Laryngeal Injury and Upper Airway Symptoms After Endotracheal Intubation During Surgery: A Systematic Review and Meta-analysis

Martin B Brodsky, Lee M Akst, Erin Jedlanek, Vinciya Pandian, Brendan Blackford, Carrie Price, Gai Cole, Pedro A Mendez-Tellez, Alexander T Hillel, Simon R Best, Matthew J Levy, Martin B Brodsky, Lee M Akst, Erin Jedlanek, Vinciya Pandian, Brendan Blackford, Carrie Price, Gai Cole, Pedro A Mendez-Tellez, Alexander T Hillel, Simon R Best, Matthew J Levy

Abstract

Laryngeal injury from intubation can substantially impact airway, voice, and swallowing, thus necessitating multidisciplinary interventions. The goals of this systematic review were (1) to review the types of laryngeal injuries and their patient-reported symptoms and clinical signs resulting from endotracheal intubation in patients intubated for surgeries and (2) to better understand the overall the frequency at which these injuries occur. We conducted a search of 4 online bibliographic databases (ie, PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature [CINAHL], and The Cochrane Library) and ProQuest and Open Access Thesis Dissertations (OPTD) from database inception to September 2019 without restrictions for language. Studies that completed postextubation laryngeal examinations with visualization in adult patients who were endotracheally intubated for surgeries were included. We excluded (1) retrospective studies, (2) case studies, (3) preexisting laryngeal injury/disease, (4) patients with histories of or surgical interventions that risk injury to the recurrent laryngeal nerve, (5) conference abstracts, and (6) patient populations with nonfocal, neurological impairments that may impact voice and swallowing function, thus making it difficult to identify isolated postextubation laryngeal injury. Independent, double-data extraction, and risk of bias assessment followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane Collaboration's criteria. Twenty-one articles (1 cross-sectional, 3 cohort, 5 case series, 12 randomized controlled trials) representing 21 surgical studies containing 6140 patients met eligibility criteria. The mean patient age across studies reporting age was 49 (95% confidence interval [CI], 45-53) years with a mean intubation duration of 132 (95% CI, 106-159) minutes. Studies reported no injuries in 80% (95% CI, 69-88) of patients. All 21 studies presented on type of injury. Edema was the most frequently reported mild injury, with a prevalence of 9%-84%. Vocal fold hematomas were the most frequently reported moderate injury, with a prevalence of 4% (95% CI, 2-10). Severe injuries that include subluxation of the arytenoids and vocal fold paralysis are rare (<1%) outcomes. The most prevalent patient complaints postextubation were dysphagia (43%), pain (38%), coughing (32%), a sore throat (27%), and hoarseness (27%). Overall, laryngeal injury from short-duration surgical intubation is common and is most often mild. No uniform guidelines for laryngeal assessment postextubation from surgery are available and hoarseness is neither a good indicator of laryngeal injury or dysphagia. Protocolized screening for dysphonia and dysphagia postextubation may lead to improved identification of injury and, therefore, improved patient outcomes and reduced health care utilization.

Conflict of interest statement

Conflicts of Interest: See Disclosures at the end of the article.

Copyright © 2021 International Anesthesia Research Society.

Figures

Figure 1.. Study selection flowchart.
Figure 1.. Study selection flowchart.
Abbreviations: LMA, laryngeal mask airway; RLN, recurrent laryngeal nerve

References

    1. Rose J, Weiser TG, Hider P, Wilson L, Gruen RL, Bickler SW. Estimated need for surgery worldwide based on prevalence of diseases: a modelling strategy for the WHO Global Health Estimate. Lancet Glob Health. 2015;3 Suppl 2:S13–20.
    1. Weiser TG, Haynes AB, Molina G, et al. Size and distribution of the global volume of surgery in 2012. Bull World Health Organ. 2016;94(3):201–209f.
    1. Durbin CG Jr., Bell CT, Shilling AM. Elective intubation. Respir Care. 2014;59(6):825–846; discussion 847-829.
    1. Beckford NS, Mayo R, Wilkinson A 3rd, Tierney M. Effects of short-term endotracheal intubation on vocal function. Laryngoscope. 1990;100(4):331–336.
    1. Hamdan AL, Sibai A, Rameh C, Kanazeh G. Short-term effects of endotracheal intubation on voice. J Voice. 2007;21(6):762–768.
    1. Geraci G, Cupido F, Lo Nigro C, Sciuto A, Sciume C, Modica G. Postoperative laryngeal symptoms in a general surgery setting. Clinical study. Ann Ital Chir. 2013;84(4):377–383.
    1. Nordang L, Lindholm CE, Larsson J, Linder A. Early laryngeal outcome of prolonged intubation using an anatomical tube: A double blind, randomised study. Eur Arch Otorhinolaryngol. 2016;273(3):703–708.
    1. Hamdan AL, Sabra O, Rameh C, El-Khatib M. Persistant dysphonia following endotracheal intubation. Middle East J Anaesthesiol. 2007;19(1):5–13.
    1. Alexopoulos C, Lindholm CE. Airway complaints and laryngeal pathology after intubation with an anatomically shaped endotracheal tube. Acta Anaesthesiol Scand. 1983;27(4):339–344.
    1. Winslow CP, Winslow TJ, Wax MK. Dysphonia and dysphagia following the anterior approach to the cervical spine. Arch Otolaryngol Head Neck Surg. 2001;127(1):51–55.
    1. Brodsky MB, Levy MJ, Jedlanek E, et al. Laryngeal injury and upper airway symptoms after oral endotracheal intubation with mechanical ventilation during critical care: A systematic review. Crit Care Med. 2018;46(12):2010–2017.
    1. Shinn JR, Kimura KS, Campbell BR, et al. Incidence and outcomes of acute laryngeal injury after prolonged mechanical ventilation. Crit Care Med. 2019;47(12):1699–1706.
    1. Krisciunas GP, Langmore SE, Gomez-Taborda S, et al. The association between endotracheal tube size and aspiration (during flexible endoscopic evaluation of swallowing) in acute respiratory failure survivors. Crit Care Med. In press.
    1. Benjamin B. Prolonged intubation injuries of the larynx: Endoscopic diagnosis, classification, and treatment. Ann Otol Rhinol Laryngol Suppl. 1993;160:1–15.
    1. Benjamin B, Holinger LD. Laryngeal complications of endotracheal intubation. Ann Oto Rhinol Laryn. 2008;117(9):2–20.
    1. Sadoughi B, Fried MP, Sulica L, Blitzer A. Hoarseness evaluation: a transatlantic survey of laryngeal experts. Laryngoscope. 2014;124(1):221–226.
    1. Colice GL. Resolution of laryngeal injury following translaryngeal intubation. Am Rev Respir Dis. 1992;145(2 Pt 1):361–364.
    1. Stachler RJ, Francis DO, Schwartz SR, et al. Clinical practice guideline: Hoarseness (Dysphonia) (Update). Otolaryngol Head Neck Surg. 2018;158(1_suppl):S1–S42.
    1. Schwartz SR, Cohen SM, Dailey SH, et al. Clinical practice guideline: Hoarseness (dysphonia). Otolaryngol Head Neck Surg. 2009;141(3 Suppl 2):S1–s31.
    1. Whited RE. A prospective study of laryngotracheal sequelae in long-term intubation. Laryngoscope. 1984;94(3):367–377.
    1. Wain JC. Postintubation tracheal stenosis. Chest Surg Clin N Am. 2003;13(2):231–246.
    1. Havas TE, Priestley J, Lowinger DS. A management strategy for vocal process granulomas. Laryngoscope. 1999;109(2 Pt 1):301–306.
    1. Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions: Version 5.1.0 (updated March 2011). Cochrane Collaboration; 2011.
    1. Higgins JPT, Altman DG, Gotzsche PC, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. British Medical Journal. 2011;343:d5928.
    1. Lindholm C-E. Prolonged endotracheal intubation: A clinical investigation with special reference to its consequences for the larynx and trachea and to its place an alternative to intubation through a tracheostomy. Acta Anaesthesiol Scand. 1969;13(s33):1–80.
    1. Eckerbom B, Lindholm CE, Alexopoulos C. Airway lesions caused by prolonged intubation with standard and with anatomically shaped tracheal tubes. A post-mortem study. Acta Anaesthesiol Scand. 1986;30(5):366–373.
    1. Thomas R, Kumar EV, Kameswaran M, et al. Post intubation laryngeal sequelae in an intensive care unit. J Laryngol Otol. 1995;109(4):313–316.
