BJA Education, 21(7): 250e257 (2021)

doi: 10.1016/j.bjae.2021.02.005
Advance Access Publication Date: 21 April 2021

Matrix codes: 1C01,

2A01, 3A01

Laryngeal complications after tracheal intubation

and tracheostomy
S. Wallace1 and B.A. McGrath1,2,*
1
Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK and 2University of
Manchester Academic Critical Care, Wythenshawe Hospital, Manchester, UK
*Corresponding author: Brendan.mcgrath@manchester.ac.uk

Keywords: complications; dysphagia; dysphonia; intra-tracheal; intubation; larynx; speech and language therapy;
tracheostomy

Learning objectives Key points

By reading this article, you should be able to:
 Describe the aetiology, prevalence and risk fac-
tors for dysphagia and dysphonia after prolonged
translaryngeal intubation and tracheostomy.
 Outline the physiological and psychological im-
pacts of laryngeal dysfunction in the critically ill.
 Discuss relevant investigations, therapeutic
strategies and specialist interventions to promote
recovery of laryngeal function.
 Summarise the effective multidisciplinary man-
agement of common laryngeal complications.
 Pharyngolaryngeal injury or dysfunction may
have significant consequences for patients
recovering from critical illness, including failed
extubation and decannulation.
 Early detection of post-extubation dysphagia and
dysphonia is important for prevention of avoid-
able complications.
 Inability to vocalise during critical illness has a
significant psychological impact, leading to anx-
iety, depression and reduced engagement with
rehabilitation.
 A variety of interventions can promote early
vocalisation and positively impact recovery.
 Management requires a multidisciplinary
approach with a fully integrated speech and lan-
guage therapist.

Sarah Wallace OBE PG Dip MRCSLT is a consultant speech and

language therapist at Wythenshawe Hospital with a clinical and
academic interest in critical care. Sarah chairs the Royal College of
Speech & Language Therapists’ Tracheostomy Clinical Excellence
Network and is a national advisor in dysphagia and fibreoptic
endoscopic evaluation of swallowing. She has led the development of
national and international guidelines for the management of swal-
lowing and communication problems in the critically ill.
Brendan McGrath FRCP FRCA DICM EDIC PGCertMedEd AHEA
FFICM MAcadMEd PhD is a consultant in anaesthesia and intensive
care medicine at Manchester University NHS Foundation Trust and
an honorary senior lecturer with the University of Manchester Ac-
ademic Critical Care Research Group. He set up and chairs the UK
National Tracheostomy Safety Project, is National Clinical Advisor
for Tracheostomy at NHS England and European Lead for the Global
Tracheostomy Collaborative.
Prolonged translaryngeal intubation or subsequent tracheos-
tomy typically occurs in the critically ill. Translaryngeal or
tracheostomy tubes can damage or impair the larynx,
affecting airway patency and function, and make vocalisation
and swallowing difficult or impossible.1,2 As a result, these
patients can have complex communication and swallowing
needs that may be further compounded by underlying critical
illness or comorbidities.3 Laryngeal injury and dysfunction are
often undetected and can lead to delays and failure of primary
tracheal extubation, tracheostomy decannulation, recovery of
speech and swallowing and recovery of functional cough.4,5
These factors can contribute to complications, such as aspi-
ration pneumonia, and significantly delay recovery, resulting
in prolonged hospital stays, financial burdens and increased
risks of mortality.

Accepted: 19 February 2021

© 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
For Permissions, please email: permissions@elsevier.com

250
 Laryngeal complications after tracheal intubation and tracheostomy

Speech and language therapists (SLTs) have an important submucosa, perichondrium and eventually cartilage. The
and evolving role in the detection, assessment and rehabili- arytenoid cartilages, vocal processes, cricoarytenoid joints,
tation of laryngeal complications as part of the multidisci- posterior glottis, vocal folds and subglottis are particularly
plinary team.6,7 Early intervention is vital for accurate vulnerable.9 After extubation, patients may have stridor, vocal
assessment, proactive decision-making and acceleration of fatigue, sore throat, hoarseness, difficulties clearing secre-
vocalisation and oral feeding. Fibreoptic endoscopic evalua- tions, audible retention of saliva in the upper airway, poor
tion of swallowing (FEES) is an essential tool that enables SLTs cough, absent or impaired swallowing and aspiration.8 Stridor
to support the multidisciplinary team in the optimal man- often indicates laryngeal oedema and hoarseness, suggestive
agement of laryngeal complications (See online of abnormal vocal cord mobility, vocal fold palsy, mucosal
Supplementary material). ulceration or granulation.2
Symptoms persisting beyond more than a few days suggest
that more significant injury has occurred, associated with
What laryngeal complications are associated worse outcomes for laryngeal function and voice. The recur-
rent laryngeal nerve innervates the intrinsic muscles of the
with translaryngeal intubation and
larynx (except cricothyroid) and is particularly vulnerable to
tracheostomy? compression by the tube cuff, especially if the cuff sits too
Laryngeal injuries as a result of intubation of the trachea are high or cuff pressures exceed capillary perfusion pressure.3
common and widely reported, occurring even after a short Anterior arytenoid dislocation may occur because of direct
general anaesthetic.8 The types of injuries sustained can be forward pressure on the posterior arytenoid on insertion of
classified by onset (Table 1) and manifest in a range of signs the tracheal tube, whilst posterior dislocation is more likely
and symptoms (Fig. 1). Even transient tracheal tube placement during extubation.3 Symptoms of hoarseness, breathiness
can cause mucosal trauma, whilst prolonged intubation can (audible breathing) and vocal fatigue are similar to the
cause a range of pressure effects, including necrosis of the symptoms of vocal cord paralysis.
Tracheostomy insertion can damage the structures of the
neck relevant to the larynx, particularly the recurrent laryn-
geal nerve. The presence of the tube results in absent or
Table 1 Laryngeal complications after tracheal intubation and
abnormal translaryngeal gas flow, desensitisation, uncoordi-
tracheostomy. VC, vocal cord.
nated glottic closure and disuse atrophy, which may impede
normal swallowing (Table 1).
Complications associated Complications associated
with tracheal intubation with tracheostomy Determining the type of laryngeal injury is important to
determine appropriate management.
Early As for tracheal intubation,
Laryngeal oedema plus:
VC palsy or paresis (unilateral Stoma infection, wound
or bilateral) breakdown and granulation Prevalence, aetiology and risk factors for
Desensitisation of the Incoordinated glottic closure laryngeal injury
laryngopharynx with mechanical ventilatory
Aspiration or aspiration airflow The wide range of vocal cord injury reported in the literature
pneumonia VC tremor after short-duration (<5 h) general anaesthesia with tracheal
Dysphagia Dysphonia
intubation can be partly explained by the methods of detection
Impaired saliva secretion Prolonged cuff inflation
management and airway leading to: used and timescale of assessment, ranging from immediate
protection Desensitisation postoperative questionnaire to follow-up FEES and video-
Intubation granuloma Stasis of secretions stroboscopy (Table 2).10 Hoarseness has been reported in up to
VC ulceration Incoordinated glottic one third of patients after short-duration intubation, although
Erythema closure
Polyp
the majority of injuries are minor, transient and usually result
Poor cough strength
VC atrophy or bowing Aspiration risk from erythema or mild oedema. Ulcers, granulomas and even
Dysphonia: temporary more significant injuries, such as vocal cord immobility, have
hoarseness been reported.10 See Supplementary Video S1.
Late There are limited published data examining the aetiology,
VC palsy or paresis nature and extent of laryngeal injury after intubation of the
Arytenoid cartilaginous trachea. Risk factors may be considered as those associated
trauma: fixation, subluxation
with patient characteristics, intubation, tracheal tube selec-
or dislocation
Persistent laryngeal oedema tion and use, and factors after intubation.
Dysphagia
VC atrophy
Anterior glottic web
Impaired saliva secretion
Patient-related factors
management and airway Patient characteristics that influence tissue perfusion, affect
protection
wound healing or predispose to neuropathy increase the risk
Aspiration
Dysphonia: prolonged of laryngeal complications after intubation. These patient
hoarseness characteristics include:
Very late (i) Age (the risk of vocal cord paralysis increased three-fold
Glottic or subglottic stenosis
in patients aged 50 yrs)
Laryngeal or tracheomalacia
(ii) Female sex
(iii) Obesity

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Laryngeal complications after tracheal intubation and tracheostomy

Fig 1 Complications associated with prolonged translaryngeal tracheal intubation.

