Laryngeal damage from tracheal intubation

After years of investigation in the field of airway perforations of the cricothyroid membrane presented as court cases. Mortality in this type of injury is about protection, our group of paediatric anaesthetists and ENT-surgeons developed the firm conviction that 50%. Normally trauma caused by intubation is not life complications of intubation in the paediatric patient are almost always preventable. This opinion is in threatening in the acute situation. In an investigation of a five-year period in children under eight years contradiction of the literature (1–8) and every day clinical experience in paediatric anaesthesia. Blurred of age we found 65 patients with intubational trauma (9). A too large bore tube was the cause of airway knowledge of the particularities of anatomy of the paediatric airway and lack of strict technical injury in 92%. Convincing arguments indicate that intubational trauma in children under the year of rules during the intubation procedure may cause preventable injuries to the airway, particularly in eight is frequently caused by a too large a tube. Major differences in the anatomy of the larynx of patients under eight years of age (9). the adult and the infant are well described in all textbooks of paediatric anaesthesia. It seems that Incidence of intubational trauma in the mere anatomical facts are not adequately transferred paediatric patient into clinical practice. Every intubation, even when performed by experts, produces subepithelial Only a small number of studies in paediatric patients oedema, small, localized haemorrhages and little about the incidence of trauma after intubation are ulcers in the mucous membranes of the larynx but published (1–6). From 0.02 to 0.1% of patients laceration of the anterior commissure of the vocal required treatment for intubational trauma after cords, ulceration by cuffed or too large tubes can elective surgery. Typical risk factors for upper airway definitely be avoided by meticulous observation of injury consist of intubation longer than 25 days, well established rules. duration of ventilation, frequency of reintubation, too large bore tubes, presence of postextubational stridor, inflammation of the larynx and extraordinary Use of cuffed tubes in paediatric mobility of the child. Intubated patients who anaesthesia eventually die show trauma to the airway in 45% of the cases in postmortem examinations (7). In infants The use of cuffed tubes until the age of eight to ten and children with severe trauma or burns an years is generally not necessary because the cricoid incidence of 37% laryngeal injury is described (8). ring, having a circular lumen, is the narrowest part According to our experience in paediatric trauma of the upper airway, therefore the small circular gap patients, incidents of intubational trauma are at least around the tube prevents aspiration, in particular if as frequent as in adult trauma patients, averaging PEEP is applied. almost 20% (10). Nevertheless, the discussion about cuffed tubes is never ending (12). Some physicians prefer to use cuffed tubes before the eighth year of age because Mechanisms of laryngotracheal injury they are afraid to choose a too large or too small tube in an emergency. Such a strategy is acceptable, Mechanisms of lesions caused by tracheal intubation are little discussed in the literature. In blunt neck if the tube can soon be changed in a safer environment. If trauma occurs by overinflation of a injuries laryngotracheal disruption occurs (11), sometimes by forceful downward pushing of the cuff, often circular necrosis leads to cicatricial subglottic stenosis. tube, in particular if a stylet is used. We saw two