Best Practice & Research Clinical Anaesthesiology

Vol. 19, No. 4, pp. 641–659, 2005

doi:10.1016/j.bpa.2005.08.002
available online at http://www.sciencedirect.com

Complications of managing the airway

Carin Hagberg* MD
Professor, Director of Neuroanesthesia and Advanced Airway Management
Department of Anaesthesiology, University of Texas Medical School at Houston, 6431 Fannin,
MSB 5.020 Houston, TX, USA

Rainer Georgi MD

Claude Krier MD
Professor and Ärztlicher Direktor
Klinik für Anästhesiologie, Klinikum Stuttgart Katharinenhospital, Stuttgart, Germany

The inability to secure the airway, with consequent failure of oxygenation and ventilation, is a life-
threatening complication. Failure of oxygenation leads to hypoxia followed by brain damage,
cardiovascular dysfunction, and finally death. Time is a very crucial factor in this context.
Complications vary widely in severity; while some are dramatic and immediately life-threatening
(unrecognized esophageal intubation), others can be severe and long-lasting (nerve injuries) or
mild and short-lived (sore throat). To minimize injury to the patient, the anesthesiologist should
examine the patient’s airway carefully, identify any potential problems, devise a plan that involves
the least risk for injury, and have a back-up plan immediately available. Each anesthesiology
department should establish guidelines/algorithms specific to their institution. Unfortunately,
a reliable test for detecting all patients at risk does not exist.

Key words: oxygenation; ventilation; intubation; complications.

Difficulty in managing the airway is the most important cause of major anesthesia-
related morbidity and mortality. In the closed claims analysis of the American Society of
Anesthesiologists (ASA), 6% of all claims concerned airway injury.1 Difficult intubation
was a factor in only 39% of airway injury claims; 87% of the airway injuries were
temporary, and 8% resulted in death. In 21% of these claims, the standard of care was
not performed. The incidence of affected anatomical structures is shown in Table 1.
Female gender, elective surgery and outpatient procedures showed a higher proportion
of injury, whereas there was no difference regarding ASA status or obesity.

* Corresponding author.
E-mail address: carin.a.hagberg@uth.tmc.edu (C. Hagberg).

1521-6896/$ - see front matter Q 2005 Elsevier Ltd. All rights reserved.
642 C. Hagberg et al

Table 1. Severity of injury and standard of care.

Severity of injury Standard of care

Non-death Death Standard Substandard
Site of injury (n (%)) (n (%)) (n (%)) (n (%))
Larynx (nZ87) 86 (99) 1 (1) 74 (96) 3 (4)
Pharynx (nZ51) 46 (90) 5 (10) 29 (71) 12 (29)
Esophagus (nZ48) 39 (81) 9 (19) 25 (60) 17 (40)
Trachea (nZ39) 33 (85) 6 (15) 20 (63) 12 (38)
TMJ (nZ27) 27 (100) 0 21 (100) 0
Nose (nZ13) 13 (100) 0 11 (85) 2 (15)

TMJ, temporomandibular joint. Modified from Domino et al (1999, Anesthesiology 91: 1703–1711) with
permission.

COMPLICATIONS WITH SUPRAGLOTTIC DEVICES

Mask ventilation

The maximum risk of airway problems presents during the ‘cannot intubate, cannot
ventilate’ situation.2,3 Difficult mask ventilation is an underestimated aspect of the
difficult airway. The ability to ventilate and oxygenate the patient sufficiently using a
mask is essential. Face masks should be completely free of residual cleansing agents, as
these can cause serious mucosal, skin or eye injury (conjunctivitis, burning, irritation)
and tongue swelling (allergic glossitis).
While applying a mask to a patient’s face, soft tissue damage may occur if the tissue is
subjected to excessive pressure. Care must be taken to avoid contact with the eyes to
prevent corneal abrasions, retinal artery occlusions, or blindness. Excessive pressure
on the mandible may damage the mandibular branch of the facial nerve, resulting in
transient facial nerve paralysis. Pressure on the mental nerves has been implicated in
causing lower-lip numbness. Oropharyngeal airways must be gently inserted into the
mouth to avoid injury (broken teeth or mucosal tears). Improper placement may
worsen airway obstruction by forcing the tongue backward. Equal care should be given
to the placement of nasopharyngeal airways to avoid epistaxis.
During the course of induction, the lifting pressure applied to the angle of the
mandible is sometimes sufficient to subluxate the temporomandibular joint. Patients
may experience persistent pain or bruising at these points, and may even have chronic
dislocation of the jaw which may cause severe discomfort.
Positive airway pressure can force air into the stomach instead of the trachea.
Gastric distention may occur, causing more difficult ventilation and an increased
propensity for regurgitation. For these reasons, mask ventilation should not be
performed in non-fasted or morbidly obese patients or patients with intestinal
obstruction, trendelenberg position, tracheo-esophageal fistula, or massive orophar-
yngeal bleeding. Cricoid pressure can help reduce the amount of air being forced into
the stomach and limit the likelihood of vomiting. Nonetheless, gastric rupture has been
reported with face mask ventilation.
Recently, it was shown that independent risk factors for difficulties with mask
ventilation include the presence of beard, body mass index O26 kg/m2, lack of teeth,
age O55 years, and history of snoring.4 Patients with trauma to the pharyngeal mucosa
 Complications of managing the airway 643

may be at risk for subcutaneous emphysema. Whenever continuous positive airway

pressure is applied to patients with basilar skull fractures, pneumocephalus may occur.

