Laryngeal Injury and Upper Airway Symptoms After Oral Endotracheal Intubation With Mechanical Ventilation During Critical Care: A Systematic Review*

Brodsky, Martin B.; Levy, Matthew J.; Jedlanek, Erin; Pandian, Vinciya; Blackford, Brendan; Price, Carrie; Cole, Gai; Hillel, Alexander T.; Best, Simon R.; Akst, Lee M.

doi:10.1097/ccm.0000000000003368

Cited by 225 publications

(250 citation statements)

References 74 publications

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“…The most common cause of postintubation injuries was over lled cuffs (31). A systematic review reported a high prevalence of intubation-related laryngeal injury (83%) (32). However, in our study, the rates were 2.6% and 5.6% in the di cult and nondi cult endotracheal intubation groups, respectively; both were signi cantly lower than previously reported, which may be due to the high consensus among the participant physicians in the present study.…”

Section: Discussioncontrasting

confidence: 93%

A Predictive Formula for Difficult Endotracheal Intubation in the Emergency Department

Liao

Chang

et al. 2020

Preprint

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Background Current predictors for evaluating difficult endotracheal intubation had poor accessibility or sensitivity at the emergency department, so we evaluated the incidence and predictive factors, then built an easy-to-use predictive formula.Methods For the 110 patients, difficult airway was defined as Cormack & Lehane classification grade III and IV at first attempt of intubation. The univariate associations between patient characteristics and difficult endotracheal intubation were then analyzed, and the significantly associated factors were included in a multivariate binary logistic regression model then a predictive formula was generated. Generalized association plot (GAP) was used to show the relationship between each variables.Results The incidence of difficult intubation in our study was 35.5%. In the difficult airway group, significantly higher rates (p<0.05) of high body mass index (BMI); double chin; thick, short neck; Mallampati difficulty; smaller inter-incisors distance; smaller thyromental distance; and upper airway obstruction were noted. Finally, a predictive formula for difficult intubation was successfully established by the combination of four predictors: BMI (odds ratio [OR]=1.270), thyromental distance (OR=0.614), upper airway obstruction (OR=4.038), and Mallampati difficulty (OR=5.163). A cut-off score of 4 provided the best sensitivity (79.5%) and specificity (81.7%)(95% CI: 0.794 to 0.938).Conclusions Our predictive formula could be used by emergency physicians to quickly identify and carefully manage patients with potentially difficult intubation. Early expert consultation could be sought when necessary.Trial registration This 17-month (2011/11/1-2013/3/31) prospective observational study was approved by the Institutional Review Board of MacKay Memorial Hospital (11MMHISO64).

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Section: Discussioncontrasting

confidence: 93%

A Predictive Formula for Difficult Endotracheal Intubation in the Emergency Department

Liao

Chang

et al. 2020

Preprint

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“…ENT SLTs also need to be vigilant of the high prevalence of laryngeal injury post‐extubation in intensive care unit (ICU) settings, which can cause dysphonia and/or dysphagia (Brodsky et al . 2018) Laryngeal trauma might also arise from acute cough (Slinger et al . 2019), with post‐viral symptoms impacting voice and swallowing even in patients who have not been admitted to hospital.…”

Section: Service Delivery/clinical Implicationsmentioning

confidence: 99%

“…Post‐extubation injuries can include laryngeal oedema, arytenoid dislocation, laryngeal ulceration and vocal cord paralysis (Brodsky et al . 2018, McGrath et al . 2020).…”

Section: Service Delivery/clinical Implicationsmentioning

confidence: 99%

“…Clinical consensus indicates that COVID‐19 has the potential to cause airway damage as a result of laryngeal manifestations of the disease (Tysome and Bhutta 2020); as well as expected long‐term airway damage due to prolonged intubation and need for tracheostomy (Brodsky et al . 2018). As a result, airway services may see an increase in referrals in the coming months as a direct result of the virus itself.…”

Section: Service Delivery/clinical Implicationsmentioning

confidence: 99%

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COVID‐19 and ENT SLT services, workforce and research in the UK: A discussion paper