    1. Wan X, Wang W, Liu J, Tong T. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol. 2014;14(1):135.
    1. Walts LF, Calcaterra T, Cohen A. Vocal cord function following short term endotracheal intubation. Clin Otolaryngol Allied Sci. 1980;5(2):103–105.
    1. Baillard C, Adnet F, Borron SW, et al. Tracheal intubation in routine practice with and without muscular relaxation: An observational study. Eur J Anaesthesiol. 2005;22(9):672–677.
    1. Friedrich T, Hansch U, Eichfeld U, Steinert M, Staemmler A, Schonfelder M. [Recurrent laryngeal nerve paralysis as intubation injury?]. Chirurg. 2000;71(5):539–544.
    1. Kambič V, Radšel Z. Intubation lesions of the larynx. Br J Anaesth. 1978;50(6):587–590.
    1. Lesser TH, Lesser PJ. Laryngeal trauma vs length of intubation. J Laryngol Otol. 1987;101(11):1165–1167.
    1. Peppard SB, Dickens JH. Laryngeal injury following short-term intubation. Ann Otol Rhinol Laryngol. 1983;92(4 Pt 1):327–330.
    1. Yamanaka H, Hayashi Y, Watanabe Y, Uematu H, Mashimo T. Prolonged hoarseness and arytenoid cartilage dislocation after tracheal intubation. Br J Anaesth. 2009;103(3):452–455.
    1. Böttcher A, Mencke T, Zitzmann A, et al. Laryngeal injuries following endotracheal intubation in ent surgery: Predictive value of anatomical scores. Eur Arch Otorhinolaryngol. 2014;271(2):345–352.
    1. Heidegger T, Starzyk L, Villiger CR, et al. Fiberoptic intubation and laryngeal morbidity: A randomized controlled trial. Anesthesiology. 2007;107(4):585–590.
    1. Mencke T, Echternach M, Kleinschmidt S, et al. Laryngeal morbidity and quality of tracheal intubation: A randomized controlled trial. Anesthesiology. 2003;98(5):1049–1056.
    1. Mencke T, Knoll H, Schreiber JU, et al. Rocuronium is not associated with more vocal cord injuries than succinylcholine after rapid-sequence induction: A randomized, prospective, controlled trial. Anesth Analg. 2006;102(3):943–949.
    1. Mencke T, Echternach M, Plinkert PK, et al. Does the timing of tracheal intubation based on neuromuscular monitoring decrease laryngeal injury? A randomized, prospective, controlled trial. Anesth Analg. 2006;102(1):306–312.
    1. Mencke T, Zitzmann A, Machmueller S, et al. Anesthesia with propofol versus sevoflurane: Does the longer neuromuscular block under sevoflurane anesthesia reduce laryngeal injuries? Anesthesiol Res Pract. 2013;2013:723168.
    1. Ovari A, Bicker I, Machmueller S, et al. Sevoflurane at 1.0 MAC together with remifentanil and propofol produces clinically acceptable intubation conditions at the vocal cords: A prospective randomized study. J Int Med Res. 2017;45(3):1098–1108.
    1. Seo JH, Cho CW, Hong DM, Jeon Y, Bahk JH. The effects of thermal softening of double-lumen endobronchial tubes on postoperative sore throat, hoarseness and vocal cord injuries: A prospective double-blind randomized trial. Br J Anaesth. 2016;116(2):282–288.
    1. Sørensen MK, Rasmussen N, Kristensen MS, et al. Laryngeal morbidity after tracheal intubation: the Endoflex((R) tube compared to conventional endotracheal intubation with stylet. Acta Anaesthesiol Scand. 2013;57(6):737–744.
    1. Zimmert M, Zwirner P, Kruse E, Braun U. Effects on vocal function and incidence of laryngeal disorder when using a laryngeal mask airway in comparison with an endotracheal tube. Eur J Anaesthesiol. 1999;16(8):511–515.
    1. Domino KB, Posner KL, Caplan RA, Cheney FW. Airway injury during anesthesia: A closed claims analysis. Anesthesiology. 1999;91(6):1703–1711.
    1. Sultan P, Carvalho B, Rose BO, Cregg R. Endotracheal tube cuff pressure monitoring: A review of the evidence. J Perioper Pract. 2011;21(11):379–386.
    1. Farrow S, Farrow C, Soni N. Size matters: Choosing the right tracheal tube. Anaesthesia. 2012;67(8):815–819.
    1. Higgs A, McGrath BA, Goddard C, et al. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth. 2018;120(2):323–352.
    1. Huth EJ, Case K. The URM: Twenty-five years old. Science Editor. 2004;27(1):17–21.
    1. International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals. N Engl J Med. 1997;336(4):309–315.
    1. Food and Drug Administration. Food and Drug Administraton Amendments Act of 2007. Pub. L. No. 110-85, 121 Stat. 823 (September. 27, 2007).
    1. National Institutes of Health. Clinical trials registration in (Public Law 110-85): Competing applications and non-competing progress reports (NOT-OD-08-023). Bethesda, MD: 2007. NOT-OD-08-023.

Source: PubMed

Patrocinadores e Colaboradores

Condições médicas

Intervenções de drogas

3
Se inscrever