Table 2 Key definitions. SLT, speech and language therapist

Terms Definitions

Dysphagia Difficulty swallowing occurring in the oral, pharyngeal and oesophageal stages of deglutition, which may
incur problems with oral movements and the process of swallowing; secondary to a primary psychological,
emotional, neurological or physical condition, and can result in negative health issues, such as chest
infections, choking, weight loss, malnutrition and dehydration with serious adverse effects
Dysphonia A range of conditions that affect the larynx, causing changes to voice quality, such as hoarseness or complete
loss of voice (aphonia); results in difficulties communicating, which may lead to frustration, low mood and
isolation
Fibreoptic Bedside instrumental assessment used by SLTs, involving transnasal insertion of a flexible nasendoscope to
endoscopic directly visualise naso-/oro- and laryngopharyngeal structures, secretions and pharyngeal swallow function;
evaluation of SLTs can gain an accurate understanding of upper airway, including dysphagia aetiology, severity and
swallowing prognosis, which can then be used to help formulate effective treatment plans; the effect of therapeutic
strategies on laryngeal function and the safety of oral feeding can also be monitored
Videofluoroscopy Modified barium swallow performed in the radiology department that produces video images rather than a
static frame; as a dysphagia assessment tool, it provides a direct, dynamic view of oral, pharyngeal and upper
oesophageal functions during swallowing
Laryngeal Enables evaluation of vocal cord vibration; during conversational speech, the vocal folds vibrate around 100
videostroboscopy e130 times a second; uses a strobe light to create a series of images that appear to show these vibrations in
slow motion; specifically, the characteristics of the folds and their precise movement pattern can be studied
in detail
Hypersalivation Increased production of saliva
Sialorrhoea Excessive accumulation of saliva
Drooling Unintentional loss of saliva from the mouth, beyond the margin of the lip

(iv) A history of diabetes mellitus or hypertension (two-fold
increase)
(v) Laryngopharyngeal reflux
(vi) Malnutrition and renal or hepatic failure
Prolonged critical illness, high-dose corticosteroids, extra-
corporeal membrane oxygenation and the direct effects of
propofol and midazolam have all been associated with
laryngeal weakness after anaesthesia, intubation and treat-
ment in the ICU.4,8,11,12
Intubation and tube-related factors
Injury may be caused during induction of anaesthesia (if a
supraglottic airway device is used), during intubation, during

