endotracheal tube which burned in the patient’s mouth in the absence of an explosive agent-at clinical concentrations.-Difficult or impossible extubation may be attributed to three different mechanisms: -Undeflated cuff. Perforation or rupture of the trachea is most apt to occur when these intubated patients are recklessly moved.-Some local anesthetics. Neurogenic or Reflexly Caused Comp1ications.206 ANESTHESIA AND ANALGESIA.-These are essentially identical to those of the first period of intubation. Current Researches VOL.G Respiratory obstruction may be due to: . The posterior. One of us witnessed this situation in a 14-year-old boy with cervical Pott’s disease. No. Neurogenic or Reflexly Caused Complications. Cardiac arrhythmias seem to be as frequent during extubation as during intubation. because the connector compresses the cuff tube. or of the thyroid. presumably due to hypersensitivity or allergy. because a constrictive band of the internal wall of the cuff isolates a herniated portion of it. or Pott’s disease of the cervical column) and can produce respiratory obstruction at extubation only. Such accidents are obviously preventable. -Tracheomalacia can be congenital or secondary (to tumors of the neck. 3. from the carina. Patients with this genetic mucopolysaccharidose should not be intubated before having a good radiologic investigation of the trachea to exclude tracheal malformation. in good position. We agree with those who say that laryngoscopy on extubation is mandatory in cases of prolonged tracheal intubation. Obstruction manifested itself on extraction of the tube 4 to 5 cm. c. Pharmacochemically Caused Complications-Bronchospasm may be due to formaldehyde having been incompletely removed from the tracheal tube or to phenol mistakenly used to clean the tube. Traumatic or Mechanical Complicacations. 53. makes a beautiful demonstration of the possibility of tracheobronchial aspi- -Biting on the tube. Pharmacochemically Induced Complications. the tube should be left in place. preventing deflation. large cuff hooking on the -Adhesion of the tube to the tracheal wall due to absence of lubricant. one should not extubate until after surgical repair of the trachea. 1974 Rupture of the inflatable cuff followed by fatal tracheal bleeding and tracheal dilation have been reported. until the tracheal lesion is surgically corrected. c. . with correction of the problem by pushing the tube to within 1 to 2 cm. Reilly reports two cases of acute swelling of the parotid gland on extubation. Glottic edema is discussed in more detail as a sequela of tracheal intubation. Mehta. Laryngospasm after extubation may disappear on removal of a nasogastric tube.

nificant lowering in the incidence of sore in 1939.According to Kanis.arytenoepiglottic folds. These areas are quela is found in 50 percent of intubated therefore prone to develop edema. within 48 to 72 hours without any specific Glottis Edema. There can be transient supraglottic edema. TABLE 3 The Frequency of Postintubation Sore Throat Authors Year Frequency in percent Number of cases Wolfson’” Brunelle e t al’ Jones et all’ Borchet” Conway e t als Paykoc et all’ 1958 1961 1968 1969 1969 1971 this complication.-Harrison and Tonkin bring out documented this sequela. Arner and Diamant reported ap. in 1942. the vocal cords Retrowytemidal Edema.-These are sequelae possibly be: due to pressure of a MacIntosh laryngoscope Supraglottic Edema-hose areolar conblade in the retrolingual region. had already reported 10 cases of glottic edema due to a gastroduodenal tube. ture on inspiration and causing severe reMacroscopically. and/or arytenoidal edema. Debain and associates6 state that aphonia without evident lesions could be of psychogenic origin. these poorly defined “functional” entities Stoelting and Proctor discuss 4 cases of which have no visible macroscopic lesion. Children are the most frequently afflicted Paresis of the Hypoglossal andlor Lin.mucous connective tissue is dense on the gestion or submucosal hemorrhages. whose localizations can gual Nerues. .-It is known that nasotracheal intubation can be followed by sinusitis.matous swelling. A sigcent of the patients intubated presented dys. in the tonicity of the vocal cords.2 percent of 617 patients who had not been inGross and Gros report a chondritis of the tubated! Since the 1951 report of Baron and cricoid cartilage with abscess formation in Kahlmoos. was the therapy. throat. with 8 cases going on to laryngeal stenosis. yet Sore Throat. difficult intubation in an obese. The epipatients.-While the submoving freely. this se.2 24. first to point to tracheal intubation as a Cinchocaine jelly-covered tubes cause a sig. . there is discreet epiglottic spiratory obstruction. blocking the glottic aperlowed to have sustained this complication.