REFERAT

Post Intubation Laryngeal Edema

By : Baiq Denda Putria Ningsih (H1A016012)
Supervisor: dr. Hj. Elya Endriani, Sp.An
Outline
01 INTRODUCTION

02 LITERATURE REVIEW

03 CLOSURE
INTRODUCTION
 INTRODUCTION
 Endotracheal intubation is an essential skill performed by multiple medical specialists to secure
a patient’s airway as well as provide oxygenation and ventilation
 Laryngeal injuries are common after endotracheal intubation, which could manifest as varying
degrees of edema
 laryngeal edema is a common complication following intubation and usually results from the
direct pressure and the inflammatory reaction triggered by the endotracheal tube on surfaces of
contact.
 The current treatment of choice for PLE consists of intravenous corticosteroids and nebulized
epinephrine.
LITERATUR
REVIEW
 Post Intubation
Laryngeal Edema

01 Definition

 Laryngeal edema (LE) is a common

complication of intubation and is caused by
trauma to the larynx.
 Post Intubation
Laryngeal Edema
 laryngeal edema represents a common cause
for breathing difficulty and/or stridor following
extubation, there by makes a common etiology
for extubation failure and the need for
reintubation
reintubation is associated with augmented
morbidity and mortality → important to prevent
reintubation
 02 Epidemiology
 The determination of the exact
prevalence of post-intubation laryngeal Prevalence
edema is challenging because of wide 01 Laryngeal Edema
variations in definition, diagnostic
cariteria, and the methods employed for 02
the detection
03 the incidence of post-intubation (extubation)
laryngeal edema varies between 5% to 54 % in
different studies
04 incidence of post-extubation stridor ranges from
1.5% to 26.3%..
05 almost up to 10.5% of patients with laryngeal edema will fail
extubation, and require reintubation. The reported overall incidence
of post-extubation failure requiring reintubation varies from 1.8% to
31.4%..
the incidence of edema is higher in females

A prospective French study on 136 intubated patients with post-extubation fibreoptic

bronchoscopy evaluation observed laryngeal injury in 73% of patients, and laryngeal
edema was the most common injury noted in 54.4% of the patients.
 Post Intubation
Laryngeal Edema

03 Etiology

 laryngeal edema is a common complication Risk Factors :

following intubation and usually results from the a. Intubation factors:

direct pressure and the inflammatory reaction  History of difficult intubation (prolonged

triggered by the endotracheal tube on surfaces of intubation attempt)

contact.  Large tube size (smaller height-to-tube diameter

ratio)
 Post Intubation
Laryngeal Edema

03 Etiology
b. Post-intubation factors:
 Prolonged endotracheal intubation
 High cuff pressures
 Agitation while intubated
 Self-extubation and reintubation
c. The patient, setting, and surgery-related
factors:
 Type of surgery (e.g., head and neck surgery)
 Prone positioning during neurosurgical
procedures
 Fluid resuscitation
 Neck and airway injuries
 Non-sedation treatment
 Female gender
 Gastro-oesophageal reflux
 Post Intubation
Laryngeal Edema

04 Diagnosis

Sign & Symptoms

 Most patients with post-intubation laryngeal
edema complain of mild symptoms like throat
ache, difficulty to speak, or swallow
 severe laryngeal edema makes a common
etiology of post-extubation stridor
 patients with stridor get reintubated
 Post Intubation
Laryngeal Edema

04 Diagnosis

Evaluation 1. Cuff Leak Test

 several tests have been proposed for The CLT is an important non-invasive test evaluation to
the evaluation of airway patency before assess the risk for laryngeal edema and/or post-

extubation. extubation stridor in intubated patients

 These methods include the cuff leak test (CLT), A qualitative assessment is done by deflating the cuff
ultrasonography, and video laryngoscopy. and auscultating the tracheal area for any audible leak.
 Post Intubation
Laryngeal Edema

