Complications of tracheal intubation are pathological conditions that occur when an intubation tube is inserted into the respiratory tract. The symptoms depend on the type of undesirable consequences. Diffuse cyanosis, barking cough, hemoptysis may occur. In the absence of timely sanitation, wheezing and gurgling can be heard at a distance. After removing the equipment, there is a sore throat. Diagnostic methods include direct laryngoscopy, examination of the oral cavity, the entrance to the trachea. If necessary, bronchoscopy, X-ray examination of the respiratory tract is performed. Treatment involves the removal of sputum using an electric pump, the correct installation of TI the introduction of hemostatics, painkillers, anti-inflammatory drugs.
T88.4 Unsuccessful or difficult intubation
Adverse events during intubation and after its completion occur with varying frequency. Laryngeal infections are diagnosed in 1 patient per thousand, edema and paralysis of the vocal cords – in 3 patients out of a thousand. Iatrogenic complications associated with severe intubation and a short thick neck of the patient are noted in 5-10% of cases. Errors of the doctor caused by inexperience and violation of the manipulation algorithm make up no more than 0.5% of the total number of laryngoscopies. Difficulties are significantly more often observed when working with overweight patients with increased body weight, suffering from endemic goiter or organic changes in the upper respiratory tract. This group consists of 60% women, 40% men.
Difficulties directly with the introduction of the tube are more likely to arise due to a medical error. With prolonged ventilation using endotracheal access, some processes occurring in the respiratory tract are not determined by the work of an anesthesiologist / resuscitator. Problems that are detected after extubation are not always directly associated with the actions of a specialist. Common causes of pathology include:
- Incorrect installation of the blade. The laryngoscope should not put pressure on the teeth in the lower direction. The tool can rely on them, but hard pressure must be avoided. Otherwise, the chewing apparatus may be damaged, followed by debris entering the digestive or respiratory tract.
- Wrong position. Erroneous introduction of intubation equipment into the esophagus provokes overstretching of the stomach, can cause regurgitation. If the patient is intubated for vital indications, respiratory failure persists and progresses, which can lead to death.
- Trauma of the trachea. Complications develop with the use of large tubes, their careless administration, intubation without medication sedation, if the patient is conscious. Such negative consequences usually occur in emergency situations, are more often observed in patients who are in a state of psychomotor agitation.
- Nasal intubation. It is practiced in ENT interventions, mandibular abscesses, operations in the field of maxillofacial and plastic surgery. The reason for traumatization of the inner nose is the use of tubes that are not suitable in size, restless behavior of the patient, thinning of the mucous membrane and the superficial location of the vascular network.
- Accumulation of sputum. The lack of timely sanitation potentiates the obstruction of the tube and the development of hypoxia. The secret can form solid accumulations, stick to the walls of the equipment. Such consequences are eliminated by bronchoscopy with visual control. It is not always possible to clean the respiratory organs with a standard electric pump.
- Contamination with bacterial flora. The pathogen enters when the rules of asepsis are violated during intubation and ventilation. Clinical manifestations of infection can be detected both during ventilation (after a few days) and after removal of the tube.
- Individual reactions. They arise as an organism’s response to the introduction of a foreign body. More often they appear after a few hours from the moment of extubation. They can lead to impaired patency of the trachea, inflammatory infiltration of tissues, respiratory failure. They are practically unrelated to the actions of the doctor and the behavior of the patient himself.
The changes depend on the type of complication. With injuries to the respiratory tract, bleeding occurs, blood aspiration is possible, the development of pneumonia or bronchospasm. Due to the violation of the integrity of the mucous membrane, the probability of infectious processes increases, since the entrance gates for pathogenic flora are formed. Swelling or spasm of the vocal cords, obstruction of the tube by bronchial secretions lead to mechanical respiratory failure. The necessary amount of air does not enter the lungs, hypoxia forms, tissues experience oxygen starvation, the work of the brain and all vital systems is disrupted.
