This document discusses airway management in intensive care units. It describes various options for securing a patient's airway, including nasotracheal intubation, orotracheal intubation, tracheotomy, and cricothyroidotomy. The risks of complications from artificial airways are examined, including laryngeal trauma, subglottic stenosis, and tracheal abrasion from prolonged intubation. Tracheotomy is presented as reducing some of these risks by bypassing the sensitive structures of the upper airway, though it requires surgery to perform. The advantages and disadvantages of both intubation and tracheotomy are weighed.
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6 Original Articles.review Article.tracheotomy in the Icu- Current Opinions, c r Van Schalkwyk w
This document discusses airway management in intensive care units. It describes various options for securing a patient's airway, including nasotracheal intubation, orotracheal intubation, tracheotomy, and cricothyroidotomy. The risks of complications from artificial airways are examined, including laryngeal trauma, subglottic stenosis, and tracheal abrasion from prolonged intubation. Tracheotomy is presented as reducing some of these risks by bypassing the sensitive structures of the upper airway, though it requires surgery to perform. The advantages and disadvantages of both intubation and tracheotomy are weighed.
This document discusses airway management in intensive care units. It describes various options for securing a patient's airway, including nasotracheal intubation, orotracheal intubation, tracheotomy, and cricothyroidotomy. The risks of complications from artificial airways are examined, including laryngeal trauma, subglottic stenosis, and tracheal abrasion from prolonged intubation. Tracheotomy is presented as reducing some of these risks by bypassing the sensitive structures of the upper airway, though it requires surgery to perform. The advantages and disadvantages of both intubation and tracheotomy are weighed.
LOCAL COMPLICATIONS OF ARTIFICIAL AIRWAYS (TABLE I) Any endotracheal intubation has certain complication risks associated with the anatomical area through which the tube may pass. Because of the differences in the way paediatric and adult airways react to instrumentation, this discussion will focus mainly on the application for adult intensive care unit (lCD) patients. Generally the intensivist has the following options available with which to control the airway: (i) nasotracheal intubation; (iz) orotracheal intubation; and (iii) tracheotomy - standard, percutaneous and cricothyroidotomy. Cricothyroidotomy is mentioned here for one reason only, and that is to place it in proper perspective. Because of an unacceptable long-term complication rate, especially regarding subglottic stenosis, it should be reserved for dire airway emergencies, and even then should be converted to a standard tracheotomy as soon as possible.' It is important to realise that the role of cricothyroidotomy is that of a life-saving procedure and that any long-term placement of an endotracheal tube in such close proximity to the cricoid cartilage should be condemned. Abrasion Pressure necrosis Trachea- oesophageal fistula
Posterior glottic fusion Subglottic stenosis Arytenoid dislocation Vocal cord palsy Abductor failure Table I. Local complications of intubation
Sinusitis hygiene Nasal ulcers ulcers However in the 1800s the situation started to improve, and in 1833 Armand Trousseau reported a 25% success rate for tracheotomy performed in cases of diphtheria. This caused such a vast improvement in the natural course of the disease that he was awarded the prize of the Academie de Medecine in ParisI By 1909 Chevalier Jackson had standardised both the technique and indications for the procedure, which at that stage was performed mainly for upper airway obstruction." In 1943 the indications were expanded to include bronchial toilet for patients with poliomyelitis 5 Long-term ventilation as an indication for tracheotomy was added as a third indication during the 1952 polio epidemic in Copenhagen. Currently tracheotomy is a widely practised procedure with an acceptably low morbidity and one that should have a minimal mortality rate. REVIEW ARTICLE Whenever one attempts to gain an overview of a subject it is always worth while, and usually humbling, to obtain a historical perspective. So often in our modern arrogance we merely succeed in reinventing the wheel. Tracheotomy is certainly no different. The first known descriptions of an incision into the trachea to alleviate upper airway obstruction appeared in ancient Egypt 3 500 years ago.! Popular legend has it that in 300 BC Alexander the Great found one of his soldiers with a life-threatening throat injury, and used his dagger to make an incision into the man's airway.' UnforturJately the chronicles do not tell us whether the patient survived; in earlier centuries terrible mortality usually accompanied this procedure. Available records indicate that only 28 successful tracheotomies were reported between the years 1546 and 1815. 3 HISTORY Airway management is a vital component of intensive care unit treatment. Unfortunately, securing the airway poses significant and often unrecognised risks to sensitive structures such as the larynx. Pressure and trauma from an artificial airway may occur anywhere in the involved anatomical regions. There is a strong association between duration of intubation and development of airway complications. Long-term intubation may be associated with some form of stenosis in up to 20% of cases. When laryngostenosis becomes established, less than 20% of these cases will eventually be successfully decanulated. TImeous evaluation and early conversion to tracheotomy for patients intubated for longer than 5 - 7 days will prevent many of these unfortunate complications. S Afr Med J1998; 88: 1444-1447. SUMMARY C R van Schalkwyk, W A Mclntosh TRACHEOTOMY IN THE leD- CURRENT OPINIONS Department of Otorhinolaryngology, University of the Witwatersrand, Johannesburg C R van Schalkwyk, MB ChB, FCS (SA) W A McIntosh, MB ChB, FCS (SA), FRCS (Edin), FRCS (Glasg), FACS ovember 199 ,Vo!. ,No. 11 SAMJ ORIGINAL ARTICLES Oro/nasopharyngeal Sinusitis is often mentioned as a complication of prolonged endotracheal intubation. Opacification of maxillary sinuses during prolonged nasotracheal intubation has been reported to be as high as 96%; even with orotracheal intubation this figure may be as high as 22.5%.' However, it should be pointed out that not every opacified sinus in an reu setting is a clinically significant sinusitis; for the diagnosis of reu sinusitis to be confirmed, an organism cultured from the sinus under sterile conditions should correspond with a bacteriological culture obtained from the blood. Under these stringent conditions true reu sinusitis is not that common' The performance of thorough oral hygiene and mouth care is certainly limited by the presence of a tube in the oral cavity. Pressure effects from endotracheal tubes may cause ulceration of mouth corners or nasal alae. lo Sloughing of inferior turbinates and even sloughing of the soft palate has been seen. Laryngeal trauma The position of the larynx relative to the oropharynx and trachea is such that any rigid structure passing through all three will tend to impinge on the posterior surface of the larynx and cause maximum pressure effects in this area." The rigidity of the posterior cricoid lamina will greatly enhance these effects. Pressure on the mucosa that exceeds capillary filling pressure will result in ischaemia and eventually lead to necrosis of the tissue. The end result is a laryngeal pressure sore in the posterior glottis. The cricoid is the only complete ring in the upper respiratory tract above the carina, making it the most important part of the laryngeal skeleton as far as injury is concerned." Trauma to the cartilage often leads to resorption and constriction, which in turn results in a subglottic stenosis. An indwelling endotracheal tube is quite capable of causing this kind of trauma. Traumatic intubation may result in dislocation of an arytenoid, most commonly the left one," the reason for this being that the tube enters the oral cavity from the right side and then impinges obliquely on the left side of the larynx. Unless this is noticed and corrected immediately the chances of ever having a normally functioning crico-arytenoid joint again are slim indeed. Damage to the nerve supply of the larynx is thought to occur when an inflated cuff is situated high in the airway, causing pressure effects on the anterior branches of the recurrent laryngeal nerves as they pass between the cricoid and arytenoid cartilages. This may result in a unilateral, or more rarely a bilateral, vocal cord palsy. The normal larynx exhibits phasic movements associated with breathing. Loss of the transglottic airflow resistance leads to an absence of phasic inspiratory abduction, resulting in an effectively immobilised larynx. Once endotracheal intubation has caused ulceration in the larynx, the patient is already in trouble. Performing a tracheotomy may remove the insult, but the resulting immobile, traumatised larynx with apposition of raw surfaces is the perfect setting for a posterior glottic fusion." Tracheal trauma Any inflated cuff in the tracheal lumen will have an abrasive effect on the mucosa, depending on the amount of movement taking place. ls With oro- or nasotracheal tubes cuff movement may be as much as a centimetre or more with flexion or extension of the head. Tracheotomy tubes also have some movement, but not of the same magnitude as the longer tubes. As far as damage caused by cuff pressure is concerned, it is accepted that the pressure effects of the cuffs of endotracheal and tracheotomy tubes are for all practical intents and purposes vi.rrually identical. '