252 BJA Education - Volume 21, Number 7, 2021

 Laryngeal complications after tracheal intubation and tracheostomy
surgery (patient movement, repositioning and coughing) or at
extubation. Direct or indirect nerve injury (typically to the
recurrent laryngeal nerve) associated with the surgical pro-
cedure occurs most commonly during cardiothoracic surgery,
heart/lung transplant or thyroid surgery. Urgent and emer-
gency intubation increases the risk of injury when compared
with elective intubation, particularly if no neuromuscular
blocking agent is used.4 The skill level and experience of the
operator along with the intubating conditions can also influ-
ence injury rates, although these factors may be interdepen-
dent.10 The use of a bougie or introducer and the coinsertion
of a gastric tube can also influence laryngeal injury.10
Complications increase with the size of the tracheal tube
used (diameter or the patient height/tracheal tube diameter
ratio), and vary with the design of the tube and cuff.2,4,10
Factors after intubation
Prolonged intubation is variably defined in the literature as
>24 or >48 h. Complications increase with duration of trans-
laryngeal intubation; the risk of vocal cord paralysis increases
two-fold in patients whose trachea is intubated for 3e6 h and
15-fold in patients whose trachea is intubated for 6 h or
more.12 In addition to the physical effects of the tube in the
airway, prolonged intubation and associated sedation, pro-
longed emergence and critical care management are associ-
ated with patient movement, coughing, mouth care and
attempted vocalisation whilst the tube is in situ. Laryngeal
stenosis, one of the more severe complications, occurs in
around 2% of patients whose trachea is intubated for 3e5 days
and 5% of patients whose trachea is intubated for 6e10 days.8
Up to two thirds of those patients who develop iatrogenic
stenosis may require long-term tracheostomy, although re-
sults from surgical intervention are generally good.13 Addi-
tional factors that may lead to laryngeal injury after
intubation include agitation, poor humidification, local
infection, high mean cuff pressure and volume and the
number of reintubations required.11 The effect of the prone
position on the laryngopharynx during intubation is little
understood, but oropharyngeal, submandibular and upper
airway oedema may occur.
Impact of dysphagia and dysphonia after
prolonged translaryngeal intubation and
tracheostomy
Prolonged intubation and tracheostomy are associated with a
high prevalence of laryngeal injury (57e83%), dysphonia
(76%), pain (76%), hoarseness (83%) and dysphagia (49%).1,2
The mechanisms of post-extubation dysphagia are multifac-
torial and may be influenced by cognitive impairment, resid-
ual effects of medications and the presence of sepsis.13
However, mechanical factors are key and directly relate to
the duration of intubation, tracheal tube size, mucosal
inflammation, disuse muscle atrophy, diminished proprio-
ception, laryngeal desensitisation and laryngeal injury. Post-
extubation dysphagia is common (reported in around 60% of
ICU patients and 50% of cardiac surgery patients) and inde-
pendently associated with duration of intubation.2,13
Dysphagia symptoms usually slowly resolve, but can persist
in up to one third of patients beyond hospital discharge. Those
patients with a longer ICU stay have a slower recovery from
dysphagia and should be considered for referral to SLT for
swallowing assessment to avoid complications.5
Patients with overt or occult laryngeal injury report
significantly worse breathing and vocal symptoms than those
patients without injury for up to 10 weeks after extubation.5
Associated vocal fold immobility leads to dysphonia,
dysphagia and increased aspiration risk caused by reduced
glottal competence.3 This condition can have significant
consequences for patients recovering from critical illness,
manifesting as failed extubation or tracheostomy dec-
annulation, delayed weaning and poor secretion manage-
ment.1 Any resultant dysphagia can delay oral feeding and
lead to malnutrition, prolonged hospital stay and excess
mortality.7
Prolonged intubation can cause laryngeal oedema, which
also increases the risk of respiratory failure and reintuba-
tion.14 Pressure from the tube may cause vascular and
mucosal damage, granulation, ulcers and later scarring and
fibrosis in the interarytenoid or posterior glottic region.3 This
pressure impairs vocal cord abduction bilaterally, resembling
bilateral vocal cord paralysis, and can lead to chronic stenosis,
compromised airway, dyspnoea, stridor or even respiratory
failure.
The timing of tracheostomy insertion and subsequent
decannulation depends on many factors, including respira-
tory and neurological function. However, laryngeal function is
directly relevant to both the requirement for tracheostomy
and progression with weaning.
Impaired laryngeal sensation, swallow function, cough
and saliva secretion clearance all delay weaning. Tracheos-
tomy itself is a risk factor for severe dysphagia, and up to 50%
of patients with a tracheostomy will suffer from aspiration at
some point, half of which may be silent.15 Aspiration is an
important contributing factor for the development of
ventilator-associated pneumonia.
The inability to vocalise or communicate during critical
illness can have a significant psychological impact, limiting
engagement with recovery and rehabilitation, and leading to
anxiety and depression.
Diagnosis and detection of laryngeal injury
Diagnosis is generally clinical, supported by appropriate im-
aging. A cuff-leak test (involving the slow deflation of the
tracheal tube cuff whilst the patient receives positive-pressure
ventilation) can be used as a screen to predict laryngeal
oedema. It can be a useful tool for assessment of both readi-
ness for extubation and risk of reintubation. The test has a
sensitivity of 88.6% and specificity of 90% when compared with
videonasendoscopy.16 Portable laryngeal ultrasound mea-
sures differences in the width of the air column with the cuff
inflated and deflated, and can also predict the occurrence of
laryngeal oedema, stridor and vocal cord immobility after
extubation.17 This technique requires experience and is not in
routine clinical use.
Early and timely SLT assessment of laryngeal function,
voice and swallowing postextubation or tracheostomy is rec-
ommended in the Guidelines for the Provision of Intensive
Care Services V2.18 Delirium may preclude early assessment,
but the inability to tolerate tracheostomy cuff deflation should
not be a barrier to SLT evaluation. Assessment may include
qualitative or quantitative evaluation of symptoms, voice
quality, cough and swallow, which can be tracked over time to
assess the impact of interventions.
Clinical evaluation can be supported by FEES, an important
tool for evaluating laryngeal injuries, function and airway
BJA Education - Volume 21, Number 7, 2021 253
Laryngeal complications after tracheal intubation and tracheostomy

abnormalities that may affect weaning, decannulation and Secretion management

rehabilitation.7 Direct visualisation of saliva, swallowing
Excessive oral secretions can restrict cuff deflation. Whilst
function and airway protection are possible at the bedside,
they can be caused by hypersalivation, the problem is usually
even with tube cuffs inflated (see Supplementary material).
impaired swallowing. Regular assessment of the volume of
Fibreoptic endoscopic evaluation of swallowing can accu-
fluid obtained by aspirating the subglottic drainage port of a
rately detect aspiration, particularly when silent, which in-
tracheostomy tube can be of benefit. This procedure will allow
forms multidisciplinary decision-making and conversely
assessment of the volume of secretions pooled above the cuff
prevents non-aspirating patients being kept ‘nil by mouth’
and assessment of response to treatment. It will also help
unnecessarily. Fibreoptic endoscopic evaluation of swallow-
keep the subglottic space clear, probably reducing the inci-
ing can also evaluate the impact of tracheostomy in-
dence of ventilator-associated pneumonia as part of a bundle
terventions, such as above-cuff vocalisation (ACV), cuff
of care.21 Subglottic suction can supplement respiratory
deflation and one-way valve placement in real time, deter-
physiotherapy, traditional swallow and vocal adduction ex-
mining optimal treatment and goal-oriented rehabilitation
ercises and cough-assist devices in managing secretions.
plans. The whole team and the patient can view the images at
Simple measures, such as upright posture, good mouth care
the bedside, reinforcing explanations and encouraging
and oral suctioning, should not be overlooked.
engagement in care, particularly for laryngeal or dysphagia
Pharmacotherapy should be viewed as an adjunct and used
therapy, and if aspiration risk necessitates remaining nil by
when simple measures do not control drooling. Options to
mouth.
reduce salivation include:
Videofluoroscopy (VFS) is an alternative dysphagia
assessment tool, but requires transfer to the radiology suite. (i) Sublingual atropine (eye drops 1% given sublingually,
Both FEES and VFS have similar sensitivities, specificities 1e2 drops two or three times per day)
and predictive values; low complication rates; and few (ii) Glycopyrrolate (5 mg kg 1 up to a maximum of 200 mg per
contraindications.19 Both are significantly more accurate dose i.v. or s.c. three to four times per day)
than clinical evaluation, which frequently fails to detect si- (iii) Hyoscine (usually by 1.5 mg patch topically, changed
lent aspiration.19 every 72 h; can also be given orally, 300 mg up to three
Laryngeal videostroboscopy enables evaluation of vocal times per day; note that hyoscine has greater systemic
cord vibration and assists with diagnostic, therapeutic and adverse effects than glycopyrrolate)
surgical decisions for the management of dysphonia. Laryn- (iv) Botulinum toxin injection into the salivary glands (usu-
geal electromyography or joint palpation under anaesthesia ally under ultrasound guidance, every 16 weeks under
by an ENT surgeon may distinguish between mechanical and specialist dosing and supervision)
neurogenic causes of vocal fold immobility.3
Salivary gland radiotherapy is an option in chronic cases,
and ACV may also assist clearance of saliva from the laryngeal
vestibule in patients unable to tolerate cuff deflation.

