1 Indeed, complications increase 7-fold after the second and third laryngoscopy attempts. Skill level inversely correlates with number of attempts at laryngoscopy, with higher skill levels correlating with fewer attempts, and repeated laryngoscopy attempts may lead to tissue trauma, edema, and bleeding. The skill level of the provider who performs the intubation has also been studied as a potential risk factor for airway complications. Patients are also more likely to be hemodynamically unstable, a condition that might contribute to the complexity of intubation in this setting. 1 Emergent airway management often requires physicians to intervene urgently, without adequate time to obtain a thorough patient history. 5 However, the incidence of difficult intubation is higher in the emergent setting compared with elective procedures (8–12 vs 6%). Nevertheless, 39% of airway injuries described in a closed-claims analysis were associated with difficult emergent intubations, even though the incidence of difficult intubation among patients undergoing elective surgery has been reported to be only 5.8%.
As might be expected, intubations categorized as difficult pose a higher risk of injury than do those that are not difficult.
In attempts to diminish morbidity and to improve patient care, many have sought to define the risk factors for airway injury during endotracheal intubation. We will review both categories of injury and focus on risk factors, pathogenesis, presentation, and management of some of the most commonly seen complications. Other injuries, such as laryngotracheal stenosis and vocal fold paralysis, may result from tissue-endotracheal tube (ETT) interactions, even if intubation was performed without direct tissue trauma. Some injuries, such as soft tissue hematomas, lacerations, and arytenoid dislocation, may result from the initial act of intubation. This review article will discuss several types of airway complications from endotracheal intubation. In addition, repeated admissions were more frequent in the injured cohort. Patients with intubation-related injuries increased hospital costs by 20%, and stay was 1 d longer than it was for matched patients without intubation injury. Beyond medicolegal issues, intubation-related injury is also a significant financial burden. Data from England documented by Cook et al 3 demonstrate a similar percentage of claims related to airway management (8%). 2 6% of claims against anesthesiology providers were for airway injury, with the larynx being the most common site of injury, followed by the pharynx and the esophagus. According to a closed-claims analysis by Domino et al. 1 Such injuries can occur at the initiation of intubation or can develop as a result of prolonged intubation. The incidence of airway injury caused by endotracheal intubation ranges from 0.5 to 7%. These can range from minor soft tissue injuries to severe, long-term, life-threatening airway complications. However, endotracheal intubation is not risk-free, and its complications are well described in the literature. Endotracheal intubation is a basic skill performed daily by health care professionals throughout the world and is a relatively safe maneuver. The establishment of an adequate airway is integral to managing patients both in the elective operating room setting and in the emergent nonoperating room setting. Finally, potential strategies to prevent intubation-associated injuries are outlined. This article also includes a review of complications of airway management pertaining to video laryngoscopy and supraglottic airway devices. We discuss the proposed mechanisms of tissue damage that relate to each and present their most common clinical manifestations, along with their respective diagnostic and management options. Injuries covered include nasoseptal injury, tongue injury, dental injury, mucosal lacerations, vocal cord immobility, and laryngotracheal stenosis, as well as tracheomalacia, tracheoinnominate, and tracheoesophageal fistulas. In this article, we review the impact of endotracheal intubation on airway injury by describing the acute and long-term sequelae of each of the most commonly injured anatomic sites along the respiratory tract, including the nasal cavity, oral cavity, oropharynx, larynx, and trachea. Although endotracheal intubation is commonly performed in the hospital setting, it is not without risk.