It is quite clear from the previous paragraphs that the effects
of endotracheal intubation may be found at all anatomical levels of the upper airways. Tracheotomy, on the other hand, bypasses the first two levels, which from a laryngologist's perspective is appealing because it spares the very sensitive and vulnerable larynx. INTUBATION V. TRACHEOTOMY Intubation Advantages of intubation to the reu physician are that no surgeon is required and no surgery is involved. The reu physician can perform it and there is no need for ca-ordination with any other specialty. Accessibility is good, with all the equipment immediately available in the reu, and it is usually a very quick procedure. Although intubation is perceived to be a reversible procedure, it should be pointed out that if laryngeal trauma occurs, it might not be as reversible as one would like it to be. Several disadvantages are associated with ora- and nasotracheal intubation. Both oral and nasal endotracheal tubes may be difficult to secure" and suctioning of a long thin tube is often problematic. Oropharyngeal and nasal trauma have been mentioned before, but certainly bear emphasising again. Sinusitis is probably less common than previously thought, but most authors agree that removal of a nasal tube is indicated if the diagnosis is suspected. By far the most important disadvantage of endotracheal intubation is the trauma inflicted on the larynx and the resultant impairment of its dynamic functions. Tracheotomy A tracheotomy tube is easier to suction and secure than oral or nasal tubes and certainly simplifies airway care." Although there is a reduction of ventilatory dead space in the order of 50%, it is rarely considered to be of Significant clinical advantage. tO Tracheotomy is much more comfortable for the ORIGINAL ARTICLES _._---- ===:::::::::>- ITracheotomy I mm I I patient who is conscious and aware, and because there is less movement of the cuff than with the endotracheal tubes, there is less mucosal abrasion. l7 However by far the most important advantage of a tracheotomy is the fact that the larynx is bypassed. Surgical complications are some of the most often-quoted disadvantages of tracheotomies. However operative morbidity overall is less than 6%, even for tracheotomies performed in the ICU.'8 Mortality directly attributable to the procedure is rare. l9 The presence of a purulent-appearing discharge from a tracheotomy site in the early postoperative phase is quite a common finding. It is, however, unusual for this to be a sign of true stoma sepsis. Much has been written about the psychological impact of having a tracheotomy.l7 When one looks at the overall psycholOgical implications for the patient requiring ICU admission, however, the tracheotomy contribution per se pales into relative insignificance. Because a tracheotomy bypasses the transglottic airflow, causing loss of the adductor reflex, an unexpected exacerbation of aspiration might occur.'" TIMING OF TRACHEOTOMY The timing of an elective tracheotomy remains controversial. The plethora of opinions on the subject is evidence of the fact that no clear answer exists. Rather an opinion should be formulated based upon an understanding of the pathophysiological factors involved. In 1984 Whited pointed out the association between duration of intubation and the occurrence of post-intubation laryngostenosis." Patients intubated for less than 5 days did not demonstrate any laryngostenosis, whereas the incidence rose to 14% for patients intubated for longer than 10 days. It is accepted that long-term intubation may be associated with some form of stenosis in up to 20% of cases. In 1992 Feinstein 22 looked at patients with established laryngeal trauma and compared intubation with non- intubation trauma. In the group with non-intubation trauma there was a 91% resolution rate, as opposed to the intubation group, where less than 20% of patients had resolution of their symptoms more than 2 years after onset. To be fair, the figures do not compare apples with apples, because the non-intubation group was treated correctly, whereas in our opinion the intubation group was not. It does, however, highlight the implications of laryngeal trauma that is not recognised and managed adequately. Opponents of early tracheotomy for possible long-term intubation point out that less than 20% of patients develop intubation-related complications and that therefore 80% of tracheotomies would have been performed unnecessarily. On the other hand, four out of five patients who do develop laryngeal fibrosis will end up being permanent laryngeal cripples with long-term tracheotornies. 22 To place the situation in numerical perspective, if 100 patients were intubated for longer than 10 days, 20 would be at risk of developing some form of laryngostenosis." Of these 20 patients, 16 run a serious risk of being permanent laryngeal cripples." If, on the other hand, the 100 patients had all undergone early tracheotomy, less than 5 would have developed an associated major or minor complication. l9 In certain instances it is possible to individualise the decision 'regarding when the correct time would be to perform an elective tracheotomy. A patient who is unlikely to survive does not require an elective tracheotomy; on the other hand, a patient who at the time of admission to the lCV is expected to require ventilation for longer than 7 days should have an elective tracheotomy performed as soon as possible. As a general rule of thumb a decision between continued intubation and conversion to tracheotomy should be made by day 5 - 7 for adult patients. Ideally this decision should be based on a thorough endoscopic assessment of the larynx.13 If a patient is too unstable at this stage for endoscopy to be performed safely and still cannot be extubated, then a tracheotomy is indicated. If endoscopy is successful and trauma is found to be limited to oedema of the cords, superficial mucosal ulceration, or a small amount of granulation tissue, then intubation can probably be continued for another 48 - 72 hours before reassessment. If, however, deep ulceration has occurred with exposed perichondrium or cartilage, the patient should be extubated as soon as possible or .converted to a tracheotomy to prevent any further damage (see algorithm).13 The dilemma faced is that if the decision to perform a tracheotomy is postponed until evidence of laryngeal trauma is found, then that patient is already at I Day '-2 Intubation for >7days? I /, ~ ~ U IDay 5-7 Intubation for >7days? I ====:::>>- ITracheotomy I I Assess larynx I= IUnable I :>- ITracheotomy I , . - - , - - - - ~ - ,---- Superficial trauma I I Deep trauma I IExtubatable? I /\ ~ ~ ---(> ITracheotomy I Intubation tracheotomy algorithm. o\'ember 199 ,Vol. , No. 11 SAMJ ORIGINAL ARTICLES significant risk of developing laryngostenosis. The key to success is to prevent damage in the first place. The argument has also been raised that the most pressure effects in the airway are found at the level of the cuff and that these are the same for both endotracheal and tracheotomy tubes. Although this is true, it should be seen in perspective. Firstly, the trachea is not a dynamic structure; secondly, because it is not a circumferentially rigid structure, it is not as sensitive to pressure effects as the larynx; and thirdly, tracheal stenosis is much more amenable to surgical correction than laryngostenosis. CONCLUSION In an ideal world no tube would ever pass through any larynx. Unfortunately we do not live in an ideal world, which is one of the reasons why we have ICUs and potential for long-term intubation. A significant amount of time, energy and money is spent on prevention of bedsores. Patients are placed on ripple mattresses, turned regularly and rubbed with alcohol. Our plea is that the state of 'laryngeal bedsores' be similarly recognised, its implications realised, and its prevention vigorously pursued. References 1. Van Heum LWE. Brink PRG, Kootstra G. De gesc.hiedenis van de tracheotomie. Ned Tijdschr Gmmkd 1995; 139, 2674-2678. 2. Alberti PW. Tracheotomy versus intubation. A 19th century controversy. Ann Otol Rhino LAryngoI1984; 93, 333-337. 3. Goodal1 EW. The story of tracheotomy. British Journal of Childrm's Diseases 1934; 31: 167-176. .;. Jackson c. Tracheotomy. LAryngoscope 1909; 19, 285-290. 5. Galloway TC Tracheotomy in bulbar poliomyelitis. JAMA 194-3; 123: 1096-1097. 6. Lassen HCA. A preliminary report on the 1952 epidemic of poliomyelitis in Copenhagen with special reference to the treatment of acute respiratory insufficiency. LAncet 1953; 1: 37- .;!. 7. Boyd AD, Romita MC, Conlan AA, Fink 50, Spencer Fe A clinical evaluation of cricothyroidotOffi}'- Surg Gyllecol Obstet 1979; 149: 365-368. 