Laryngeal mask airway

The laryngeal mask airway (LMA) has been used in millions of patients and is accepted
as a safe technique. Muscle relaxation is unnecessary, laryngoscopy is avoided, and
hemodynamic changes are minimized during insertion. However, numerous compli-
cations are associated with the LMA. The tip of the epiglottis can be folded into the
vocal cords during placement, inducing labored breathing, coughing, laryngospasm, and
sometimes complete airway obstruction. Excess lubricant can promote coughing or
laryngospasm. A known disadvantage of the device is its inability to protect against
pulmonary aspiration and regurgitation of gastric contents. The incidence of
regurgitation of small amounts of gastric contents was reported to be as high as
25%.5 However, the overall risk of aspiration and regurgitation using the LMA is in the
same low range as for endotracheal intubation when the indications and contra-
indications of LMA usage are respected.6
Laryngospasm and coughing may result from inadequate anesthesia, tip impaction
against the glottis, or aspiration. The incidence of sore throat is reported to be 7–12%,
an incidence similar to that seen with oral airways.7 The incidence of failed placement is
1–5%, although this tends to decrease with increasing operator experience. The LMA
cuff is permeable to nitrous oxide and carbon dioxide, which results in substantial
increases in cuff pressure and volume during prolonged procedures. Increased intra-cuff
pressures may increase the incidence of postoperative sore throat or cause transient
dysarthria. Edema of the epiglottis, uvula, and posterior pharyngeal wall may at worst
lead to airway obstruction. Hypoglossal nerve paralysis, post-obstructive pulmonary
edema, tongue cyanosis, transient dysarthria, tension pneumoperitoneum and gastric
rupture have also been reported.
To minimize the risk of aspiration and regurgitation, the LMA-Proseale—a laryngeal
mask with an esophageal vent—was developed.8 Cases of gastric insufflation and
aspiration have been reported when this device was malpositioned.9 Branthwaite reported
a case of laryngeal perforation leading to mediastinitis and patient death following blind
insertion of an endotracheal tube through the intubating laryngeal mask airway(ILMA).10
Contraindications for using an LMA include non-fasted patients, morbid obesity,
necessity for high inspiratory pressures (O20–25 cmH2O) in the presence of low
pulmonary compliance or chronic obstructive pulmonary disease (COPD), acute
abdomen, hiatal hernia, Zenker’s diverticulum, trauma, intoxication, airway problems at
the glottic or infraglottic level, and thoracic trauma.

Esophageal/tracheal combitube

The Esophageal/Tracheal Combitube (Combitube) is an esophagotracheal double-lumen

airway designed for emergency use when standard airway management measures have
failed. Disregarding recommendations for use of the proper size of the device (depending
on the patient’s height) may cause injury to the esophagus. Contraindications for using a
Combitube are intact gag reflexes, ingestion of caustic substances, known esophageal
disease, airway problems at the glottic or infraglottic level, and latex allergy.
Obstruction of the upper airway, subcutaneous emphysema, pneumomediastinum
and pneumoperitoneum during resuscitation settings, and several cases of esophageal
644 C. Hagberg et al

lacerations or perforation have been reported.11–13 The incidence of sore throat with
the use of this device is high.

Other Supraglottic Airway Devices

There are many other devices available for managing the airway at the supraglottic level:
laryngeal tube, ambu laryngeal mask, softseal laryngeal mask, laryngosed streamlined
linear of the pharynx, and perilaryngeal airway. Most clinical problems are similar to
those found with the LMA (for example, aspiration) and result from dislodgement,
overfilling of cuffs, and insufficient depth of anesthesia.

COMPLICATIONS WITH INTUBATION

Endotracheal intubation

The main injury associated with use of laryngoscopes is damage to the teeth.
Laryngoscopy usually requires deep anesthesia because it causes stimulation of
physiological reflexes, and adverse respiratory, cardiovascular and neurological effects
are possible (Table 2). Patients with a history of hypertension, pregnancy-induced
hypertension and ischemic heart disease are at additional risk. Deep anesthesia,
application of topical anesthetics, drug prevention of the sympathoadrenal response
using atropine or intravenous lidocaine, as well as minimizing mechanical stimulation,
attenuate these adverse effects. Rigid optical instruments such as the Bonfils
Retromolar Intubation Fiberscope, the Bullard, Upsher and WuScope laryngoscopes
and the rigid bronchoscope have similar complications.
There is a close relationship between difficult intubation and traumatic intubation.
In cases of difficult intubation (poor view of the vocal cords), the practitioner tends to

Table 2. Pathophysiological effects and complications of laryngoscopy and endotracheal intubation.

1. Cardiovascular system
Dysrhythmia
Hypertension
Myocardial ischemia and infarction
2. Respiratory system
Hypoxia
Hypercarbia
Laryngeal spasm
Bronchospasm
3. Central nervous system
Increased intracranial pressure
4. Eye
Increased intraocular pressure
5. Miscellaneous
Toxic and adverse effects of drugs related to laryngoscopy and intubation

Modified from Shang Ng, W. (1997, in Latto I.P, Vaughan RS (eds) Difficulties in Tracheal Intubation, pp. 000–
000. London: Saunders) with permission.
 Complications of managing the airway 645

increase the lifting forces of the laryngoscope blade, which may lead to damage of the
intraoral tissues and osseous structures. A difficult intubation may thus become a
traumatic intubation. Use of increasing force may induce swelling, bleeding or
perforation as the intubation becomes more and more difficult and may turn into a
‘cannot intubate’ and possibly even a ‘cannot ventilate’ situation. If intubation fails after
three attempts, another technique should be used in accordance with the airway
management algorithm.14
Lip injuries include lacerations, hematomas, edema, and teeth abrasions. They are
usually secondary to inattentive laryngoscopy performed by inexperienced prac-
titioners. These lesions are annoying to the patient, but are usually self-limited.
The incidence of dental injuries associated with anesthesia is greater than 1:4500.15
Maxillary central incisors are at most risk. Fifty percent of dental trauma happens during
laryngoscopy, 23% following extubation, 8% during emergence, and 5% in the context of
regional anesthesia. Dental trauma is also associated with LMA devices and
oropharyngeal airways. Dental injuries are most common in small children, patients
with periodontal disease or fixed dental work, and patients in whom intubation is
difficult. Pre-existing dental pathology (protrusion of the upper incisors, carious teeth,
paradentosis or periodontitis) should be thoroughly explored before the induction of
anesthesia, and the patient must be advised of the risk of dental damage. Although
tooth guards may possibly obstruct vision, their use may be indicated in
certain situations.
In the event that an entire tooth is avulsed, it should be retrieved and saved in a
moist gauze or in normal saline. Aspiration of the tooth may induce serious
complications requiring bronchoscopy for removal. With a rapid response from an oral
surgeon or dentist, an intact tooth can often be reimplanted and saved, but only when
performed within 1 hour.
Massive tongue swelling, or macroglossia, has been reported in numerous instances
in both adult and pediatric patients. Although macroglossia (occasionally of life-
threatening proportions) is associated with angiotensin-converting enzyme inhibitors,
some cases have occurred while a bite block was in place and when there was
substantial neck flexion during endotracheal intubation. Loss of tongue sensation is
possible after a compression injury to the lingual nerve during forceful laryngoscopy
or after LMA placement with an over-inflated or malpositioned cuff. Reduced sense
of taste and cyanosis of the tongue caused by lingual artery compression are
additional injuries that may be caused by an oversized, malpositioned, or over-
inflated LMA.
Damage to the uvula (edema and necrosis) is usually associated with an endotracheal
tube, oro- and nasopharyngeal airways, an LMA, or an alternative supraglottic airway
device, or by overzealous use of a suction catheter. Sore throat, odynophagia, painful
swallowing, coughing, foreign body sensation and serious life-threatening airway
obstruction have been reported.
The incidence of sore throat after intubation is approximately 40% and O65% when
blood is noted on the airway instruments.16 The incidence of sore throat following LMA
placement is 20–42%, depending on cuff inflation, and 8% with face mask ventilation.17
Fortunately, pain on swallowing usually lasts no more than 24–48 hours. Topical
anesthesia, such as lidocaine jelly, applied to the endotracheal tube does not lessen the
incidence of this problem and may actually worsen it.
Trauma to the larynx and vocal cords is not uncommon following endotracheal
intubation. It depends on the experience and skill of the intubator, as well as the degree
of difficulty. In one large study, 6.2% of patients sustained severe lesions, 4.5% developed
646 C. Hagberg et al

a hematoma of the vocal cords, 1% developed a hematoma of the supraglottic region,

and 1% sustained lacerations and scars of the vocal cord mucosa.18 Recovery is
generally prompt with conservative therapy, although hoarseness may appear even after
a 2-week interval.19 Granulations usually occur as a complication of long-term
intubation but may occur with short-term intubation as well. Injuries of the laryngeal
muscles and suspensory ligaments are also possible. Patients with hoarseness should be
examined preoperatively by an ENT specialist.
Arytenoid dislocation and subluxation have been reported as rare complications.20
Mitigating factors include traumatic and difficult intubations, repeated attempts at
intubation, and attempted intubation using blind techniques such as light-guided
intubation, retrograde intubation, and the use of the McCoy laryngoscope. However,
these complications are also found after easy intubations. Early diagnosis and operative
repositioning of arytenoid dislocation is necessary, because fibrosation with
consecutive malposition and ankylosis may occur after 48 hours.
Numerous investigators have reported vocal cord paralysis after intubation with
no other obvious source of injury. Paralysis may be unilateral (hoarseness) or
bilateral (respiratory obstruction). The most likely source of injury is an
endotracheal tube cuff, malpositioned in the subglottic larynx that presses on the
recurrent laryngeal nerve. Permanent voice change after intubation because of
external laryngeal nerve trauma occurs in up to 3% of patients undergoing surgery
in sites other than the head or neck. However, vocal cord paralysis after intubation
is usually temporary. Its incidence may be decreased by avoiding over-inflation of
the endotracheal tube cuff and by placing the endotracheal tube at least 15 mm
below the vocal cords. Vocal cord paralysis may also have a central origin. Eroded
vocal cords may adhere together, eventually forming synechiae. Surgical correction is
usually necessary.
Tracheobronchial trauma has various causes. Injury may result from an over-inflated
endotracheal tube cuff, inadequate tube size, malpositioned tube tip, laryngoscope,
stylet, tube exchanger or related equipment. Predisposing factors include anatomic
difficulties, blind or hurried intubation, inadequate positioning, poor visualization, or—
most commonly—inexperience on the part of the intubator. Edema after extubation
limits the lumen diameter and increases airway resistance. Small children are most
susceptible to this problem; almost 4% of children 1–3 years of age develop croup
following endotracheal intubation. Tracheal rupture, especially after emergency
intubation, has been reported, as well as a bronchial rupture secondary to use of an
endotracheal tube exchanger.21
Endotracheal tube cuffs inflated to a pressure greater than that of the capillary
perfusion may devitalize the tracheal mucosa, leading to ulceration, necrosis, and loss of
structural integrity. Ulceration will occur at even lower pressures in hypotensive
patients. The need for increasing cuff volumes to maintain a seal is an ominous sign of
tracheomalacia. The various nerves in this region of the neck are also at risk. Erosion of
the endotracheal tube into the paratracheal nerves may result in dysphonia,
hoarseness, and laryngeal incompetence. Tracheomalacia results from erosion confined
to the tracheal cartilages. It is imperative that the anesthesiologist inflate the cuff of the
endotracheal tube only as much as is necessary to ensure an adequate airway seal. If
using nitrous oxide during a lengthy surgical procedure, the pressure in the
endotracheal tube cuff should be checked by a cuff pressure control device. The cuff
pressure should not exceed 25 cmH2O.
The incidence of granulomas has been reported to range from 1:80022 to 1:20 000.23
Several months after prolonged endotracheal intubation, tracheal stenosis and fibrosis
 Complications of managing the airway 647

may occur, typically at the site of an inflated cuff, sometimes at the location of
the endotracheal tube tip. Dilation of the stenosis is curative if the stenosis is caught in
its early stages. However, surgical correction may be necessary once the tracheal lumen
has been reduced to 4–5 mm.
Supraglottic complications induced by long-term intubation may be prevented by
early tracheostomy. There is no evidence about the ideal time for tracheostomy in long-
term ventilated patients.
Barotrauma, inducing pneumomediastinum or tension pneumothorax, results from
high-pressure distention of intrapulmonary structures. High-flow insufflation tech-
niques are most often associated with barotrauma. Such problems are common in
microlaryngeal surgery in which jet ventilation is used.
Laryngoscopy and cuffed supraglottic airway devices may cause periodical or
permanent nerve injury. Transient weakness, numbness, or paralysis of the tongue can
occur after laryngoscopy, presumably because of pressure on the laryngeal and
hypoglossal nerves. Damage of the internal branch of the superior laryngeal nerve
during difficult intubation leading to anesthesia of the upper surface of the larynx may
occur. Transient palsies may occur when an LMA device is used because it affects the
hypoglossal and lingual nerves. The authors personally observed five cases of hyposmia
following uncomplicated nasotracheal intubation for head and neck surgery, and one
case of anosmia despite the use of preformed, warmed and lubricated nasotracheal
tubes. The hyposmias completely recovered in 3–6 months, whereas the anosmia
became permanent.
Airway management techniques such as chin lift, jaw thrust and direct
laryngoscopy transmit movement to the cervical spine and may induce cervical
spine injury. Attempts to hyperextend the necks of patients with ankylosing spondylitis
may result in cervical fractures and quadriplegia. Special attention should be given to
patients with C1 or C2 fractures because any degree of extension might compromise
spinal cord function.
Several conditions—such as Down syndrome, Arnold-Chiari malformation and
rheumatoid arthritis—are associated with atlantoaxial instability. Also, elderly patients
and those with pathological fragility—such as connective tissue disorders, lytic bone
tumors and osteoporosis—should be intubated with caution. Awake fiberoptic
intubation should be considered in all cases where time is not crucial.
Corneal abrasions are the most common eye complications that occur during general
anesthesia. They are primarily caused by a facemask being placed on an open eye or by
the eyelids not being completely closed during anesthesia. Prevention consists of
vigilance on the part of the anesthesiologist and application of adhesive tape over the
closed eyelids, especially during head and neck surgery. Although these injuries typically
heal within 24 hours, they are usually painful and can lead to corneal ulceration. An
immediate ophthalmologic consultation is recommended. In the presence of a
penetrating eye injury, an increase in intraocular pressure should be avoided by
adequate anesthesia.
Temporomandibular joint injury (TMJ) is a rare but serious complication. Rupture of the
lateral ligament is possible. TMJ injuries are caused by increasing force during
laryngoscopy to optimize the view of the glottis. As a result, limited mouth opening,
pain in the joint, lateral deviation of the mandible (in case of unilateral luxation),
protrusion of the mandible, and lockjaw may occur. Most of the cases of TMJ injury have
not been associated with difficult airway management.24 In the ASA closed claims
database, only 17% of the claims had documented pre-existing TMJ disorders, such as
pain.25
648 C. Hagberg et al

Nasotracheal intubation

Nasotracheal intubations are potentially hazardous. In the presence of basilar skull

fractures or certain facial fractures (such as LeFort II or III fractures) the endotracheal
tube may be inadvertently introduced into the cranial vault. A case of an uncomplicated
nasotracheal intubation in which asystole occurred after the tube was introduced into
the orbit has been reported.26 Substantial facial trauma and evidence of basilar skull
fractures are usually considered to be contraindications for this technique.
Nasotracheal tubes may also dissect backward and run behind the posterior pharyngeal
wall.
Nasal intubation may cause lacerations of the nasal mucosa, hemorrhage, and
epistaxis. Nosebleeds are common but are relatively easy to prevent. It is paramount
that the nasal mucosa be vasoconstricted before instrumentation (0.5% phenylephrine).
To minimize the chance of nasal injury, a small endotracheal tube that has been
lubricated well and presoaked in warm water (to increase its pliability) should be used.
Should epistaxis occur, it is recommended that the endotracheal tube cuff be inflated
and remain in the nostril to tamponade the bleeding.
Additional complications caused by nasotracheal intubation include dislodgement of
nasal polyps or turbinates, adenoidectomy, injury of the nasal septum, and perforation
of the priform recess or epiglottic vallecula. In case of injury to the priform recess,
damage of the internal branch of the superior laryngeal nerve (which supplies the
epiglottis and soft tissue of pharynx and larynx) or superior laryngeal vessels may occur.
Delayed complications of nasotracheal intubation are pharyngitis, rhinitis, and synechia
between the nasal septum and inferior turbinate bone. Distortion of the nares can lead
to the development of ischemia, skin necrosis, or nasal adhesions.
Even in the absence of gross trauma, the mechanical damage to the superficial
epithelial layers caused by nasal intubation results in mucociliary slowing and
bacteremia. Even short-term intubation has been reported to cause nasal septal and
retropharyngeal abscesses. Acute otitis media has been reported to occur in 13% of
nasally intubated neonates.27 Paranasal sinusitis has also been reported, most
commonly with nasal intubation for more than 5 days.
Fractures of the frontal part of the skull base with cerebrospinal rhinorrhea,
intranasal abscesses or abscesses with intranasal expansion, choanalatresia, hyperplastic
tonsils, tendency to uncontrollable nasal bleeding and coagulopathies are contra-
indications for nasotracheal intubation.

Esophageal intubation

When visualization of the glottis is difficult, the endotracheal tube may inadvertently be
introduced into the esophagus. Esophageal intubation is more common with
inexperienced practitioners but may also occur in experienced hands. Intubating the
esophagus is not disastrous, but failure to detect and correct the condition is. A closed
claims analysis of adverse anesthetic events reported that 18% of respiratory-related
claims involved esophageal intubation.28 Preoxygenation can help alleviate this problem
by allowing a longer apneic period for endotracheal intubation and by delaying the onset
of hypoxemia.
End-tidal CO2 monitoring is essential in confirming endotracheal placement of the
endotracheal tube. Capnography should be available wherever intubation is performed.
Fiberoptic bronchoscopy is another safe method for confirming the proper position of
 Complications of managing the airway 649

an endotracheal tube. All other signs, such as equal bilateral breath sounds, symmetric
bilateral chest wall movement, epigastric auscultation and observation of tube
condensation, are potentially misleading.
Perforation of the esophagus and retropharyngeal abscess has been reported on several
occasions.29 It is most likely to occur when inexperienced clinicians handle emergency
situations, when intubation is difficult, or in the presence of esophageal pathology.
Subcutaneous emphysema, pneumothorax, fever, cellulitis, cyanosis, sore throat,
mediastinitis, empyema, pericarditis, and death can occur. The mortality rate of
mediastinitis is O50%.

Bronchial intubation

Bronchial intubation often occurs and is sometimes difficult to identify. Asymmetric chest
expansion, unilateral presence of breath sounds (usually on the right side), and arterial
blood gas abnormalities are diagnostic features. Bronchial intubation (most commonly
right-sided) is more common in infants and children because of the small distance
between the carina and the glottis. If bronchial intubation goes undetected, it may lead
to atelectasis, hypoxia, and pulmonary edema. Fiberoptic bronchoscopy is the best
method for detecting the proper position of the endotracheal tube.
The tip of the endotracheal tube may be moved during flexion or extension of the
patient’s head as the patient is positioned for surgery. The tip of the endotracheal tube
can move an average of 3.8 cm (up to 6 cm) toward the carina when the neck is moved
from full extension to full flexion. When inadvertent bronchial intubation is discovered,
the endotracheal tube should be withdrawn and the lungs hyperinflated sufficiently to
expand any atelectatic areas.
Bonchial intubation is deliberately achieved in thoracic surgery with double-lumen
tubes. Even in the best of hands, tracheobronchial injuries occur during double-lumen
intubation. Bronchial rupture is a very serious complication. Using double-lumen tubes
that are too large may cause bronchial trauma.

Maintenance of the endotracheal tube

Airway obstruction can occur at any time during general anesthesia, particularly in
prolonged surgery or in patients with predisposing anatomic abnormalities. Airway
obstruction can result from diverse factors, including a sharp bend or kink in the
endotracheal tube or a tube that is obstructed with mucus, blood, foreign bodies, or
lubricant. Reinforced wire tubes may be used to avoid kinking, and their use is
recommended in prolonged procedures, oral surgery or during surgery associated with
special positioning of the patient. Nitrous oxide can cause expansion of gas bubbles
trapped in the walls of an endotracheal tube, leading to airway obstruction.
The cuff of an endotracheal tube can also cause airway obstruction. An over-inflated
cuff may compress the bevel of the endotracheal tube against the tracheal wall,
occluding its tip. The cuff may also herniate over the tip of the endotracheal tube. When
faced with any of these problems, the best solution is to pass a suction catheter or a
fiberoptic bronchoscope down the lumen of the endotracheal tube and attempt to
clear it. If the endotracheal tube is totally obstructed, passage of a stylet should
be attempted. Total obstruction that cannot be remedied quickly requires removal
of the endotracheal tube followed by reintubation. A common and serious
complication of endotracheal intubation is disconnection of the endotracheal tube from
650 C. Hagberg et al

the anesthesia circuit. This was identified as the most common critical incident in a study
of anesthesia-related human errors and equipment failures.30 Alarms to signal airway
disconnection are included on all modern anesthesia machines.
Leaks in an air delivery circuit can cause hypoventilation and dilution of the inspired
gases by entry of room air into the system.
Lasers are frequently used in the operating room to ablate benign and neoplastic
tissues in the airway. Laser fire is a very serious complication. The use of special laser
guarded or metal tubes is recommended, and all inflammatory materials such as
dentures and nasogastric tubes should be removed. One of the most catastrophic
events associated with their use is an airway fire, which occurs when the laser ignites
the endotracheal tube. The heat and fumes of the burning plastic may cause severe
damage to the airway. Treatment consists of immediately disconnecting the circuit from
the endotracheal tube and removing the burning tube from the airway. The fire should
be extinguished with saline, and the patient should be supported by facemask
ventilation. The airway should be evaluated for damage with bronchoscopy. Numerous
precautions can reduce the risk of an airway fire. If possible, placement of an
endotracheal tube may be avoided (ventilating laryngoscope, jet ventilation system,
intermittent apneic ventilation).31 Endotracheal tubes may be protected by wrapping
them in non-combustible tapes; alternatively, red rubber or metal non-combustible
endotracheal tubes may be used. Cuff ignition can be minimized by filling the cuff with
saline solution instead of air. Nitrous oxide should not be used in laser surgery because
it supports combustion. It is recommended that inert gases, such as helium or nitrogen,
be used instead of nitrous oxide, and that concentrations of oxygen do not exceed 40%.

Special techniques

Fiberoptic intubation is one of the most common methods utilized in cases of anticipated
difficult intubation. Intubation with a fiberoptic bronchoscope should not be attempted
when the pharynx is filled with blood or saliva, when inadequate space exists within the
oral cavity, or when time is critical and creating a surgical airway is the priority. Relative
contraindications include marked tissue edema, distortion of the oropharyngeal
anatomy, blood in the airway, soft tissue traction, or a severe cervical flexion deformity.
Potential complications associated with the fiberoptic bronchoscope include
bleeding, epistaxis (especially if a nasal airway is attempted), laryngotracheal trauma,
laryngospasm, bronchospasm, and aspiration of blood, saliva, or gastric contents.
Another possible hazard is associated with the practice of insufflating oxygen through
the suction channel. Subcutaneous emphysema of the pharynx, face, and periorbital
regions may occur in case of injury of the pharyngeal mucosa.
The lighted stylet may be used to facilitate intubation under both local and general
anesthesia. Sore throat, hoarseness, arytenoid subluxation and mucosal damage are
possible. Heat damage to the tracheal mucosa in prolonged intubation is a potential risk
with inappropriate handling.

COMPLICATIONS WITH INFRAGLOTTIC PROCEDURES

Infraglottic airway access is the last step in the ASA airway management algorithm.14 In
cases in which endotracheal intubation is impossible and the patient’s condition
deteriorates into a ‘cannot ventilate, cannot intubate’ situation, lifesaving steps must be
 Complications of managing the airway 651

immediately undertaken. Despite possible (and severe) complications, there are no

contraindications for infraglottic procedures in these critical situations. The most
severe complication is failure to establish an airway before brain damage or death
results.

Translaryngeal airway

Retrograde wire intubation is an excellent technique for securing a difficult airway. The
procedure takes some time to perform and should not be considered under emergency
circumstances unless the practitioner is extremely experienced in the technique.
Bleeding may occur at the site of the tracheal puncture. Cases of severe hemoptysis with
resultant hypoxia, cardiopulmonary arrest, dysrhythmias and death following retro-
grade wire intubation have been reported. Subcutaneous emphysema localized to the
area of the transtracheal needle puncture is common. In severe cases pneumomedias-
tinum and pneumothorax may occur.21 Laryngospasm may result from irritation by the
retrograde wire unless the vocal cords are anesthetized or relaxed. Other, less common
complications include esophageal perforation, tracheal hematoma, laryngeal edema,
infection, tracheitis, tracheal fistula, trigeminal nerve injury, and vocal cord damage.32
In both the surgical cricothyroidotomy (using a scalpel) and the needle cricothyroidotomy
(using a needle-set) procedures, the cricothyroid membrane requires penetration.
Acute complications are bleeding (especially during surgical cricothyroidotomy),
misplacement of the tube (especially after needle cricothyroidotomy) and barotrauma.
Subcutaneous emphysema, pneumothorax, pneumomediastinum and pneumopericar-
dium tube malposition or failure of airway access, wound infection, displaced cartilage
fractures and laryngotracheal separation may occur during this technique.
Granulation tissue around the tracheostomy site, subglottic stenosis, massive laryngeal
mucosa trauma, endolaryngeal hematoma and laceration, vocal cord paralysis,
hoarseness, and thyroid cartilage fracture with dysphasia are direct long-term
complications. All emergency translaryngeal airways should be eventually changed to a
formal tracheostomy. Subglottic stenosis is a delayed complication, especially in children.

Transtracheal airway

Transtracheal jet ventilation (TTJV) is accomplished by introducing a small percutaneous

catheter into the trachea and insufflating the respiratory tract with high-pressure
oxygen over a jet ventilator or a hand jet device. Although this technique may be helpful
in critical situations, life-threatening problems are associated with its use.
If the TTJV catheter is displaced from the trachea, subcutaneous emphysema,
hypoventilation, pneumomediastinum, pneumothorax, severe abdominal distention, or
death may result. Oxygen delivered through a transtracheal catheter must be able to
escape the lungs freely or over-distention and pulmonary rupture may occur. In cases of
total airway obstruction, the risk for pneumothorax is greatly increased because gas
cannot escape from the lungs. Strong consideration should be given to placing a second
transtracheal ‘egress’ catheter in these circumstances or simply avoiding this technique
altogether. Laryngospasm can also impede the outward flow of oxygen from the
trachea. Inadvertent placement of a gas delivery line into the gastrointestinal tract may
also result in complications (gastric rupture, esophageal perforations, bleeding,
hematoma, and hemoptysis). Damage to the tracheal mucosa may occur in patients
who are managed with long-term TTJV, especially if the gas is not humidified.
652 C. Hagberg et al

Although percutaneous dilatational tracheostomy (PCDT) is not usually recommended

for emergency use, it appears to be suitable for emergency situations in skilled hands.
Many different sets are available. Bleeding, subcutaneous and mediastinal emphysema,
pneumothorax, airway obstruction, aspiration, infection, accidental extubation and
death are early complications. Delayed complications are tracheal stenosis, scars,
hoarseness, tracheoesophageal and tracheocutaneous fistulae.
Minitracheostomy occasionally results in excess bleeding into the airway, necessitating
progression to a full surgical tracheostomy. Air embolism, subcutaneous emphysema,
pneumomediastinum and tension pneumothorax may occur.
Subglottic stenosis is a complication of long-term intubation. This is much more
difficult to repair and frequently results in permanent speech impairment or laryngeal
damage. A tracheostomy tube can cause tracheal erosion, particularly into the
esophagus (tracheoesophageal fistula) or the brachiocephalic artery. Accidental
extubation and dislodgement of the cannula occur occasionally, most commonly in
the early postoperative period. Infection, mediastinal sepsis, tracheal stenosis and
tracheomalacia are rare late complications.

RESPONSES TO INTUBATION

The larynx has the greatest afferent nerve supply of the airway. Airway reflexes require
suppression for stress-free airway management, especially for endotracheal intubation.
Intensive autonomic responses may occur during placement, maintenance and removal
of all airway devices.

Hemodynamic changes

Direct laryngoscopy and endotracheal intubation are both stimulating procedures that
may cause intense autonomic responses.33 Tachycardia, hypertension, dysrhythmias,
bronchospasm, and bronchorrhea are common; hypotension and bradycardia occur
less often. Patients with pre-existing hypertension are at higher risk.
The sympathetically mediated responses to mechanical stimulation of larynx,
trachea-carina and bronchi may be blocked by topical or intravenous lidocaine, by giving
opioids or short-acting selective a1-blockers before laryngoscopy and intubation. Large
hemodynamic responses have to be prevented in patients with coexisting
cardiovascular disease. More than 11% of patients with myocardial disease develop
some degree of myocardial ischemia during intubation.34 The key element is to provide
an adequate depth of anesthesia with either intravenous or inhalation agents before
instrumentation of the airway.
Fiberoptic intubation performed under adequate local anesthesia and conscious
sedation is an appropriate technique to prevent major hemodynamic changes during
intubation. The lowest cardiovascular responses were registered in patients after
insertion of a LMA.

Laryngospasm and bronchospasm

Due to reflex responses to stage II of anesthesia, laryngospasm can occur during

intubation. Laryngospasm involves more than spastic closure of the vocal cords.
An infolding of the arytenoids and the aryepiglottic folds occurs; these structures
 Complications of managing the airway 653

are subsequently covered by the epiglottis. This explains why a firm jaw thrust can
sometimes break the spasm: the hyoid is elevated, thereby stretching the epiglottis and
aryepiglottic folds to open the forced closure. Malpositioning due to incorrect insertion
techniques, as well as inadequate depth of anesthesia during LMA insertion, may induce
laryngospasm. It may also occur during fiberoptic intubation performed in non- or sub-
anesthetized laryngeal structures. Positive mask pressure may help; treatment with a
short-acting muscle relaxant may be necessary to break the spasm.
Tracheal irritation from the endotracheal tube can cause bronchospasm that is
sufficiently severe to prevent air movement throughout the lungs. The incidence of
intraoperative bronchospasm is almost 9% with endotracheal intubation, 0.13% with an
LMA, but close to 0% with mask ventilation.35 Poor correlation is seen with age, sex,
duration or severity of reactive airway disease, or duration of anesthesia. Factors that
may contribute to bronchospasm include inhaled stimulants, release of allergic
mediators, viral infections, exercise, or pharmacologic factors (including a-blockers,
prostaglandin inhibitors, and anticholinesterases). Bronchospasm may also occur during
fiberoptic intubation.
The spasm can be treated with inhalation of epinephrine or isoproterenol or an a2-
agonist (such as albuterol, metaproterenol, or terbutaline) or by deepening the level of
a volatile anesthetic.

Coughing and bucking

Two additional adverse responses to intubation are coughing and bucking. Such
responses are potentially hazardous in cases of increased intracranial pressure,
intracranial vascular anomalies, open-globe injuries, ophthalmologic surgery, or in cases
in which increased intra-abdominal pressure could rupture an abdominal incision.
Coughing and bucking occur less frequently with the LMA; however, in the presence
of lubricant globules on the anterior surface of the cuff, light anesthesia or
malpositioning, these adverse reactions may be observed. The incidence of coughing,
gagging and retching has been reported as 0.8% using an LMA with a fentanyl-propfol-
O2-N2O-isoflurane technique.35

Vomiting, regurgitation and aspiration

The overall incidence of aspiration during general anesthesia varies and has been
reported as 1/2131 (in Sweden) to 1/14 150 (in France), and 1/3216 in the USA, with an
associated mortality of 1/71 829 in the USA.36
A meta-analysis of publications concerning the LMA (547 publications) suggested
that the overall incidence of pulmonary aspiration was approximately 2/10 000.37 An
endotracheal tube and a Combitube are most effective in preventing pulmonary
aspiration. To reduce the risk of pulmonary aspiration, some new designs of airway
management devices were developed: the ProSeal-LMA and the Laryngeal Tube
Suctione.
In any patient considered to have a full stomach, the likelihood of vomiting in
response to irritation of the airway is increased, and aspiration of stomach contents is a
constant concern. Aspiration leads to coughing, laryngospasm and bronchospasm,
assuming that protective reflexes are intact. In consequence of these reactions,
hypertonia, bradycardia, asystole and hypoxia may occur. The magnitude of the
pulmonary reactions depends on the type and quantity of the aspirated material.38
654 C. Hagberg et al

The Sellick maneuver, or cricoid pressure, has removed much of the fear of
emergency intubation. Cricoid pressure is effective in raising the pressure in the upper
esophageal sphincter, thus preventing aspiration.

Intraocular and intracranial pressure

With thiopental, etomidate and halothane anesthesia, an increase in intraocular pressure

was observed during laryngoscopy as well as LMA insertion, but not with TIVA or
remifentanil and sevoflurane. Decreases in intraocular pressures were observed under
endotracheal intubation during general anesthesia with propofol and sevoflurane, both
combined with remifentanil. Intraocular pressure may also increase during extubation.
Insertion of an LMA does not increase intraocular pressure in children after
sevoflurane induction.51 Sufentanil is also effective in preventing an intraocular pressure
increase caused by rapid-sequence induction with succinylcholine.52 It is extremely
important that an increase in intraocluar pressure should be avoided in patients with
penetrating eye injury.
Intracranial pressure markedly and transiently rises during laryngoscopy and
endotracheal intubation. Patients with head injury are at higher risk from this increase
as it reduces cerebral perfusion and thus may increase secondary brain damage. Deep
anesthesia during induction can prevent these adverse effects.

Latex allergy

Almost 17% of overall anaphylaxis in surgical procedures are related to latex

anaphylaxis.39 To prevent anaphylaxis in patients during anesthesia and surgery, the
patient’s history has to be carefully evaluated preoperatively. There is currently no
therapy for latex allergy, and avoidance of latex-containing products is mandatory for
predisposed individuals.40 Latex allergy is present in 8% of the general population in the
USA, with a prevalence of 30% in health-care workers.41 There is an increased
incidence of type I and type IV latex sensitivity in the general population. The prevalence
of latex sensitivity among anesthesiologists is approximately 12.5% and of
allergy 2.4%.42
Patients with spina bifida, rubber industry workers, atopic patients, patients with a
multiple surgery history and with certain exotic food allergies are most at risk.
Contamination with latex in anesthesia is possible through direct contact by face mask,
endotracheal and gastric tubes, gloves, syringes, electrodes; through inhalation from
contaminated circuits and room air; and through the parenteral path with latex-
containing intravenous administration sets.
Considerations for anesthesiologists handling patients with latex allergy are available
at the ASA’s website [http://www.asahq.org/publicationsAndServices/latexallergy.pdf].
In a pediatric study, Nakamura et al found that a high percentage of children with home
mechanical ventilation have undiagnosed latex allergy.43

COMPLICATIONS WITH EXTUBATION

Primary and secondary responses to extubation are possible. The primary effects
include local and systemic responses. The same responses that follow intubation may
be observed at extubation. During intubation the patient is more protected by
 Complications of managing the airway 655

anesthesia induction than during extubation, therefore the cardiovascular responses

may be even more exaggerated. The most serious complication after extubation is the
occurrence of acute airway obstruction. Decrease in consciousness, central respiratory
depression, decrease in muscle tone, and tongue obstruction may lead to inspiratory or
expiratory stridor, dyspnea, cyanosis, tachycardia, hypertension, agitation and sweating.

Hemodynamic changes

Hemodynamic changes, including a 20% increase in heart rate and blood pressure,
occur in most patients at the time of extubation. Patients with cardiac disease,
pregnancy-induced hypertension30 and increased intracranial pressure may be at
particular risk for life-threatening ischemic myocardial episodes. Management consists
of deep extubation or pharmacologic therapy.