Therapeutic options and multidisciplinary

Restoring translaryngeal gas flow
team management
Promoting normal laryngeal physiological function can
Once a problem with the larynx that may have an impact on
enhance recovery and rehabilitation whilst reducing the time
recovery has been identified, a multidisciplinary plan must be
to oral intake and vocalisation.22 Strategies include increasing
made. This plan may involve SLTs, respiratory physiothera-
trials of early cuff deflation and use of a one-way in-line
pists, nursing and medical colleagues from anaesthesia,
ventilator speaking valve (such as a Passy Muir Valve) or ACV.
intensive care medicine and head and neck surgical spe-
Cuff deflation causes a controlled leak of gas via the upper
cialties. Often, the presence of a translaryngeal tube is either
airways, and non-invasive ventilators capable of compen-
causing or contributing to the problem, and if the patient’s
sating for such leaks are required. As cuff deflation reduces
condition or ventilatory requirements preclude removal, then
the ventilatory support delivered, it may not be well tolerated
a tracheostomy is usually considered. A trial of extubation
if ventilatory requirements are high.
with continued non-invasive respiratory support is an option
Above-cuff vocalisation is particularly useful in facilitating
in certain specific circumstances, but this trial requires very
speech when the tracheostomy cuff cannot be deflated, and
careful consideration of the risks and benefits.
can produce significant improvements in laryngeal func-
The principles of management are to reduce or eliminate
tion.23,24 See Supplementary Video S2. Above-cuff vocalisation
contributory factors, manage secretions, promote rehabilita-
involves a retrograde flow of gas that can be delivered above the
tion of the larynx and, in doing so, facilitate speaking and
tracheostomy cuff, passing out of the mouth via the vocal cords
swallowing, both of which are key priorities for patients
and facilitating vocalisation.25 Subcutaneous emphysema with
recovering from critical illness.20
facial and neck swelling has been reported and may occur if a
patient has a partially or fully obstructed airway caused by
laryngeal injury. Fibreoptic endoscopic evaluation of swallow-
ing can assist in both assessment of suitability for ACV and its
Laryngeal oedema
safe use.
Specific treatments for oedema include the corticosteroid
dexamethasone, although hyperglycaemia, generalised
Voice and swallow exercises
weakness and delirium are important potential adverse ef-
fects. If gastro-oesophageal or laryngopharyngeal reflux is Rehabilitation of swallowing by SLT is individually tailored
identified or suspected, then a trial of high-dose proton pump with strategies and exercises targeted at specific impair-
inhibitor (such as omeprazole) should be considered. ments. Specific voice exercises support recovery of