Infectious lesions cause inflammation, general intoxication, edema of the affected area. With the spread of the process, there is a risk of developing an infectious and toxic shock. The main danger of erroneous introduction of TI into the esophagus is persistent respiratory failure. Overstretching of the stomach does not entail a threat to the patient’s life, but creates difficulties during extubation (the risk of inhaling gastric contents).
Complications of tracheal intubation can be systematized for reasons (mechanical, infectious), according to the degree of influence of the doctor (iatrogenic, independent of the actions of a specialist, autoaggression), by pathogenesis (causing hypoxia, bleeding). However, the main one is the classification according to the time of development of negative consequences. In accordance with modern concepts , there are the following types of pathology:
- During intubation. When the tube is inserted, the patient has fractures of teeth, bleeding, ruptures of the mucous membranes, damage to the pharyngeal space, mediastinal emphysema. It is possible to form atelectasis of the opposite lung and single-lung ventilation when entering the bronchus, overstretching of the stomach with erroneous introduction of endotracheal equipment into the esophagus. When the vagus nerve is irritated, bradycardia develops up to cardiac arrest.
- After intubation. The obstruction of the hose may be determined due to its inflection or biting by the patient himself. With prolonged ALV or ventilator, there is an accumulation of sputum that interferes with the passage of the mixture, the formation of bedsores, hernial protrusion of the cuff. If the patient is mobile, the exit of the equipment from the trachea, twisting, the emphasis of the lower opening into the wall of the windpipe may be detected.
- During TI removal. Difficulties with removing equipment arise when the cuff is not completely deflated. There are injuries of the respiratory tract, ruptures of the mucous membrane. Immediately after the exit of TI from the trachea, the latter may collapse, followed by suffocation. If the patient is in a passive position on his back, there is a risk of aspiration of saliva with the development of aspiration pneumonia.
After removing the tube. On the first day, the appearance of soreness, swelling of the larynx is detected. Infectious complications manifest themselves in the period from 1 to 3 days of independent breathing. In the late period, ulcers, fibrosis of the larynx and trachea, stenosis of the nostrils during nasal intubation are diagnosed. Sometimes complications remain undiagnosed for a long time, are diagnosed accidentally during subsequent interventions for another reason.
Complications arising from the insertion of an endotracheal tube and ventilation differ in a variety of symptoms. Fractures of teeth are visible visually. There are fragments in the patient’s mouth, the affected tooth is visible. When the mucous membranes are traumatized, there is an outflow of blood from the mouth and nose. In the patient’s position on the back, extravasate accumulates in the oropharynx area, which allows you to notice it during laryngoscopy. The ingress of equipment into the esophagus is characterized by rhythmic bloating and falling of the abdomen, the absence of respiratory noises in the lungs. With unilateral intubation, one lung is tapped, the second is “mute”.
The snacking of the contour by the patient is determined visually. Obstruction by sputum leads to the appearance of typical wheezing. In both cases, the alarm system of the ventilator is activated, which emits a specific signal indicating obstruction of the respiratory tract. The patient has diffuse cyanosis, decreased SpO2, tachycardia, anxiety, excitement. Aspiration of sputum after extubation is manifested by progressive respiratory failure, symptoms develop within a few hours. Decompensation of the condition with the collapse of the trachea occurs almost immediately.
With laryngeal edema, a barking cough, shortness of breath of a mixed type, hoarseness of voice is detected. Massive phenomena lead to a symptom complex of ARF. Stenoses cause constant shortness of breath, moderate hypoxia, subjective feeling of heaviness of inhalation. Ulcers potentiate the occurrence of chronic inflammation, infectious complications, tracheitis, bronchitis. They may be accompanied by capillary bleeding with hemoptysis (up to 15 ml of blood is released per day) or hemorrhage (more than 15 ml).
