Adverse effects of Endotracheal Intubation
OVERVIEW
- Can be classified anatomically or into immediate, short and long term complications.
- Below is anatomically.
AIRWAY
- Dental Trauma
- Failure to intubate
- careful assessment of risk factors (history, examination, previous intubations)
- optimal positioning
- having a back up plan to provide oxygenation (bagging, LMA, guedels, nasopharyngeal airways, trans-tracheal airways)
- Failure to Ventilate or Oxygenate (see above)
- Damage to airway (cord injury, false passage creation)
- multiple laryngoscopies
- intubation for a prolonged length of time
- limit laryngoscopies
- have a back up plan
- gentle manipulation with airway devices
- Oesophageal intubation
- ETCO2 use
- Subglottic stenosis
- assessment for early extubation
- vigilant cuff pressure measurement
- early tracheostomy
- Tracheo-oesophageal Fistula (see subglottic stenosis above)
RESPIRATORY
- Endobronchial intubation
- careful attention on insertion
- clinical assessment after intubation
- CXR
- Aspiration
- aspiration of N/G tubes
- starve if able
- prokinetics
- rapid sequence induction
- Bronchospasm
- if occurs can treat with: salbutamol, adrenaline, ketamine, Mg
- Hypoxia from de-recruitment of lungs
- conversion from spontaneous ventilation -> positive pressure ventilation results in de-recruitment when patient apnoeic
- preoxygenation
- quick securement of airway
- increasing PEEP on ventilator
- Sputum retention + pneumonia
- head up
- suction
- chest physio
- early antibiotics
- Barotrauma
- protective lung ventilation
CARDIOVASCULAR
- Hypotension (cardiovascular collapse)
- multi-factorial: drug induced, patient often have high sympathetic tone which is obtunded with induction of anaesthesia
- use of balanced, haemodynamically stable agents for induction
- judicious use of vasoactive medications
- assess for tension pneumothorax and decompress if indicated
- Hypertension and Myocardial Ischemia
- from laryngoscopy and tracheal stimulation
- balanced anaesthetic on induction
NEUROLOGICAL
- Increased ICP
- obtund haemodynamic response to laryngoscopy with hypnotic and fasting acting opioid
- Potential spinal cord injury on laryngoscopy in patient with an unstable cervical spine
- inline immobilisation
- awake fiber-optic intubation
- Requirement for sedation and analgesia
OTHER
- Adverse drug reactions
- Bacteraemia
- Requirement for close monitoring (one-one nursing care)
References and Links
CCC Airway Series
Emergencies: Can’t Intubate, Can’t Intubate, Can’t Oxygenate (CICO), Laryngospasm, Surgical Cricothyroidotomy
Conditions: Airway Obstruction, Airway in C-Spine Injury, Airway mgmt in major trauma, Airway in Maxillofacial Trauma, Airway in Neck Trauma, Angioedema, Coroner’s Clot, Intubation of the GI Bleeder, Intubation in GIH, Intubation, hypotension and shock, Peri-intubation life threats, Stridor, Post-Extubation Stridor, Tracheo-esophageal fistula, Trismus and Restricted Mouth Opening
Pre-Intubation: Airway Assessment, Apnoeic Oxygenation, Pre-oxygenation
Paediatric: Paediatric Airway, Paeds Anaesthetic Equipment, Upper airway obstruction in a child
Airway adjuncts: Intubating LMA, Laryngeal Mask Airway (LMA)
Intubation Aids: Bougie, Stylet, Airway Exchange Catheter
Intubation Pharmacology: Paralytics for intubation of the critically ill, Pre-treatment for RSI
Laryngoscopy: Bimanual laryngoscopy, Direct Laryngoscopy, Suction Assisted Laryngoscopy Airway Decontamination (SALAD), Three Axis Alignment vs Two Curve Theory, Video Laryngoscopy, Video Laryngoscopy vs. Direct
Intubation: Adverse effects of endotracheal intubation, Awake Intubation, Blind Digital Intubation, Cricoid Pressure, Delayed sequence intubation (DSI), Nasal intubation, Pre-hospital RSI, Rapid Sequence Intubation (RSI), RSI and PALM
Post-intubation: ETT Cuff Leak, Hypoxia, Post-intubation Care, Unplanned Extubation
Tracheostomy: Anatomy, Assessment of swallow, Bleeding trache, Complications, Insertion, Insertion timing, Literature summary, Perc. Trache, Perc. vs surgical trache, Respiratory distress in a trache patient, Trache Adv. and Disadv., Trache summary
Misc: Airway literature summaries, Bronchoscopic Anatomy, Cuff Leak Test, Difficult airway algorithms, Phases of Swallowing
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC
