Acta Otolaryng 75: 377-378, 1973

WHAT IS PROLONGED INTUBATION? Steen Johnsen

From the Department of Otolaryngology, Glostrup Hospital, Copenhagen, Denmark

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Abstract. The risk of damage to the upper airways by nasotracheal intubation is influenced not only by its duration, but also by a number of other factors. Among 29 patients treated by nasotracheal intubation, as a rule for 2-3 days, none showed laryngo-tracheal damage after extubation. Among 20 patients intubated for a longer period (5-56 days) numerous cases of damage to the respiratory tract were found. Prolonged intubation should be taken to mean intubation lasting longer than 6-7 days. With prolonged intubation the risk of severe damage to the larynx and trachea is so great that the possibility of replacing it by tracheostomy should be seriously contemplated.

Through the past 20 years oro- and nasotracheal intubation has been gaining ever increasing ground in the treatment of pulmonary insufficiency. In Scandinavia this development was triggered by the polio epidemic of 1952 in Copenhagen, when tracheal intubation was performed through tracheostomy (Lassen, 1956). The hazards involved by an oro-nasotracheal tube, especially to the larynx and subglottis, were soon realized, and it was generally considered that the tube had to be removed within 12-24 hours (Lewy & Sibbert, 1951; Dam & Zwergius, 1952). As recently as 1962 Bergstrom recommended removing nasotracheal tubes at the end of 24 hours. Since that time, opinions have become more liberal, and it was considered justified to continue the intubation for 2 or 3 days (Fearon et al., 1966; Hatch, 1968; Hedden et al., 1969). In Denmark too nasotracheal intubation of an average duration of 2-3 days was reported in a series of patients without deleterious effects (Hansen & J#rgensen, 1968; Traff & Tos, 1969).

In the literature prolonged intubation is often mentioned without any explanation of what Lprolonged is taken to mean. Many variables play a role in damaging the respiratory tract: The general condition of the patient, the state of consciousness, premorbid respiratory infections and age. The material of the tube, the cuff pressure, and the frequency of changing the tube are also contributory pathogenetic factors. In the present study it was endeavoured to ascertain for how long nasopharyngeal intubation can be maintained without a risk of clinical damage to the larynx and trachea.

Present investigations Twenty-nine cases of acute epiglottitis in children were treated with nasotracheal intubation and antibiotics. The majority were intubated for 2 or 3 days, and after extubation no patient of the entire group exhibited lesions of the larynx or trachea that required treatment. There was merely some hoarseness or stridor for a few days after extubation. In another series comprising patients with respiratory insufficiency, often of complex genesis, the nasopharyngeal intubation was of longer duration. The primary disease that provided the indication for intubation was pulmonary in 9, whereas 8 patients had cerebral contusion. 3 patients were intubated for various reasons. The patients of this group were in an extremely poor condition, 17 were primarily unconscious,
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S. Johnsen

Table I. Zntubation group Z (29 patients)

Duration of intubation in days:

Table 111. Influence of the duration of intubation upon the severity of laryngo-tracheal sequelae
Sequelae Sequelae Trachea
No. of days
11
-t

<1 8 pts.

1-<2 14 pts.

2-<3 5 pts.

3-<4 2 pts.

No. of days 5 5 6 8 8 8 9 10 10
10

lar.+ subgl. 0
-t 3-

lar. t subgl.
-1-1 i-b

Trachea

Table 11. Zntubation group ZZ (20 patients)

Duration of intubation in days:
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++

5-6 3 pts.

8-1 2 11 pts.

14-21 3 pts.

> 21

3 pts.

++ +++ i- + -t + + + -t + 1-+ +

12 12 12 14 15 21 26 30 56

+ +

++ -t + i-k + + + i+++

-t

11 were treated in a respirator, and 3 had cardiac arrest. Within intubation group I1 there was clinically demonstrable damage to the larynx and subglottis in practically all patients, although no or negligible damage was found in those who had been intubated for 5 and 6 days. The severity of the laryngo-tracheal damage was to some extent dependent upon the duration of the intubation, but this was not a rule without exceptions, as may be seen from Table 111. Among the cases designated + + the vocal cords were found to be immobile in a position of adduction, exactly like the appearance of bilateral paralysis of the recurrent laryngeal nerve, but being in fact a sequel to fibrous changes in the articular and muscular apparatus of the vocal cords. Since no patient of group I had clinically demonstrable damage in the trachea and since the first 3 patients of group I1 did not have such damage, or at least only very mild laryngo-tracheal changes, it may be concluded that naso-tracheal intubation may be maintained for 6-7 days without major risk of damage. If it is kept up longer, it must be called prolonged intubation, which means a considerable risk of severe sequelae in the larynx and subglottis, possibly requiring treatment. In such cases, therefore, it must be carefully contemplated whether; instead of continuing the risk of prolonged
Acta Otolaryng 75

+ : Mild mucosal thickenings, granulation tissue. + f : Permanent, considerable stenosis of the lumen of firm, fibrous nature. + + + : Anatomical structures in the larynx are desorganized, larynx funnel-shaped, a few mm passage to a greatly narrowed subglottis.

intubation, it is not advisable to replace it by intubation through tracheostomy.

REFERENCES
Bergstrom, J. 1962. Laryngological aspects o the f treatment of acute barbiturate poisoning. Acta Otolaryng (Stockh.), Suppl. 173. Dam, W. & Zwergius, E. 1952. Laryngeale komplikationer efter langvarig endotracheal intubation of narkotisk forgiftede patienter. Nord Med 48, 1095. Fearon, B., MacDonald, R., Smith, C. & Mitchell, D. 1966. Airway problems in children following prolonged endotracheal intubation. Ann Otol 75, 605. Hansen, M. & Jgirgensen, S. 1968. Tracheotomy and prolonged nasotracheal intubation. Danish Med Bull 15, 53. Hatch, D. J. 1968. Prolonged nasotracheal intubation in infants and children. Lancet I, 1273. Hedden, M., Ersoz, C. J., Donnelly, W. & Safar, P. 1969. Laryngotracheal damage after prolonged use of orotracheal tubes in adults. JAMA 207, 703. Lassen, H. C. A. 1956. Managen?ent of life-threating poliomyelitis. London. Lewy, R. B. & Sibbert, J. W. 1951. Tracheotomy in barbiturate poisoning. Amer Practit 2, 257. Traff, B. & Tos, M. 1969. Nasotracheal intubation in acute epiglottitis. Acta Otolaryng (Stockh.) 68, 363.
S . Johnsen, M . D . Dept. of Otolaryngology Clostrup Hospital DK-2600 Copenhagen Denmark