Complications of endotracheal intubation

By Alex Yartsev - 16/06/2016

Question 23 from the second paper of 2005 asked the candidate to "list the potential adverse effects of endotracheal intubation". Judging from the college answer, they were after the specific complications of intubation, rather than the broader complications of invasive mechanical ventilation.

With only a few additional embellishments, the following table of complications and their solutions is presented here copied and pasted straight from Question 23. The model for this table was the excellent review article by Divatia and Bhowmick (2005), which can be recommended as the one article you need to read for this topic.

Complication	Preventative measure
Failure of intubation	Skilled practitioner adequate preparation, cluding detailed airway assessment backup plan(s) difficult intubation equipment
Oesophageal intubation	Visual confirmation of ETT position Capnometry Auscultation of the chest
Right main bronchus intubation	auscultation of both lungs chest Xray Bronchoscopic confirmation
Bronchospasm	Pre-intubation nebulised salbutamol or adrenaline
Hypoxia	Pre-oxygenation Continuous pulse oximetry
Aspiration	Cricoid pressure (debatable) Aspiration of stomach contents by NG tube Fasting the patient in preparation Careful bag-mask ventilation to prevent gastric inflation Alternatively: do not bag-mask ventilate (RSI)
Pneumothorax and tension pneumothorax	Use of moderation in bag-mask ventilation volumes Post-intubation CXR
Cuff leak	Select a size-appropriate tube
Myocardial ischaemia	Use of opiate analgesics as part of intubation drug cocktail to prevent the sympathetic response to laryngoscopy Anaesthtising the vocal cords
Spinal injury	Correctly identify patients at risk of spinal injury, and use of inline stabilisation Fiberoptic bronchoscopy
Increased intracranial pressure	Use of opiate analgesics as part of intubation drug cocktail to prevent the sympathetic response to laryngoscopy Hyperventilation with bag to decrease CO2 post intubation
Increased intraocular pressure	Use of opiate analgesics as part of intubation drug cocktail to prevent the sympathetic response to laryngoscopy Anaesthtising the vocal cords
Structural damage: -lips -teeth -tongue	Skilled practitioner Limit the number of attempts by unskilled practitioners Videolaryngoscopy Avoid the use of stylet or bougie Ensure the tip of the stylet is well within the ETT when it is advanced (i.e. not sticking out past the end of the ETT)

References

Griesdale, Donald EG, et al. "Complications of endotracheal intubation in the critically ill." Intensive care medicine 34.10 (2008): 1835-1842.

Rashkin, Mitchell C., and Tern Davis. "Acute complications of endotracheal intubation. Relationship to reintubation, route, urgency, and duration." CHEST Journal 89.2 (1986): 165-167.

Divatia, J. V., and K. Bhowmick. "Complications of endotracheal intubation and other airway management procedures." Indian J Anaesth 49.4 (2005): 308-18.

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