Diagnosis of complications of tracheal intubation is made on the basis of physical examination data. If necessary, instrumental and laboratory techniques can be used. In most cases, it is possible to determine the pathological condition directly in the operating room or intensive care unit. Late complications of tracheal intubation are detected in the general department during outpatient follow-up of the patient. The following diagnostic procedures are used:
- Physical examination. During the examination of the ART and the general assessment of the patient’s condition, blood clots and sputum in the oropharynx are detected during injuries, cyanosis and the absence of a chest excursion with incorrect installation of TI. Auscultation of the lungs allows you to determine the degree of conduction of respiration and identify areas that do not receive air.
- Instrumental examination. The main method is bronchoscopy. During the procedure, the doctor examines the condition of the respiratory tract, confirms the correct installation of the equipment. If necessary, radiography, computed tomography can be used. According to the results of all studies, the tube should be in the trachea. In emergency situations, it is possible to assess the correctness of the procedure according to kapnosat data – during intubation into the esophagus, pCO2 will be zero.
- Laboratory examination. Required if late complications are suspected. Capillary bleeding leads to the development of anemia, infectious processes cause the appearance of nonspecific changes in the blood – an increase in ESR, leukocytosis. It is possible to determine the presence of hypoxia by shifting the pH of the blood to the acidic side and changing the gas composition of the blood.
If the tube is installed incorrectly, it is removed and a second attempt is made. Before that, oxygenation with 100% oxygen should be carried out for 2-4 minutes. If new attempts do not lead to success, it is possible to use the method of nasal intubation or the introduction of TI on the finger using a stiletto. In situations where these techniques are ineffective, installation of a laryngeal mask or non-invasive ventilation is allowed. If there is a need for prolonged artificial aeration, a tracheostomy is performed.
Mucosal injuries are an indication for therapeutic bronchoscopy. With the help of this procedure, bleeding is stopped, the severity of the damage is assessed. The introduction of hemostatic agents is recommended. Repeated intubation attempts are not made. Noninvasive ventilation (only after hemostasis), tracheostomy are considered possible options. The appointment of reparative means is allowed. Broad-spectrum antibiotics are used to prevent infectious complications.
In case of violation of the patency of the tube, the TBT is sanitized using suction or a bronchoscope. The procedure should be carried out every 2-4 hours or more often. Atropine is used to reduce the amount of discharge. If the patient is conscious and bites TI with his teeth, hypnotics and antipsychotic drugs are administered. The dosage is selected so as not to suppress attempts at independent breathing. If necessary, the introduction of peripheral muscle relaxants with subsequent transfer to forced ventilation is allowed.
Suffocation that occurs shortly after extubation requires reinsertion of the tube. It is not necessary to connect the patient to a ventilator in all cases. Complications are often caused by the collapse of the trachea, in which the general ability to breathe independently is not lost. Fibrosis and stenosis are corrected promptly in a planned manner after the patient has fully recovered. Infectious processes are eliminated with the help of antibiotics. To relieve laryngeal edema, inhalations of bronchodilators, glucocorticosteroids, vasoconstrictors are used.
Prognosis and prevention
Prognosis of complications of tracheal intubation is favorable. With timely diagnosis and medical care, complications are not accompanied by delayed consequences or death of the patient. In case of violations of the patency of RT without corrective measures, suffocation and death become the outcome. Biting the hose by the patients themselves does not lead to such consequences. Difficulties during intubation can be fatal with erroneous actions of the doctor and preliminary administration of muscle relaxants to the patient. If ventilation was not provided in time, cardiac arrest occurs against the background of hypoxia.
Prevention consists in a thorough study by an anesthesiologist-resuscitator of the algorithm of actions during difficult intubation, preparation of the necessary equipment. For rapid relief of complications, you should have an Ambu bag, a set for emergency tracheostomy or conicotomy, a laryngeal mask, a breathing apparatus, a set of drugs for resuscitation, a defibrillator, a pulse oximeter. In order to avoid tracheal pressure sores with prolonged ventilation, TI is replaced every 4 days. The amount of air injected into the cuff should not exceed 30 ml. The diameter of the tubes is selected in strict accordance with the size of the patient’s body. After extubation, the patient should stay in the ICU for at least 3-5 hours.