04 Diagnosis

The quantitative test is done by putting the patient The positive predictive value for postextubation stridor
in volume control mode and calculating the was 80% if the cuff leak was <110 mL, and the negative
difference between the inspiratory tidal volume and predictive value was 98% if the cuff leak was >110 mL.
the average value of lowest three expiratory tidal
volumes obtained over a period of 6 breaths (cuff
leak volume).
 Post Intubation
Laryngeal Edema
04 Diagnosis
2. Laryngeal Ultrasonography
Laryngeal ultrasonography is a simple, rapid, and non-invasive
evaluation which could be done at the bedside
It measures the Air Column Width (ACW), which is the width
of the acoustic shadow at the level cords before and after cuff
deflation in the intubated patients.
The ACWD is the difference in the air column measurement in
the intubated and deflated state.
 Post Intubation
Laryngeal Edema
04 Diagnosis
2. Laryngeal Ultrasonography
Ding et al., in a study on 51 patients (out of whom four developed post-
extubation stridor) has shown significantly low ACW (4.5mm versus 6.4)
and ACWD (0.35 mm versus 1.5 mm) in those who developed post-
extubation stridor
Further statistical analysis of available evidence indicates that
ultrasonography has a low positive predictive value, sensitivity, and
specificity for predicting PES or PLE or both
 Post Intubation
Laryngeal Edema
04 Diagnosis
3. Video Laryngoscopy
Video laryngoscopy or fiber optic endoscopy evaluation is
conceptually promising in that they would be able to visualize
the peri laryngeal structures and abnormalities.
Unlike CLT, video laryngoscopy or fibreoptic evaluation can
identify and differentiate between the structural versus
functional laryngeal abnormalities (e.g., laryngeal edema versus
laryngospasm) guiding appropriate management
 Post Intubation
Laryngeal Edema

04 Treatment

 Current treatment of choice for LE consists of

intravenous corticosteroids and nebulized epinephrine.
 Corticosteroids decrease LE by reducing response and
decreasing capillary dilation and permeability.
 use methylprednisolone in the dose of 20 mg
intravenous (IV) 4 hourly over 12 hours prior to
extubation or a single dose methylprednisolone 40 mg
IV at least 4 hours before extubation
 Post Intubation
Laryngeal Edema

04 Treatment

 Adrenaline nebulization is thought to decrease LE via  Heliox reduces the airways resistance with decreased
vasoconstriction work of breathing without changing the clinical
 Adrenaline nebulizations in the dose of 1 mg in 5 ml of outcome.
0.9 % sodium chloride over 10 minutes duration.  Thus, it may only provide more time before a more
 Heliox (helium and oxygen mixture) has been shown definite intervention at airway obstruction is executed
to decrease the post-extubation stridor scores in
pediatric trauma patients.
 Post Intubation
Laryngeal Edema

04 Treatment

 Symptomatic patients not getting better with anti-edema

 Reintubated patients are also continued on IV steroids
measures (IV steroids / adrenaline nebulizations) are
and adrenaline nebulizations for 24 to 48 hours before
monitored up to an hour before reintubation.
reassessing for extubation versus tracheostomy
 If the patient is significantly symptomatic in the post-
extubation period but slowly getting better clinically within
this one hour period, IV steroids and adrenaline nebulization
are continued for 24 to 48 hours.
 Post Intubation
Laryngeal Edema
 CLOSURE

 Endotracheal intubation is one procedure that affects the patient's airway and provides
oxygenation and ventilation
 Laryngeal edema is a common complication of intubation and is caused by trauma to the
larynx.
 Edema of the larynx usually results from direct pressure and inflammatory reactions in
contact with the surface of the endotracheal tube.
 CLOSURE
 Current treatment of choice for edema consists of intravenous corticosteroids and nebulized
epinephrine.
 Corticosteroids can relieve laryngeal edema by reducing the inflammatory response and
decreasing capillary dilation and permeability.
 Adrenaline nebulization decreases laryngeal edema by vasoconstriction.
 In addition, Heliox (a mixture of helium and oxygen) has also been shown to reduce post-
extubation stridor scores in children who work by reducing airway supply. However, the use
of Heliox in adults has yet to be investigated.
 Reference
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