2. Risk assessment and general preventive measures

Risk assessment and preventive measures of the intubation-related complications should be undertaken immediately after the decision for an endotracheal tube (ETT) insertion is taken for the patient's management. These measures can be divided into three main groups:

3. Complications that occur immediately during endotracheal tube (ETT)

Long-Term Complications of Tracheal Intubation http://dx.doi.org/10.5772/intechopen.74160 91

Complications of tracheal intubation might occur at any stage during the intubation with

Table 1A lists the chronic complications that usually result from trauma during intubation.

Temporary hoarseness is a common complain that occur in one third [3] to half [4] of the intubated patients and usually resolve spontaneously within 1 week; however, the incidence of prolonged hoarseness (>7 days) is estimated to be less than 1% [4, 5]. Vocal cord edema or lacerations, epiglottic hematoma and vocal cord paralysis secondary to compression of anterior branch of the recurrent laryngeal nerve are all potential etiologies of prolonged hoarseness [6]. In a prospective study 7 out of 25 cases (28%) of prolonged hoarseness had no identifiable causes [4]. Permanent hoarseness is even more rare, and being caused by granuloma of the vocal cord or arytenoid dislocation. The risk factors for this complication found to be longer duration of intubation, older age [4] and female gender [7]. Using a smaller size tube especially for females has been suggested to decrease the incidence of prolonged voice hoarseness [4, 8].

Arytenoid dislocation is a rare cause of vocal cord paralysis with less than 0.1% incidence rate [9]. The commonest mechanism of intubation related vocal cord paralysis is compression of the anterior branch of the recurrent laryngeal nerve as a result of prolonged intubation which will be discussed separately under complication of prolonged intubation subtitle. Risk factors for this complication can either be related to patients or the procedure. Patients related factors include retrognathia, dental malocclusion, a large tongue base, and cricoarytenoid joint involvement by rheumatoid arthritis. While; Procedure related risk factors include traumatic and/or prolonged intubation, protrusion of the endotracheal tube stylet, pressure from the distal curved part of the ETT and inexperience and poor techniques by the performance [10]. The majority of the patients present with dysphagia [11]; prolonged hoarseness, sore throat, and cough are less frequent symptoms. There are two types of dislocation, the posterolateral and the anteromedial dislocation; the latter being the most dangerous as it can compromise the

devastating consequences which may last as long as patients survive.

3.1. Post intubation prolonged voice hoarseness

Table 1A. Chronic complications that occur immediately at ETT insertion.

3.2. Arytenoid dislocation

insertion

Prolonged voice hoarseness Arytenoid dislocation

Traumatic dental injury

Cervical spine and spinal cord injuries

#### I. Measures that should be taken before intubation:

	- A. Preparing an initial tracheal intubation plan that includes using the direct laryngoscopy.
	- B. Preparing a secondary intubation plan which includes using a dedicated supraglottic airway device such as the classic laryngeal mask airway (LMA) in case of plan A has failed.
	- C. When plan B fails; the physician should be prepared to oxygenate and ventilate the patient, postpone the surgery, and awaken the patient.
	- D. In cases where physician 'cannot intubate, cannot ventilate' (CICV) rescue techniques such as cannula or surgical cricothyroidotomy should be available at the facility.

#### II. Measures that applied during intubation:


#### III. Measures which should be applied after intubation:

