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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.

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.

Figure 242-2.

Steps in assessing a tracheostomy patient with respiratory distress. ENT = ear, nose, and throat; ETT ...

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