Self-extubation after major trauma: another trauma?

Self-extubation can lead to detrimental outcomes for the patient. Complications that result from self-extubation range from laryngeal injury, respiratory distress, arrhythmia, pneumonia, to even death. With respect to patient safety, not only is prevention of self-extubation one of the most important goals in all intensive care units around the world, but also it is one of the most common mishaps in the area of intensive care. Since self-extubation and consequent re-intubation are unexpected events, they can embarrass the medical staff and negatively affect the treatment choice, and consequently, require other invasive procedures that may not have been necessary. The most important thing for patients exposed to self-extubation is to keep in mind the presence of airway damage, which can be confirmed through our experience as described here, through repeated re-intubations and eventually tracheostomy.

Head-neck movement may predispose to the development of arytenoid dislocation in the intubated patient: a 5-year retrospective single-center study

Background Arytenoid dislocation is a rare laryngeal injury that may follow endotracheal intubation. We aimed to determine the incidence and risk factors for arytenoid dislocation after surgery under general anaesthesia. Methods We reviewed the medical records of patients who underwent operation under general anaesthesia with endotracheal intubation from January 2014 to December 2018. Patients were divided into the non-dislocation and dislocation groups depending on the presence or absence of arytenoid dislocation. Patient, anaesthetic, and surgical factors associated with arytenoid dislocation were determined using Poisson regression analysis. Results Among the 25,538 patients enrolled, 33 (0.13%) had arytenoid dislocation, with higher incidence after anterior neck and brain surgery. Patients in the dislocation group were younger (52.6 ± 14.4 vs 58.2 ± 14.2 yrs, P = 0.025), more likely to be female (78.8 vs 56.5%, P = 0.014), and more likely to be intubated by a first-year anaesthesia resident (33.3 vs 18.5%, P = 0.048) compared to those in the non-dislocation group. Patient positions during surgery were significantly different between the groups (P = 0.000). Multivariable Poisson regression identified head-neck positioning (incidence rate ratio [IRR], 3.10; 95% confidence interval [CI], 1.50–6.25, P = 0.002), endotracheal intubation by a first-year anaesthesia resident (IRR, 2.30; 95% CI, 1.07–4.64, P = 0.024), and female (IRR, 3.05; 95% CI, 1.38–7.73, P = 0.010) as risk factors for arytenoid dislocation. Conclusion This study showed that the incidence of arytenoid dislocation was 0.13%, and that head-neck positioning during surgery, less anaesthetist experience, and female were significantly associated with arytenoid dislocation in patients who underwent surgeries under general anaesthesia with endotracheal intubation.

Risk factors of laryngeal injuries in extubated critical pediatric patients

Background The larynx in children is unique compared to adults. This makes the larynx more prone to trauma during intubation. Under sedation and frequent repositioning of the tube are recorded as risk factors for laryngeal injury. We examined the larynx of 40 critically ill children in the first 24 h after extubation to estimate the frequency and analyze the risk factors for laryngeal trauma using the classification system for acute laryngeal injury (CALI). Results The post-extubation stridor patients had a higher frequency of diagnosis of inborn errors of metabolism, longer duration of ventilation, longer hospital stay, moderate to severe involvement of glottic and subglottic area, frequent intubation attempts, and more than 60 s to intubate Regression analysis of the risk factors of severity of the injury has shown that development of ventilator-associated pneumonia carried the highest risk (OR 32.111 95% CI 5.660 to 182.176), followed by time elapsed till intubation in seconds (OR 11.836, 95% CI 2.889 to 48.490), number of intubation attempts (OR 10.8, CI 2.433 to 47.847), and development of pneumothorax (OR 10.231, 95% CI 1.12 to 93.3). Conclusion The incidence of intubation-related laryngeal trauma in pediatric ICU is high and varies widely from mild, non-symptomatic to moderate, and severe and could be predicted by any of the following: prolonged days of ventilation, pneumothorax, multiple tube changes, or difficult intubation.

Role of Tracheostomy in Dealing with Penetrating Neck Trauma: A Double Edged Sword

Background Penetrating neck trauma is an injury in which platysma muscle in neck is breached. It is a life threatening emergency and it requires urgent management by securing airway and neck exploration. Tracheostomy is one of the important procedures as it secures the airway though associated with complications and morbidity in the patients. Case Presentation We present 3 cases of penetrating neck trauma. Each patient is managed by different means of securing airway depending on the site of trauma and associated laryngeal injury. Conclusion Tracheostomy in penetrating neck trauma helps in securing the airway and paves way for safe neck exploration. Minor laryngeal injuries are managed conservatively in order to avoid complications associated with tracheostomy. Tracheostomy and other means of airway management in penetrating neck trauma depend mainly on individualised approach though tracheostomy at a lower site to that of wound should be preferred in major laryngeal injuries. Keywords: Penetrating Neck Trauma; Tracheostomy; Laryngeal Injuries; Airway Management.

Postacute COVID-19 Laryngeal Injury and Dysfunction

Objective Patients with COVID-19 are at risk for laryngeal injury and dysfunction secondary to respiratory failure, prolonged intubation, and other unique facets of this illness. Our goal is to report clinical features and treatment for patients presenting with voice, airway, and/or swallowing concerns postacute COVID-19. Study Design Case series. Setting Academic tertiary care center. Methods Patients presenting with laryngeal issues following recovery from COVID-19 were included after evaluation by our laryngology team. Data were collected via retrospective chart review from March 1, 2020, to April 1, 2021. This included details of the patient’s COVID-19 course, initial presentation to laryngology, and subsequent treatment. Results Twenty-four patients met inclusion criteria. Twenty (83%) patients were hospitalized, and 18 required endotracheal intubation for a median (range) duration of 14 days (6-31). Ten patients underwent tracheostomy. Patients were evaluated at a median 107 days (32-215) after their positive SARS-CoV-2 test result. The most common presenting concerns were dysphonia (n = 19, 79%), dyspnea (n = 17, 71%), and dysphagia (n = 6, 25%). Vocal fold motion impairment (50%), early glottic injury (39%), subglottic/tracheal stenosis (22%), and posterior glottic stenosis (17%) were identified in patients who required endotracheal intubation. Patients who did not need intubation were most frequently treated for muscle tension dysphonia (67%). Conclusion Patients may develop significant voice, airway, and/or swallowing issues postacute COVID-19. These complications are not limited to patients requiring intubation or tracheostomy. Multidisciplinary laryngology clinics will continue to play an integral role in diagnosing and treating patients with COVID-19–related laryngeal sequelae.

Laryngopharyngeal Reflux and GERD

Since the early 1990s, the consequences of extra-esophageal reflux in the larynx have been recognized to be related to a variety of laryngeal symptoms with certain endoscopic manifestations. The paper by Dr. Koufman described various types of laryngeal injury which were attributed to extra-esophageal reflux also known as laryngopharyngeal reflux (LPR). The mechanism of injury was postulated to be a consequence of acid refluxate as well as from pepsin. Since that time there has been a surge of literature devoted to the topic of LPR seeking to refine its diagnosis, elucidate its pathophysiology, and treat its symptoms and sequelae. Our goal in this chapter is to provide a balanced, evidence-based framework for identifying LPR and providing treatment while balancing the benefits versus the risks of overtreatment and escalating therapy. This review contains 13 figures, 7 tables and 49 references. Key Words: LPR, GERD, PPI, RSI, TLESR