-Shaw. in 1946. I n the vocal cords. These include: .1 29 6 43 38. Intermittent Aphonia and Recurrent Sore Kauffman and colleagues. found that sore throat occurred in 10.and behind the arytenoid cartilages. nective tissue is found.nificant edema behind these cartilages can We divide this class of complications of tracheal intubation according to clinicopathologic criteria (table 2 ) . at most accompanied by con.4 521 863 190 500 642 45 11. Albeit rare in this era of antibiotics and sterilized tracheal tubes. This laryngitis disappeared without treatment in 2 to 3 days. Humidity seems to benefit patients suffering from postintubation sore throat. Infections.cause of laryngeal edema. in the larynx. it is loose just below the cords Baron and Kahlmoos study: some 42 per. Conway and coworkers* secretions.-The most benign and the there remains the risk of pulmonary infecmost frequent of the sequelae of tracheal intion due to atelectasis caused by retained tubation (table 3 ) . postintubation infections can still occur if a terrain exists for their development: retropharyngeal abscess after a difficult intubation for thyroid surgery. These conditions can persist for many years postextubation respiratory obstruction and after extubation and may be due to minor provide a classification of the causes of postalterations in the laryngeal articulations or intubation laryngeal edema. bullnecked patient. further Throat.glottis may be pushed backwards by edeproximately one-third of 77 patients fol. Iglauer and Molt. Blanc and Tremblay 207 phonia with congestion and edema of the posterior third of the vocal cords.Complications . on the Traumatic Laryngitis (Dysphonia or anterior surface of the epiglottis and on the Aphonia) . SEQUELAE ( LATE COMPLICATIONS ) Airway infection is less common from prolonged intubation than in tracheostomy. .s authors generally agree that a patient who had been intubated for 34 this is a fleeting sequela that disappears days.

and at the inner posterolateral area of the cricoid region. LindholmT describes laryngeal ulcers at the interarytenoid thick on the internal subglottic perimeter is sufficient to reduce the mentioned area to 5 sq. within 6 hours. epithelial degeneration with ulcer formation covered by a pseudomembrane of fibrin and necrotic epithelial debris. and that within 96 hours all cases had pronounced ulcerations. In these conditions. An important bibliography has accumulated since then. There are some reports on polyps coughed out spontaneouslyla and on granulomas healed without treatment. Several cases were published all around the world. Subglottic Edema. separation o f the pseudomembrane by edema formation.7 percent o f normal).20. The cricoid cartilage surrounding completely the subglottic region forestalls any external expansion of the swollen surfaces. Hilding. there is laryngeal irritation with mucosal congestion.21 Many good reviews exist on this s~b. in 1965. Way and Sooy. chronologically.~3 Howland and LewiG3 fix the incidence of laryngeal granuloma at 1:800 to 1000 intubations.ject. 1974 limit their movement and so limits the abduction of the vocal cords on inspiration. The cuff area was always affected to some degree. With prolonged intubation. and that re-epitheliazation begins within 48 hours after extubation to end about 100 hours later. giving rise to a very dangerous airway obstruction.--This subject was masterfully reviewed in 1953 by Chevalier Jackson. it has been recognized that mucosal necrosis can easily reach the adjacent cartilage. Of important moment is that laryngeal ulcers are most probably the lesions on which more serious lesions may develop. the posterior halves of the cords and the posterior commissure of the larynx.208 ANESTHESIA AND ANALGESIA . Clausen'8 and Griffith19 reported the first cases of laryngeal granuloma attributed to endotracheal intubation. Laryngeal Granulomas and Polyps. Debain and associates6 found that the most common localizations of laryngeal ulcers are the free edges of the posterior halves Gf the vocal cords (along with a reduction in the arytenoidal mobility) .'-' The internal cross-section area of the larynx of a newborn is no greater than 14 sq. Moreover.1z who had first coined the term in 1928. on the cricoid plates. and stated that dexamethasone decreases the intensity of the inflammation. . laryngeal erosions are invariably present.--In 1932. MARCH-APRIL. Laryngeal granuloma locations correspond approximately to those of laryngeal ulcers. Current Researches VOL. demonstrated identical lesions in 14 cynamolgus monkeys.~2.53. found that after 48 hours there is also bacterial infection of the perichondral vocal processes and of the cricoid lamina. Laryngeal Ulcers.