This chapter discusses complications of airway device—endotracheal tubes,
tracheostomy tubes, laryngeal stents, and laryngeal speech devices.
Acute complications of endotracheal intubation range from minor
to catastrophic. Minor complications include lip lacerations, corneal
abrasions,1 dental fractures, and tongue injuries,
all of which are usually avoidable with proper technique. More serious
complications of endotracheal intubation include damage to the soft
tissues of the larynx or pharynx and dislocation of the arytenoid
cartilage. Repetitive or blind intubation attempts are more likely
to result in this type of injury. Mucosal tears may present early
with immediate bleeding and subcutaneous emphysema, or late with
septic shock.2 Tracheal injuries are much more common
in women, perhaps because of the use of improperly large tubes.3 Mucosal
injuries usually require immediate surgical repair by an otolaryngologist.
If the endotracheal tube tip is placed in the soft tissue of
the neck through a mucosal tear, bag ventilation will be very difficult
and will cause subcutaneous emphysema with pneumothorax. If bag
ventilation is difficult, stop ventilating though the tube and consider
a surgical airway. See Chapter 30, Tracheal Intubation and Mechanical Ventilation for review of other complications
of endotracheal intubation.
The endotracheal tube itself may be the source of complications.4 Airway obstruction
can result from kinking or biting the tube or from secretions blocking
the tube. An overinflated cuff may herniate over the end of the tube
and obstruct it. If the obstruction cannot be cleared by suctioning or
modification of tube position, the tube must be replaced.
A standard adult tracheostomy is a surgical procedure in which
an opening is created between cartilaginous rings in the trachea,
and the skin of the neck is frequently sutured to the anterior tracheal
wall (Figure 242-1). In pediatric and some
adult tracheotomies, a vertical incision is made through two or
three tracheal rings, and the lateral edges are tagged with temporary
stay sutures. These sutures are usually removed before the patient
leaves the hospital.
Creation of a tracheal flap.
Skills needed for tracheostomy management in the ED include replacement
of an uncuffed with a cuffed tracheostomy tube for mechanical ventilation,
replacement after accidental decannulation, correction of tube obstruction,
and control of bleeding or infection at the tracheostomy site (Figure 242-2). Key information in managing
a tracheostomy includes why and when the procedure was performed
and what type of tracheostomy tube is currently being used. Determine
if the patient can be orally intubated if needed. Patients
who have undergone a laryngectomy or who have tumors or scarring
that occlude the upper airway cannot be orally intubated.
Steps in assessing a tracheostomy patient with respiratory
distress. ENT = ear, nose, and throat; ETT ...