Patterson

Govender

Roe

et al. 2020

Intl J Lang & Comm Disor

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Background The COVID‐19 pandemic and the UK government's subsequent coronavirus action plan have fundamentally impacted on every aspect of healthcare. One area that is severely affected is ear, nose and throat (ENT)/laryngology where speech and language therapists (SLTs) engage in a diverse range of practice with patients with a range of conditions, including voice disorders, airway problems, and head and neck cancers (HNCs). A large majority of these patients are in high‐risk categories, and many specialized clinical practices are vulnerable. In addition, workforce and research issues are challenged in both the immediate context and the future. Aims To discuss the threats and opportunities from the COVID‐19 pandemic for SLTs in ENT/laryngology with specific reference to clinical practice, workforce and research leadership. Methods & Procedures The relevant sections of the World Health Organisation's (WHO) health systems building blocks framework (2007) were used to structure the study. Expert agreement was determined by an iterative process of multiple‐group discussions, the use of all recent relevant policy documentation, and other literature and shared documentation/writing. The final paper was verified and agreed by all authors. Main Contribution The main threats to ENT/laryngology SLT clinical services include increased patient complexity related to COVID‐19 voice and airway problems, delayed HNC diagnosis, reduced access to instrumental procedures and inequitable care provision. The main clinical opportunities include the potential for new modes of service delivery and collaborations, and harnessing SLT expertise in non‐instrumental assessment. There are several workforce issues, including redeployment (and impact on current services), training implications and psychological impact on staff. Workforce opportunities exist for service innovation and potential extended ENT/SLT practice roles. Research is threatened by a reduction in immediate funding calls and high competition. Current research is affected by very limited access to participants and the ability to conduct face‐to‐face and instrumental assessments. However, research opportunities may result in greater collaboration, and changes in service delivery necessitate robust investigation and evaluation. A new national set of research priorities is likely to emerge. Conclusions & Implications The immediate impact of the pandemic has resulted in major disruption to all aspects of clinical delivery, workforce and research for ENT/laryngology SLT. It is unclear when any of these areas will resume operations and whether permanent changes to clinical practice, professional remits and research priorities will follow. However, significant opportunity exists in the post‐COVID era to re‐evaluate current practice, embrace opportunities and evaluate new ways of working.

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“…Laryngeal injury following intubation and mechanical ventilation is a common occurrence with an estimated prevalence of 83% immediately following extubation [3]. Although a majority of such injuries are trivial and self-limiting, moderate to severe injuries occur in an estimated 13-31% of patients [3]. Such injuries include laryngotracheal stenosis, vocal cord immobility, ulceration and granulation, and can carry signi cant morbidity without prompt diagnosis and treatment.…”

Section: Introductionmentioning

confidence: 99%

Airway, voice and swallow outcomes following endotracheal intubation and mechanical ventilation for COVID-19 pneumonitis: preliminary results of a prospective cohort study

Miu

Miller

Tornari

et al. 2020

Preprint

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Introduction: The coronavirus pandemic has resulted in unprecedented rates of patients requiring intubation and ventilation over a short period of time. The authors present 3-month data on airway, voice and swallow outcomes for this cohort to better understand the impact of COVID-19 critical illness on laryngotracheal morbidity. Methods: An observational cohort study was performed on all patients discharged following critical illness at our tertiary institution over a 2-month period (1st March 2020 - 30th April 2020). Patients were stratified on the basis of primary diagnosis: COVID-19 pneumonitis, Non-COVID-19 respiratory failure and non-respiratory. Our primary outcome measure was reported airway, voice, and swallow dysfunction during inpatient admission and on 6-12 week Critical Illness Recovery Clinic follow up. Endoscopic findings of patients referred onward to our Multidisciplinary Laryngology-Speech Therapy Clinic were recorded.Results: 141 patients were included in our study. During inpatient admission there were no statistically significant differences in reported rates of airway, voice, or swallow dysfunction. In Critical Illness Recovery Clinic, there were markedly higher rates of reported airway, voice and swallow dysfunction in the COVID-19 pneumonitis cohort, although these rates only reached statistical significance in respect to airway outcomes (airway p=0.038, voice p=0.064, swallow p=0.240). 100% of patients reviewed to date in the Laryngology-Speech Therapy Clinic following COVID-19 critical illness had clinically significant laryngeal pathology.Conclusion: Our data highlights an impending surge in COVID-19 related laryngotracheal morbidity. Robust, prospective screening and clear referral pathways for all patients following COVID-19 critical illness are essential to identifying and managing this cohort.

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Laryngeal Injury and Upper Airway Symptoms After Oral Endotracheal Intubation With Mechanical Ventilation During Critical Care: A Systematic Review*

Cited by 225 publications

References 74 publications

A Predictive Formula for Difficult Endotracheal Intubation in the Emergency Department

A Predictive Formula for Difficult Endotracheal Intubation in the Emergency Department

COVID‐19 and ENT SLT services, workforce and research in the UK: A discussion paper

Airway, voice and swallow outcomes following endotracheal intubation and mechanical ventilation for COVID-19 pneumonitis: preliminary results of a prospective cohort study

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