Potential Complications of Intubation

In the clinical setting, intubation is a life-saving strategy. Consequently, mitigating potential complications of intubation, such as airway injury and respiratory infections, is a priority. While all patients are susceptible to complications, high-risk patient cohorts include the critically ill and neonates. Research shows that repeated tracheal intubation attempts are associated with a heightened risk of tracheal intubation-associated events (TIAEs), such as severe oxygen desaturation and hemodynamic instability, which adversely impact health outcomes. Multiple attempts are more common in neonates due to their small airways and anatomy, increasing the chance for minor and severe TIAEs.¹ Complications can also occur in other patient populations and can include discomfort, lacerations, perforation, vocal cord injury, and more.

Intubation complications occur because the tube is the incorrect size or the wrong technique has been implemented. Serious airway injuries may lead to subcutaneous emphysema or pneumothorax. Prolonged intubation can also cause airway trauma like tissue ischemia that leads to necrosis of the airway. In some cases, injury leads to long-term impacts on quality of life. For example, laryngeal injury can lead to vocal cord dysfunction or tracheal stenosis. Psychological crises may follow adverse events, and patients may suffer from anxiety, depression and post-traumatic stress disorder. These complications underlie the significance of training highly skilled healthcare professionals who can intubate effectively.^{1, 2}

Reinforcing sterility training among clinicians can reduce the infection caseload among intubated patients. Challenges to adequate sterilization include poor hand washing and sterilization protocol among healthcare professionals. Infections during intubation also arise due to bacterial resistance to antibiotics. Aerosols have been identified as another source of infection.

Manipulation of the airway during intubation and extubation generates aerosols that create the potential for transmission of infections which would otherwise only be transmissible by the droplet route. These types of complications were widespread during the COVID-19 pandemic, presenting clinicians with a massive challenge. To identify route of transmission, researchers used fluorescent markers to track the deposition of infectious agents post-intubation. The exposed facial skin, hair, and shoes of the health care personnel tested positive for infectious agents which could be inadvertently transmitted as personnel navigated patients, colleagues and family. To mitigate this, intubation was only performed on critically ill COVID-19 patients, and PPE and barriers were used to reduce the spread of infectious particles.^1,3

Research aims to continue improving outcomes and reducing complications for intubation. Merelman et al. report using ketamine to improve the accessibility of the airway in patients under general anesthesia.  Lim et al. find that the use of the ProSeal™ laryngeal mask airway is the superior choice to laryngoscope-guided tracheal intubation for gynecological laparoscopy. Their study found an improvement in the following variables – reduced time used to prepare the airway, ventilation, airway pressure, surgery duration and hemodynamic responses.^4,5 Additional studies will help clinicians to further improve quality of care.

References

1. Singh, Neetu, et al. “Impact of Multiple Intubation Attempts on Adverse Tracheal Intubation Associated Events in Neonates: A Report From the NEAR4NEOS.” Journal of Perinatology, vol. 42, no. 9, Aug. 2022, pp. 1221–27, doi:10.1038/s41372-022-01484-5.

• Hyzy, Robert C., and Scott Manaker. “Complications of the Endotracheal Tube Following Initial Placement: Prevention and Management in Adult Intensive Care Unit Patients.” UpToDate, edited by Geraldine Finlay, 1 Feb. 2023, www.uptodate.com/contents/complications-of-the-endotracheal-tube-following-initial-placement-prevention-and-management-in-adult-intensive-care-unit-patients.

• Weissman, David N., et al. “COVID-19 and Risks Posed to Personnel During Endotracheal Intubation.” JAMA, vol. 323, no. 20, May 2020, p. 2027, doi:10.1001/jama.2020.6627.

• Merelman et al. “Alternatives to Rapid Sequence Intubation: Contemporary Airway Management With Ketamine.” The Western Journal of Emergency Medicine/Western Journal of Emergency Medicine, vol. 20, no. 3, Apr. 2019, pp. 466–71, doi:10.5811/westjem.2019.4.42753.

• Lim, Y., et al. “The ProSeal^TM Laryngeal Mask Airway Is an Effective Alternative to Laryngoscope-Guided Tracheal Intubation for Gynaecological Laparoscopy.” Anaethesia and Intensive Care/Anaesthesia and Intensive Care, vol. 35, no. 1, Feb. 2007, pp. 52–56, doi:10.1177/0310057×0703500106.