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The term endotracheal intubation, or tracheal intubation, broadly refers to the insertion of a definitive artificial airway into the trachea by either the translaryngeal or transtracheal route. Translaryngeal intubation (TLI), a more specific term, is transoral or transnasal intubation of the airway through the larynx. The term endotracheal tube (ETT), as opposed to tracheostomy tube, refers to a tube passed via the mouth or nose into the trachea.


Macewen is usually given credit for the first successful translaryngeal intubation. In a landmark paper in 1880, he described TLI in four patients for as long as 35 hours and reported complications, including cough, discomfort, tracheal mucosal congestion, and thickening of the vocal cords and posterior rim of the glottis.1 The modern era of TLI began in the 1950s when it was used to manage respiratory failure from drug overdose2,3 and polio,4 and to provide an alternative to immediate tracheotomy when patients required prolonged ventilator support. As experience with TLI grew, so did knowledge of its complications and limitations. Comprehensive reviews of this subject appeared first in 19505 and frequently thereafter.614


This chapter provides a practical review of complications of TLI in critically ill adult patients, helps the reader understand the mechanisms underlying these adverse events, and illustrates how awareness of these complications may lead to their prevention, earlier recognition, and successful management. The chapter reviews important complications and consequences of TLI with standard ETTs that are encountered in the practice of adult critical care medicine. They are arranged according to the outline in Table 39-1. Complications of anesthetic intubations are occasionally cited to add awareness of complications that may also be seen in the critical care setting.

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Table 39-1: Classification of Complications of Translaryngeal Intubation

The complication rate of TLI varies with the setting, the urgency of the procedure, the skill of the intubator, patient anatomy, and other factors. In the prehospital setting, the rate of complications of TLI ranges from 9.515 to 22.7%.16 In the emergency department, 8%17 to 38%18 of patients undergoing TLI experience one or more complications.


In a prospective study in the adult critical care setting, Stauffer et al observed that 62% of all TLIs had one or more associated adverse events either during intubation or while the ETT was in place.19 The mean number of complications per patient was 1.2. The most common early clinical problems were, in descending order of frequency, excessive cuff pressure required to seal the airway, self-extubation, inability to seal the ...

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