-This is the gravest of the glottic edemas and the most susceptible to be the cause of urgent reintubation or tracheostorny. that the ulcers are more likely to be found on the same horizontal plane as the cricoid cartilage. Lu and coworkers describe the microscopic pathology. . . Donnelly and colleagues. showed convincingly that the maximal damage occurs on the arytenoid vocal processes. Since the report of Bergstrom's group in 1962. Zinc sulphate treatment has also been reported. An edema 1 mm. a more-or-less pronounced respiratory obstruction may be established. the subglottic region has a fragile respiratory epithelium with loose submucosal connective tissue that is easily traumatized and is edema prone. the posterior subglottic region. and on the anterior wall of the trachea. Glottic edema persisting beyond 24 hours after extubation is often associated with more serious lesions. the medial sides of the arytenoids. just below the arytenoid vocal processes. but usually these sequelae require surgical in a prospective study of 99 necropsies. Dwyer and associates describe the macroscopic laryngeal lesions from tracheal intubation in the following sequence of events: Within 2 to 4 hours of endotracheal intubation. using methylene blue staining in necropsies. whose larynges resemble quite closely those of humans. as follows: inflammatory reaction with small hemorrhages. Tonkin and Harrison" report 4 cases in 166 patients and Lindholm? gives 4 cases out of 267 patients. 2. Hilding and Hilding'? stated that laryngeal ulcers heal by epithelial regeneration from the basilar layer of the remaining epithelium. (35. especially in infants and children. which can expand only internally.

The result is always respiratory obstruction. Minnigerade adding from a few weeks to a few months after tra. We have divided this chapter into three classes of factors (table 4 ) .Z1 losis of the cricoarytenoid joints.Complications . and Fishman tunately rare. adults. and colleagues found the same in 9 out of Synechia of the Vocal Cords. Miller and Gulsha feel so strongly about the fact that the cuff level is the preferred site of tracheal stenosis that they have replaced the cuff by Teflon rings. especially if the le. since surgical correction is limited. The KamenWilkinson endotracheal and tracheostomy tubes were also conceived to eliminate the pressure effects of the cuff. Lindholm. in 10 dogs. Granuloma can be very large and present as report 1 case among 342 patients with prorespiratory obstruction. . leading to sudden respiratory obstruction. Salem and associates classify the factors favoring vocal cord paralysis in pediatric patients submitted to anesthesia under tracheal intubation. 2.' There is is not particularly a predisposing factor to aphonia and respiratory obstruction.-This is the gravest of the postintubation sequelae. Pearson and cosion is subglottic. early diagnosis.and stated that induced hemorrhagic shock arytenoidal slit for the airway. Fibrous tissue formation leads to laryngeal stenosis.workers found that in 7 out of 25 cases the stenosis was at the cuff site. surgical correction is satisGreisen relates 9 cases of tracheal stenosis factory. ventilation. 5 Usually.-Necrosis of 12 cases. sore throat. below). showed conditions for sticking and welding of their posterior third. as follows: 1. thereby leaving the more that the cuff pressure is elevated. These sequelae are particularly dangerous since a portion of the membrane can free itself. an eventuality that is for." to the use of intermittent positive pressure Luryngotracheal Membranes and Webs. Warner reports a case of subglottic fibrous cord developing in a 25-year-old woman. as they epithelialize in continuance with the laryngotracheal mucosa. when present. Adjuvant factors: Those factors or causes which. the free edges of the vocal cords can set the Shelly and associates. Surgical removal of membranes and webs can be difficult. . gives recommendations for their prevention. whereas Kenntnis describes a subglottic web in a 64-year-old woman 4 days after tracheal intubation.another case. Laryngeal Fibrosis. They are narrowing of the subglottic lumen or by imusually unilateral but many reports of bi. Predisposing factors: Those factors irremediably present which render the patient more liable to the adverse effects of other factors.6 but is rare. Blanc and Tremblay 209 from which they appear to emerge. The same can occur with the that tracheal stenosis favors the cuff site all arytenoid vocal processes. Acute granuloma existsG Sudaka and colleagues report 9 cases. cheal intubation. Membrane formation between the vocal cords can occupy some 213 of the glottic opening. be it by ETIOLOGY OF THE SEQUELAE OF TRACHEAL INTUBATION Campbell and Bryce and colleagues give classifications of the causes of the sequelae of tracheal intubation. these lesions manifest themselves women and 4 children.longed tracheal intubation.Laryngeal and subglottic membranes can be congenital or acquired from tracheal intubation.mobilization of the vocal cords due to ankylateral granulomata have been published. Stein and coworkers found 3 cases of laryngotracheal membrane formation in a series of 42 autopsies performed on previously intubated patients. Symptoms Laryngeal granuloma affects adults more come late (45 to 60 days after extubation) than children and women more than men and children are more susceptible than (see etiology of sequelae. dysphagia. probably secondary to 5 days of nasotracheal intubation 2 years before. enhance the . With such a complication.9 Clinical manifestations Tracheal Stenosk-Dixon and associates are hoarseness. only a small anterior aperture and a retro.' in one of the most exhaustive studies on the pathologic consequences of prolonged tracheal intubation.

53. stiffer epiglottis. terior larynx. heading is that of Ryan and coworkers. and cows. can cause sequelae of tracheal inc. such as the presence of a tracheal the anatomic peculiarities of the larynges of tube. the unfortunate use of oversized tracheal by themselves (as opposed to the two for.210 ANESTHESIA AND ANALGESIA . Age.5 per2. as such. .-The first study found under this 1. clearly more common in women. Anatomic Characteristics. using exfolianeonates and infants: a higher and more an. . MARCH-APRIL.--Children appear to withstand noted no relation between the thickness of prolonged tracheal intubation better than the mucosa and the age of the patients but adults. They are determinant factors.Postintubation sore throat is ficult and so predispose the patient to traumatic intubation. Adjuvant Factors.4~1~)~1~ Tonkin and H a r r i ~ o n 'show ~ that 36. a larger. Hilding and Hilding. children are more apt to who underlined that males have a thicker sustain glottic edema. receding chin. obvious predisposing factors of laryngotraAdults appear to be more prone than in.mucosa than females. a more fragile epithelium.'T osis afflicts newborns and infants especially. Sex. 1974 TABLE 4 Etiology of the Sequelae of Tracheal Intubation 1. . concluded that the respiratory epithelium in which forms a more acute angle with the children is easily damaged by tracheal intubation. However. it is known that tal or acquired anomalies of the larynx (lathe infant cricoid is the narrowest part of ryngeal webs or bands. tumors) are his larynx. cosa. fants and children to develop granulomatous as well as short neck. No. Fragility of the Laryngotracheal Mutubation. Farmati and associates. Current Researches VOI. cysts. chickens. Griffithlg cent of the patients in their series with mild stated that for apparently equal conditions or absent sequelae were female but that 72. Decisive factors: Fragility of the laryngotracheal mucosa Anatomic characteristics Circumstances affecting healing Circumstances favoring edema formation Upper respiratory obstruction State of hydration Nasogastic or duodenal tubes Stasis of septic secretions Surgery of t h e neck Postintubation vocal abuse Traumatic intubation Duration of intubation Traction and rubbing of the tube Cuff pressure Material of construction of tubes Other irritants This overwhelming difference in incidence o f postintubation granulomas in women appears related to the greater resistance of the male laryngeal epithelium to trauma and to 3. can be treated or prevented. Facial or cervical anomalies. Granulomas others.tubes in females. Predisposing factors: Age Sex 2. Predisposing Factors. The following pathologic conditions also are much more common in women. who a.CongeniSince Bayeux (1897).. can render the laryngoscopy particularly difb. showed that The reasons for this have been beautifully this tissue is very susceptible to the least described by E c k e n h o P who underlines trauma. . .4 certain patients were more susceptible to percent of those with moderate to severe sequelae from tracheal intubation than laryngeal sequelae were women.cheal sequelae. d. They are not irremediably present in the patient and.-In 1932. while subglottic sten."-':< must be considered: action of decisive factors. reactions to intubation. glottic opening. obesity. 2. Adjuvant factors: 3. mer ones ) . Decisive factors: Those factors which. in dogs.tive cytology before and after intubation.

-One would not seriously consider using prolonged tracheal intubation in laryngeal obstruction due to tumor. Nasogastric and Nasoduodenal Tubes. etc. Postintubation Vocal Abuse. Circumstances Favoring Edema Formation. External Diameter of Tube.Blind nasotracheal intubation can be particularly traumatic and associated with complications.hurry. experience of the performer. Other authors. for many variables are involved ( age. Blanc and Tremblay 21 1 h. 3. underlying pathology. -As noted earlier (glottic edema).) or in the patient (predisposing and/or adjuvant factors). State of Hydration. Other factors include hyperhydration (see below: state of hydration).-Wyliel and Iovannovich describe laryngeal granulomas after only 15 and 21 minutes of intubation. The maximal permissible time for safe prolonged tracheal intubation is not easily determined. . . hypovitaminosis. poor muscle relaxation. respectively. etc. Upper Respiratory Obstruction.-This can pre. for Dwyer and associates and Bergstrom showed a direct correlation between the gravity of laryngotracheal lesions and the duration of the intuba t ion. showed that the degree of damage to the mucous membrane is related to the length of exposure to dry anesthetic gases. too light anesthesia.' we consider this an adjuvant factor. We feel the maximal safe permissible time of prolonged tracheal intubation to be that time when the incidence of sequelae increases significantly." .-Bergstrim and associates report that even with serious damage from tracheal intubation. The same is probably true with hyponatremia.' Furthermore. Traumatic Intubation. favor the development of glottic edema and of other sequelae from tracheal intubation.Complications . tube caliber. in addition to which we have found a reported range in adults of from 8 hours to 1 week and in children from 48 hours to 3 weeks. treatment. bore. while Smith reports two examples (an infant and a boy of 14) in which intubation lasted 6 weeks without complications. traumatic intubation is associated much more frequently with sequelae than a correctly performed intubation. tions from intubation. thereby opening the route for infection of the nearby laryngotracheal structures. Duration of the Intubation. Overhydration by excessive intravenous fluids facilitates the development of laryngeal edema. Circumstances Affecting Healing. Traction and Rubbing of the Tube on formed during upper respiratory tract infections. cause laryngeal edema and stenosis. tuberculosis or laryngeal abscess. there may be no evidence of infection at necropsy.' found that the incidence of tions from an ulcer in contact with septic sore throat increases with increased tube secretions than from a clean one. Many others have found a similar g. Donnelly found microscopic evidence the Larynx and Trachea will be studied unof bacterial infection in every larynx or der the following headings: trachea intubated for more than 48 hours. f. such tubes can produce esophageal ulcerations a t the level of the cricoid sphincter. .-Dehydration. in an exfoliative cytology study. Be the cause in the operator (inexperience. anemia. by themselves. Evidently. renal and hepatic diseases. allergies. consider such infection likely to be spread if intubation is perc. by diminishing mucus secretion. angioneurotic edema. b. hypoproteinemia.-Upper respiratory infections. d.Brunelle It is logical to expect more serious complicaand colleagues.intubation tracheal stenosis or increased incidence of laryngeal sequelae. Sore throat is significantly more frequent when use d nasogastric tubes accompanies tracheal intubation. e. Chalon and colleagues.) . Surgery of the Neck. a. however. gastroduodenal tubes can. alcoholism. c. by ever improving the overall care of the patient. b. . these are extremes. cardiac failure. steroid Farrior reports a laryngeal ulcer related to vocal abuse in a 60-year-old woman. Harrison and Tonkin and Bain summarize the maximal safe permissible times suggested in the literature. Chronic and debilitating diseases. makes the laryngotracheal mucosa more susceptible to trauma. Fields. no doubt. Stasis of Septic Secretions.relationship with the development of postdispose the intubated patient to complica. and this in that particular center where the patient is treated! The aim is to decrease such complications to their lowest. Decisive or Determinant Factors. -With a.