8. Rouby jJ, Laurent P, Gosnach ~ , t , et al. Risk factors and clinical relevance of nosocomial maxillary sinusitis in the critically ill. Am JRespir Crit Care Med Im; 150: 776-783. 9. Weymuller EA jun, Rice OH. Surgical management of infectious and inflammatory disease. In, Cummings CW, Fredrickson ~ I , Harker LA, Krause Cj, 5chuller DE, eds. Otolo'Yngology - Head and Neck Surgery. 2nd ed. St Louis, Mosby-Year Book, 1993, 9- 960. 10. Da\-is NJ. Endotracheal intubation and tracheostomy. In: Oh TE, ed. Intensive Core M!lnll.al. Sydney: Buttenvorths, 1990: 150-153. 11. Heffner JE. TlID.ing of tracheotomy in mechanically ventilated patients. Am Rev Respir Dis 1993; 147, 768-771. 12. Cotton RT, Myer CM. Contemporary surgical management of laryngeal stenosis in children. AmJOtoloryngoI1984; 5, 360-368. 13. Benjamin B. Laryngeal trauma from intubation: Endoscopic evaluation and classification. In: Cummings CW, Fredrickson JM, Harker L-'\, Krause Cj, 5chuller OE, eds. Otolaryngology- Head and Nrck Surgery. 2nd ed. St Louis' "Iosby-Year Book, 1894-1895. 14. Asher VA, 5asaki cr, Gracco Le Laryngeal physiology. In, Fried MP. The LArynx. A Multidisdplinary Approach. 2nd ed. St Louis' Mosby-Year Book, 1996, 51-53. 15. Zalzal GH. Cotton RT. Glottic and subglottic stenosis. In: Cum.mings CW, Fredrickson IM, Harker LA, Krause Cl, 5chuller DE, e<!s. Otolaryngology - Head and Neck Surgery. 2nd ed. St Louis, Mosby-Year Book, 1993, 198-1. 16. Coppolo Dr. May JJ. 5elf-extubatioos. A 12-month experience. Chest 1990; 98, 165-169. 17. Astrachan 01, Kirchner JC, Goodwin WJ jun. Prolonged intubation vs tracheotomy: Complications, practical and psychological considerations. Laryngoscope 19 ': 98: 1165-1169. 18. Pogue MD, Pecaro BC. Safety and efficiency of elective tracheostomy performed in the intensive care unit. / Oral MDXilloJac Surg 1995: 53: 895-897. 19. Stock MC, Woodward CG, Shapiro BA, Cane RD, Lewis V, Pecaro B. Perioperative complications of elective tracheostomy in aitically ill patients. Crit Care Med 1986; 14: 861- 863. 20. Sasaki cr, Suzuki M, Horiuchi M, Kirchner JA. The effect of tracheostomy on the laryngeal closure reflex. LAryngoscope 1977; 87, 1428-1433. 21. Whited RE. A prospective study of laryngotracheal sequelae in long-term intubation. LAryngoscope 198-l; 94, 367-377. 22. Feinstein JH. A four year retrospective analysis of laryngeal trauma at the Johannesburg HospitaL MNted (OrI) thesis, University of the Wit\vatersrand, Johnannesburg. 1992.. OUTCOME OF MECHANICAL VENTILATION IN CHILDREN INFECTED WITH THE HUMAN IMMUNODEFICIENCY VIRUS L Rudo Mathivha, David K Luyt, Hubert Hon, Melanie Dance, Menachem Litmanovitch ABSTRACT Objective. To evaluate and compare the outcome of HIV- positive (HIV+) and negative (HIV-) paediatric patients presenting with severe community-acquired pneumonia and requiring mechanical ventilation for respiratory failure. Design. Prospective descriptive analysis. Setting. Multidisciplinary intensive care unit (lCD) in a tertiary care university-based referral hospital, staffed by paediatric intensivists and anaesthetists. Patients. All 110 paediatric patients admitted to the ICD with severe community-acquired pneumonia requiring mechanical ventilation during the 2 years 1992 through 1993. No patient had any defined clinical manifestations of acquired immunodeficiency syndrome on admission to the lCU. Methods. HIV infective status was determined by p24 antigen detection. Age, nutritional status, predicted mortality, ventilatory requirements, oxygenation indices, other organ dysfunction and mortality were compared between the 17 HIV+ and 93 HIV- patients. Results. The patient groups did not differ significantly with regard to age or nutritional status. The ventilatory requirement measurements, positive end-expiratory pressure time product, fraction of inspired oxygen (FiO,) time product, and measurements of oxygenation were significantly worse in HIV+ patients_ IDV+ patients had a mean predicted mortality of 40_1% compared with 22.2% in HIV- patients on admission. Mortality was dose to predicted in the HIV- group at 31% (29/93), while in the HIV+ patients mortality at 88% (15/17) was significantly worse than predicted. All deaths in the HIV+ group were due to severe respiratory failure. Intensive Care Uni/, Department of Anaesthesia and Intensive Care, Chris Hani Baragwanath Hospital and University of the Witwatersrand, Johannesburg L Rudo Mathivha, FCPaed (SA), FCCrit Care David K Luyt, FCPaed (SA), FCCrit Care Hubert Hon, FCPaed(SA) Melanie Dance, FCPaed (SA), FCCrit Care Menachem Litmanovitch, MD