Airway management changes associated with rising radiologic incidence of external laryngotracheal injury

Abstract

Background: Traumatic laryngeal injuries are uncommon life-threatening injuries that require prompt, rational management of a potentially precarious airway. It is unclear whether the current incidence of laryngotracheal injury is due to enhanced injury detection or increased occurrence. The objective of this study was to evaluate the relations between diagnostic imaging with both initial airway management and surgical treatment in patients with external laryngotracheal injuries (ELTIs) in Alberta. Methods:In this large-scale population-based analysis, we used regional health databases containing inpatient admissions, emergency department visits and trauma service activations employing International Classification of Diseases diagnostic codes to identify all ELTIs diagnosed from Apr. 1, 1995, to Dec. 31, 2011, in adults (age ≥ 16 yr). We evaluated health records and diagnostic imaging for injury features, airway management, operative interventions and hospital length of stay (LOS).Results: Eighty-nine patients met the inclusion criteria. The incidence of ELTIs increased over time, paralleling a rise in detection during the period incorporating greater computed tomography (CT) use (p = 0.002). Endotracheal tube intubation was performed in 8/30 cases (27%) in the pre-CT era, compared to 38/59 cases (64%) in the post-CT era (p = 0.001); the use of surgical intervention remained consistent. The largest contributors to increased endotracheal tube placements were the emergency department and emergency medical services. No change in survival was detected, but mean LOS among patients admitted for minor, isolated ELTIs increased by 2.3 (95% confidence interval 0.14-4.8) days (p = 0.06), mostly for patients admitted under critical care for mechanical ventilation. Conclusion:Management of ELTIs shifted from predominantly conservative airway monitoring to endotracheal tube intubation over the study period in spite of no clinically significant change in injury severity or operative intervention frequency. The location of endotracheal tube placement suggests less comfort with ELTI among first-responder and emergency personnel.

Damage Control of Laryngotracheal Trauma: The Golden Day

“…The reported complications associated with this procedure are pharyngeal mucosal or skeletal injury, iatrogenic injury, or respiratory arrest 23,24 . Other ways to secure the airway include tracheostomy and endotracheal tube passage through the traumatic wound reported in up to 25% of the cases 6,18,25 . The management of this type of trauma depends on the severity of larynx or tracheal injuries.…”

“…Laryngotracheal trauma incidence is variable; the US National Emergency Service Sample reports an incidence of 1 in 125,000 visits to the emergency department 1 . Shaefer reported an incidence of 1 in 30,000 emergency department visits and 1 out of each 445 patients admitted with head-neck injuries 6,7 . Airway injuries present a mortality rate of 82% at the scene 8 .…”

“…The severity of laryngeal injuries is assessed according to Schaefer-Fuhrman's classification (Table 1). Grade I injuries are the most frequent, present in 52% of the patients 10 , followed by Grade II injuries representing 37% to 45% of the cases 6,7 . Laryngeal trauma mortality rate is reported between 1.6% and 11% and is associated with secondary lesions 1,6,7,10 .…”

“…A higher complication rate has been observed in the most severe lesions such as grade IV and V in the Shaefer-Furhman's classification, which has been estimated at 31% for voice sequelae and 6.1% for any grade of airway obstruction 7 . The glottis compromise is a crucial factor in determining voice impairment and the remaining sequelae 6 .…”

Laryngeal trauma: a review of current diagnostic and management strategies

“…The scale was further modified by Fuhrman and colleagues to include laryngotracheal separation (Table 1), and again by Verschueren in 2006 to include computed tomography (CT) guidance in staging (Fig. 1) [2 ▪ ,3,4,5,6 ▪▪ ,7–20].…”