Laryngospasm

Laryngospasm, a protective reflex mediated by the vagus nerve, is the most frequent
cause of postextubation airway obstruction. It may be provoked by movement of the
cervical spine, pain, vocal cord irritation by secretions, or sudden stimulation while the
patient is still in a light plane of anesthesia. In a large study in 136 929 patients, the
incidence of laryngospasm was 50/1000 in children with bronchial asthma and airway
infection and 25/1000 in children in the age group of 1–3 months when endotracheal
intubation had been performed.44
The optimal course for dealing with laryngospasm is to avoid it. It is imperative that
no saliva, blood, or gastric contents touch the glottis while the patient is lightly
anesthetized. In cases in which laryngospasm is anticipated, the patient may undergo a
deep extubation. A patient undergoing deep extubation should be placed in the lateral
position with the head down to keep the vocal cords clear of secretions during
emergence. Because suctioning of the oropharynx does not adequately remove
secretions around the vocal cords, it is best to extubate patients during a positive-
pressure breath. This is the procedure of choice in children too. In a recent study,
children could be safely extubated in deep anesthesia from 1.5 minimum effective
alveolar anesthetic concentration of either sevoflurane or desflurane.45
In a survey of United States anesthesiologists deep extubation is performed by 64%
of the interviewed practitioners.46 The study of Koga et al47 has shown that the rate of
airway obstruction in patients extubated during deep anesthesia (17/20) was not higher
than in patients extubated after regaining consciousness (18/20).

Laryngeal edema

Laryngeal edema is an important cause of postextubation obstruction, especially in

neonates and infants. Supraglottic edema most commonly results from surgical
manipulation, positioning, hematoma formation, overaggressive fluid management,
impaired venous drainage, or coexisting conditions (such as pre-eclampsia or
angioneurotic edema). Retroarytenoidal edema typically results from local trauma or
irritation. Subglottic edema occurs most often in children, particularly neonates and
infants. Factors associated with the development of subglottic edema include traumatic
intubation, intubation lasting longer than 1 hour, bucking on the endotracheal tube,
changes in head position, or tight-fitting endotracheal tubes. Laryngeal edema usually
656 C. Hagberg et al

presents as stridor within 30–60 minutes after extubation, although it may start as late
as 6 hour postextubation.48 Regardless of the cause of laryngeal edema, management
depends on the severity of the condition. Therapy consists of humidified oxygen,
racemic epinephrine, head-up positioning, and occasionally reintubation with a smaller
endotracheal tube. The practice of administering parenteral steroids with the goal of
preventing or reducing edema is controversial.48

Bronchospasm

In patients at risk for bronchospasm the timing of extubation is of equal concern. These
patients may be extubated either during deep anesthesia (if this approach can be used
safely) or when they are fully awake and the own airway reflexes are present. Although
the degree of spasm in this condition may be severe, it is usually self-limited and short-
lived.

Negative-pressure pulmonary edema

When airway obstruction occurs after extubation, such as in case of laryngospasm,

negative-pressure pulmonary edema may occur in the spontaneously breathing patient.
As a result of inspiratory effort against the closed glottis, these patients generate
negative intrapleural pressure O100 cmH2O. Increases in left ventricular preload and
afterload, altered pulmonary vascular resistance, increased adrenergic state, right
ventricle dilatation, intraventricular septum shift to the left, left ventricular diastolic
dysfunction, increased left heart loading conditions, enhanced microvascular intramural
hydrostatic pressure, negative pleural pressure, and transmission to the lung
interstitium may result in a marked increase in transmural pressure, fluid filtration
into the lung and development of pulmonary edema.49
The condition is seen within minutes after extubation. Management involves
removing the obstruction, supporting the patient with oxygen, monitoring the patient
closely, and reducing the afterload. Reintubation is rarely necessary; most cases resolve
spontaneously without further complications.

Aspiration

Pulmonary aspiration of gastric contents is a constant threat for any patient who has a
full stomach or is at risk for postoperative vomiting. Laryngeal function is altered for at
least 4 hour after tracheal extubation. Depression of coughing reflexes, along with the
presence of residual anesthetic agents, places almost all recently extubated patients at
risk. Aspiration is probably more prevalent than is currently thought. Most cases are so
minor that they do not affect the patient’s postoperative course. Reducing gastric
contents by suctioning through a gastric tube and extubation with the patient placed in
the lateral position with a head-down tilt is the safest protection against aspiration.

Airway compression

External compression of the airway after extubation may lead to obstruction. A rapidly
expanding hematoma in close proximity to the airway is a very dangerous situation. This
may occur after certain surgeries, such as carotid endarterectomy, and must be quickly
diagnosed and treated before total airway obstruction occurs. Immediate surgical
 Complications of managing the airway 657

re-exploration is indicated, although the airway concerns in these patients should be

approached with extreme caution.
External compression of the neck, such as chronic compression of a goiter, may also
result from tracheomalacia. Management includes reintubation, surgical tracheal
support (stenting), or tracheostomy below the level of obstruction.

Difficult extubation and accidental extubation

Possible causes of difficult removal of the endotracheal tube are failure to deflate the
cuff, use of an oversized tube, adhesion of the tube to the tracheal wall, or transfixation
of the tube by an inadvertent suture to a nearby organ or a screw in the oro-maxillo-
facial surgery. Possible sequelae of these complications include airway leak, aspiration,
tube obstruction, and trauma from attempts at forceful extubation. In most cases the
problem arises from an inability to deflate the cuff, commonly as a result of failure in the
cuff-deflating mechanism. Should this problem occur, the cuff should be punctured with
a transtracheal needle. Forceful removal of an endotracheal tube with the cuff inflated
may result in damage to the vocal cords and arytenoid dislocation.
Accidental extubation during anesthesia may occur with disposable tonsillectomy
instruments and change of the patient’s head position. Most accidental extubations
were reported from intensive care unit patients.50 Complications after accidental
extubation may include hypoxia, hypercarbic respiratory failure, aspiration, retention of
pulmonary secretion, arrhythmia and tachycardia. Reintubation may be very difficult,
especially after a difficult intubation. The use of the combitube or the LMA may be very
useful in this critical situation.

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