d. coughing. particularly in conditions of hyperthermia. can produce fibrosing reaction when implanted in rabbit paravertebral muscles. swallowing. He accordingly concludes that during the second period of intubation. With controlled respiration. Little and Parkhouse demonstrated that polyvinyl chloride. Artificial ventilatiofi seems to contribute to the frequency and to the gravity of postintubation sequelae.” in intubated patients with recurrent unilateral vocal cord paralysis. As the temperature of the cuff-enclosed air rises from room temperature to the patient’s temperature. laboratory investigation has crumbled the myth of the “innocuity” of plastics. Other articles have warned of the possible dangers from plastic tracheal tubes. f. Current Researches VOL. shows that in the later instance the tube rubs on the posterior region of the larynx. Shape of Tube. the vocal cords open and close. a low-pressure soft teflon cuff (Lomholt) . stabilizers or antioxidants (against the deterioration of the material in the presence of heat and/ or oxygen). Construction Material. while certain polymers contain chemical bonds which tissue enzymes can attack and split off. Several authors agree in considering direct pressure from a distended balloon on the tracheal wall as the major factor of tracheal sequelae. phenolnaphthylamine derivatives (antioxidants) have cancerigenic properties. Lindholm’ showed that if patients are well sedated and did not resist the ventilator.53. . triorthocresyl phosphate ( plasticizer) is a powerful neurotoxin. -During spontaneous ventilation. MARCH-APRIL. Hg (arterial end) and 9 mm.212 ANESTHESIA AND ANALGESIA . at minimal occlusive volume (the least volume of air required to make the airway air leakproof) the cuff pressure in a Latex tube equals 18 to 22 mm.-Tubes in current use do not correspond anatomically to the airways and thereby exert traction on some of the laryngotracheal structures.’ disregarding the fact that the trachea is not round on crosssection but rather more imperfectly circular with a flattened posterior segment.-Glues employed to fasten cuffs to tubes can be considered as irritants insofar as they possess strong bacteriostatic activity.” Barton. No. plasticizers (to soften) . As the mean capillary pressure lies between 25 to 30 mm. like most plastics. All these movements cause the tube to rub against the airway surface. the cuff pressure rises still further. on the posterior half of the vocal cords. and on the dorsal wall of the trachea. 2. the patient’s head should be hyperextended. fillers (to harden). 1974 In 1950. Such ingredients include catalyzers (to facilitate polymerization). Now. then passively constrict and shorten with each inspiration and expiration. in comparing the absence of laryngeal lesions from bronchoscopy to the presence of such lesions from tracheal intubation. they were less likely to suffer from such damage. pigments (to color). etc. found a strong predominance of lesions on the tonic vocal cord.G The following corrections against excessive pressure on the tracheal wall have been proposed: a new cuff design ( McGinnis and associates). it follows that the cuff pressure brings about capillary stasis with tissue anoxia and edema. Hg (venous end). Identical ronditions exist with bucking. the lower airways dilate and lengthen. Beecher proved that relatively small tracheal tubes can be used to maintain normal blood gases with spontaneous respiration. rtqectively.-Smith and Knowlson and Bassett have noted that. vulcanizers or accelerators (to facilitate solidification). Movements of Vocal Cords and Trachea. Cuff Pressure. Certain nonpolymerized monomers (with free radicals) can cause tissue damage. Debain and associates. the tracheal tube moves along its longitudinal axis. . Hg.-Whereas clinical experience has shown that rubber tubes give rise to more secretions than plastic tubes. organotin (stabilizer) has necrotizing actions and cellgrowth-inhibiting properties. Intracuff pressures above 400 mm. Stetson and Guessz5gave a thorough account of the causes of the possible damage from such tubes and of the ingredients used in their manufacture. From these findings he constructs a more anatomic tracheal tube. . Hg and C-T pressures (pressures between cuff and tracheal wall) above 200 mm. automatic intermittent cuff inflation. replacing the cuff altogether by soft teflon rings (Miller and Gulsha) . e. arterial hypotension and/or a hyper-inflated cuff. a polyurethane foam-filled cuff (Kamen and Wilkinson) . The position of the patient’s head is also of great moment. Hg were recorded by Kamen and Wilkinson. Linholm7 shows beautifully how ordinary tubes exert pressure on the arytenoids. Other Irritants. In 1970.

and also warn very clearly on the package label against sterilization or other procedures which may enhance tissue irritation. 1970 . Harrison GA: The effect on the larynx of prolonged endotracheal intubation. ethylene oxide forms ethylene glycol. Wasmuth CE.1950 tion granuloma of the larynx. 1951 10. Canad Anaesth Soc J 8:581-585. Anesthesiology 9: 490-497. Clausen RJ: Unusual sequelae of tracheal intubation. Baron SH. Sagden FLH: Sore throat after anaesthesia. et al: 24. Generic and Trade Names of Drugs Cinchocaine chloride-Nupercaine Dexamethasone-Decadron Noradrenaline-Levophed Phentolamine-Regitine 18.1966 15. Griffith HR: Futher experiences with endotracheal gas-oxygen anesthesia. Kahlmoos H W : Laryngeal sequelae of endotracheal anesthesia. Borchet K: Die Haufigkeit postoperative Halsbeschwerdewn nach endotrachealen Intubationsnarko1960 sen. . Hale DE. Ann Otolaryng (Paris) 85: 379386. Epstein SS. 1932 19. 9. Lewis JS: Post-intubation 509-518. Brunelle JP. Anesth & Analg 11 :206-209. 1953 16. Tip Fak Mec (Istanbul) 14:72-77. Wylie WD: Hazards of intubation. Brit J Anaesth 32:219-223. Eckenhoff J E : Some anatomic considerations L'intubation orotrachtiale et les maux de gorge of the infant larynx influencing endotracheal anespost-op6ratoires. Lewis RN. Anesth & Analg 45: 2 .1971 14. Donnelly WA. Boucher J. Ann Otol 71:455479. Lebrigand H. Winston P: Intubation granuREFERENCES loma. Grossman AA. Anesth Prox 4:91-95. Laryngoscope 69: 22. Cancer 9:1244-1247.1948 17. larynx following intratracheal anesthesia. is absorbed into the polyvinyl chloride and dissipates very slowly. J Laryng 71:37-48. Cossette G. Anesthesiology 33: 44:601-605." According to Andersen. Brit J Anaesth 30:326-332. Guess WL: Causes of damage to tissues by polymers and elastomers used in the 5.1951 1961 25. 1969 8. Savkilioglu E: Sore throat and upper respiratory infection following endotracheal intubation.1972 635-652. Miller JS. Anesthesiology 14:425-436. Conway CM. Jones GOM. Swerdlow M: Hazards of endo23. Ann Otol 60: 767-792. 1957 1. or mercury biniodine. Binet JB. Cleveland Clin Quart 35: 23-31. As others have stressed. 1968 7. Hence. Paykoc R. thesia. Anaes21. Blanc and Tremblay 213 6. Snow JC. . Tracheitis has been reported due to errors in the cleansing of tracheal tubes by the use of ethylene glycol. Harano M. 1960 Several cases of vocal cord paralysis have been related to tubes sterilized in ethylene oxide. Hilding JA: Tolerance of the respiratory mucous membrane to trauma: surgical swabs and intratracheal tubes.1968 12. not easily removed. 13. phenol. Wolfson B: Minor laryngeal sequelae from endotracheal intubation. 1958 11. Stetson JB.1932 20. Acta Anaesth Scand Suppl 33. 1965 3. Maria Emilia Lopes for assistance in manuscript preparation. Arch 1964 Otolaryng 62:182-186. Mehta S: The risk of aspiration in the presence of d e d endotracheal tubes. it is hoped that manufacturers providing medical equipment to be used for prolonged contact with human tissue will ensure that their products are nontoxic. Lindholm DE: Prolonged endotracheal intubation (a clinical investigation with specific reference to its consequences for the larynx and the trachea and to its place as an alternative to intubation through a tracheostomy). Balogh K: Postintubathesia 5:143-148.Complications . like ethylene chlorohydrine.1955 4. Akkartol B. Myerson MC: Granulomatous polyp of the tracheal anaesthesia. Grem FM: Imcal sequelae of endotracheal anesthesia. Tonkin JP. Debain JJ. 1962 ACKNOWLEDGMENT We are grateful to Mrs. Brit J Anaesth 36:504-515. Hilding AC. Proc Roy SOC Med 25:1507. this gas dissolves relatively well in polyvinyl chloride and is then released in concentrations high enough to damage tissues. any material sterilized by ethylene oxide should be well aerated before contact with live tissues. Fields JA: Injuries and sequelae associated 425-429. liquid ethylene chlorohydrin. Gamma irradiation of polyvinyl chloride tubes releases chloride ions which can combine with ethylene oxide to form the very toxic. Med J Aust 2:581-587. Brit J Anaesth fabrication of tracheal devices. Jackson C: Contact ulcer granuloma and other laryngeal complications of endotracheal anesthesia. Anesthesiology 12:401-410. Howland WS. et al: A survey of acute complications associated with endotracheal intubation. Monique Tremblay and Mrs. et al: Quelques incidents et accidents de l'intubation trachtiale prolongbe. In the presence of moisture. a tissue irritant which.1966 with endotracheal anesthesia.1959 granulomas of the larynx.