254 BJA Education - Volume 21, Number 7, 2021

 Laryngeal complications after tracheal intubation and tracheostomy
dysphonia after extubation or tracheostomy. Fibreoptic
endoscopic evaluation of swallowing and VFS can assist in
determining optimal strategies more effectively, but early
exercise therapy for laryngeal and swallow function re-
mains key to recovery even if these investigations are un-
available. Speech and language therapists may also provide
a closely monitored programme of therapeutic oral tastes
for rehabilitation from dysphagia and stimulation of
swallowing.
Adjunctive therapies
Pharyngeal electrical stimulation is an established therapy to
promote recovery of laryngopharyngeal function, particularly
after desensitisation and for severe neurogenic dysphagia.
The technique involves insertion of a specialised nasogastric
feeding tube that allows short targeted therapeutic stimula-
tion of the pharynx, which can have striking results in
recovering critically ill patients with dysphagia and laryngeal
dysfunction.26 Pharyngeal electrical stimulation is not yet in
widespread use, although evidence is growing of the benefits
in carefully selected patients.
Surface EMG may be potentially beneficial to augment
swallow strengthening exercises through biofeedback. Expi-
ratory muscle strength training can support recovery of
cough, voice and swallowing functions in certain patients.
Surgical options
For patients with problematic or persistent anatomical or
physiological laryngeal dysfunction, a multidisciplinary team
approach is invaluable. Surgical options for glottic insuffi-
ciency related to vocal fold paralysis include vocal cord
medialisation or reconstruction (vocal fold injection, laryn-
geal framework surgery and arytenoid adduction procedures).
These techniques can re-establish glottal competence and
improve voice and swallowing safety, but there are data that
suggest up to 35% of patients with unilateral vocal fold pa-
ralysis will recover without the need for intervention. Other
surgical interventions include vocal cordectomy, dilation for
stenoses, tracheal stenting for tracheomalacia and tracheal
reconstruction for severe or refractory cases.3
Post-extubation screening for dysphagia and
dysphonia
Where ICUs do not have access to SLT, screening tools may
identify dysphagia. In one study, patients who underwent
consecutive daily screening by nursing staff showed an 11%
increase in odds of oral feeding at ICU discharge and 60%
reduction in post-extubation pneumonia.27 However, there is
no established reliable standard swallow screening tool in the
UK and none specific to ICU. Some centres use the Yale
Swallow Protocol, which includes a brief cognitive screen, oral
motor examination and 3 oz water swallow test. Whilst some
units have developed their own tools, no swallow screening
can reliably detect silent aspiration. Around one-third of all
tracheostomised patients that ‘pass’ a clinical assessment of
swallowing are at risk of penetration or aspiration (compared
with FEES), risking failed decannulation. Evaluation of
dysphagia on ICU discharge should be mandatory for
survivors of severe critical illness to identify and meet specific
swallowing rehabilitation needs.7
The Intensive Care Society has developed a ‘framework for
assessing early rehabilitation needs’, which encompasses the
post-ICU presentation screen tool.28 This framework can
support identification of problems associated with the upper
airway, voice and swallowing, and the need for more detailed
SLT assessment. Concerns regarding dysphonia should be
referred to ENT and SLT, where available. Questionnaires,
such as the Voice Handicap Index-10, can be used by patients
who are cognitively able to report symptoms and their
impact.29
Laryngeal complications and COVID-19
Laryngeal issues have had a significant impact on the man-
agement of critical illness during the COVID-19 pandemic.
Prolonged periods of intubation, widespread use of proning and
prolonged cuff inflation attributable to aerosol generation
concerns have exacerbated laryngeal complications, com-
pounded by the apparent potential of the SARS-CoV-2 to
directly cause airway oedema and laryngitis.30 Laryngitis and
cough are common presenting symptoms of COVID-19 even in
mild cases, but the long-term impact on laryngeal function and
voice is as yet unknown. Postextubation dysphonia is common
(as high as 90% from the authors’ own data), can be severe and
may be unresolved by hospital discharge. Post-extubation
dysphagia has been reported in up to 60% of patients and per-
sists in some beyond discharge.31 International guidelines for
the management of communication and swallowing and tra-
cheostomy in the context of COVID-19 are available.32,33 Late
airway complications, such as stenosis, are a concern, given the
duration of intubation, but the scale of this problem is yet to be
determined. Post-ICU follow-up clinics and primary care should
be aware of the need to screen for airway and laryngeal prob-
lems as a cause of breathlessness, dysphonia and dysphagia.
Conclusions
Laryngeal complications, such as dysphagia and dysphonia,
are frequent after tracheal intubation and tracheostomy, and
are associated with significant morbidity. Whilst the principal
mechanisms of laryngeal complications, including dysphagia
and dysphonia after tracheal intubation and tracheostomy, are
relatively well documented, the impact of specific in-
terventions, such as prone positioning or subglottic suction
tracheal tubes for example, is not well studied. More research is
required to understand the impact and effectiveness of estab-
lished and emerging interventions and therapies for dysphagia
and dysphonia in both generic and specific patient cohorts.
Simple approaches, such as using early cuff deflation, one-way
valves and dysphagia exercises, can be very effective if carried
out safely and within a targeted multidisciplinary approach.22
Recent development of newer techniques and treatments,
such as ACV and pharyngeal electrical stimulation, provides
exciting prospects for expediting laryngeal functional recov-
ery and for involvement of SLT much earlier in the critical care
journey. Considering laryngeal dysfunction in all patients af-
ter intubation or tracheostomy is an important first step, and a
coordinated multidisciplinary team with an integrated SLT is
essential for the prompt identification and management of
laryngeal complications.
BJA Education - Volume 21, Number 7, 2021 255
Laryngeal complications after tracheal intubation and tracheostomy

Declaration of interests respiratory failure in critically ill adult patients: updated

review. Crit Care 2015; 19: 295
The authors declare that they have no conflicts of interest.
15. Zielske J, Bohne S, Brunkhorst F, Axer H, Guntinas-
Lichius O. Acute and long-term dysphagia in critically ill
Supplementary material patients with severe sepsis: results of a prospective
controlled observational study. Eur Arch Otorhinolaryngol
Supplementary data to this article can be found online at
2014; 271: 3085e93
https://doi.org/10.1016/j.bjae.2021.02.005.
16. Chung Y, Chao T, Chiu C, Lin M. The cuff-leak test is a
simple tool to verify severe laryngeal edema in patients
MCQs undergoing long-term mechanical ventilation. Crit Care
Med 2006; 34: 409e14
The associated MCQs (to support CME/CPD activity) will be
17. Zytoun T, Noeman Y, Abdelhady M, Waly A. The role of
accessible at www.bjaed.org/cme/home by subscribers to BJA
laryngeal ultrasound in predicting postextubation laryn-
Education.
geal edema. Res Opin Anesth Intensive Care 2019; 6: 294e9
18. Faculty of Intensive Care Medicine. GPICS v2 (2019).
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