What are the effects and management of prolonged intubation?

Effects and Management of Prolonged Intubation

Prolonged endotracheal intubation causes significant laryngotracheal complications including vocal cord injury, granuloma formation, and airway stenosis, requiring early intervention and consideration of tracheostomy after 14-21 days to minimize long-term morbidity and mortality. 1

Common Complications of Prolonged Intubation

Laryngeal Injuries

• Direct laryngoscopy of patients intubated for more than four days shows that 94% develop laryngeal injury, including edema and ulceration of the posterior and medial vocal folds 1
• Up to 44% of patients with prolonged intubation develop vocal fold granulomas within four weeks of extubation 1
• Vocal cord immobility occurs in approximately 20% of patients following prolonged intubation, with half developing immediately after extubation and half developing about 4 weeks later 2
• Risk factors for vocal cord immobility include duration of intubation and larger endotracheal tube size (particularly size 8) 2

Airway Stenosis and Structural Changes

• Prolonged intubation can lead to subglottic and tracheal stenosis due to pressure necrosis and subsequent scar formation 1
• Specific patterns of injury include "tongues of granulation tissue," "ulcerated troughs," "healed furrows," and "healed fibrous nodules" 3
• These structural changes can cause long-term breathing difficulties and may require surgical intervention 1

Infectious Complications

• Longer intubation duration (10-20 days vs. 1-9 days) significantly increases pathogen colonization rates over the endotracheal tube cuff region (100% vs. 69.2%) 4
• Increased colonization contributes to higher risk of ventilator-associated pneumonia and subsequent morbidity 4

Functional Impairments

• Common post-extubation symptoms include dysphagia (43%), pain (38%), coughing (32%), sore throat (27%), and hoarseness (27%) 5
• Vocal fold motion impairment risk increases by 68% after 21 days of intubation 6
• Many patients report dysphonia, dysphagia, and dyspnea on exertion during follow-up appointments 1

Management Strategies

Timing of Tracheostomy

• Consider tracheostomy when prolonged mechanical ventilation is anticipated, particularly after 14-21 days of endotracheal intubation 1
• Early tracheostomy may reduce pharyngolaryngeal lesions, lower risk of sinusitis, reduce sedation requirements, improve patient comfort, and facilitate communication 1
• Benefits must be weighed against potential risks of the procedure 1

Prevention of Complications

• Use appropriately sized endotracheal tubes to minimize pressure on laryngeal structures 1
• Avoid aggressive cuff over-inflation which increases risk of mucosal injury 1
• Implement early extubation strategies when possible, aiming for extubation within 6 hours of ICU arrival for appropriate patients 1
• Maintain proper positioning of the endotracheal tube to prevent cuff-related injuries 1

Post-Extubation Monitoring and Care

• Monitor patients closely for signs of respiratory compromise for 6-24 hours after extubation, depending on the cause and severity of respiratory failure 1
• Consider flexible fiber-optic examination of the larynx before extubation in high-risk patients 1
• Implement staged reintroduction of oral nutrition, ensuring adequate swallowing and airway protective reflexes 1
• For patients with significant respiratory secretions, provide assistance with "pulmonary toilet" through airway suctioning or chest percussion with postural drainage 1

Treatment of Laryngotracheal Injury

• Early endoscopic intervention improves outcomes for post-intubation airway stenosis 1
• Consider inhaled steroids and antibiotics with anti-inflammatory effects (such as macrolides and trimethoprim/sulfamethoxazole) to promote mucosal healing 1
• Early operative assessment with debridement of necrotic mucosa can limit mature scar formation 1
• For patients with respiratory muscle weakness after prolonged ventilation, assisted coughing and/or hyperinflation therapy may be beneficial 1

Special Considerations

• Patients with diabetes and ischemic disease have increased risk of laryngeal injury from prolonged intubation 1
• Hoarseness is not a reliable indicator of laryngeal injury or dysphagia, so protocolized screening for these conditions is recommended 5
• Longer intubation increases the likelihood of requiring re-intubation or tracheostomy (28.9% vs. 9.3% for >10 days vs. 1-9 days) 4
• Elevating the head of the bed at least 30 degrees can reduce the incidence of gastric material migrating to the trachea 1