指導醫師: 劉宏濱主任報告人: 王德傑

Laryngeal injury

� Prolonged intubation (variably defined as ≥36 hours to ≥3 days)

� Traumatic intubation

� Not using a muscle relaxant drug during � Not using a muscle relaxant drug during intubation

� A large ETT (>8 mm in men, >7 mm in women)

� Suction

� Nasogastric tube

Laryngeal edema

� More than half of patients

� Clinically significant : vocal cord mobility is impaired, 5 to 13 percent of patients

� reintubation in approximately 1 percent � reintubation in approximately 1 percent

Mucosal ulceration

� > 4 days, a third of patients

Granulomas

� Hoarseness that persists longer than 7 to 10 days

Vocal cord paralysis

� 0.07% ( on the left side in 70% of cases)� Hoarseness immediately after extubation and

resolves over days to months� Arytenoid cartilage dislocation, compression of

anterior branch of the recurrent laryngeal nervenerve

� Risk : oversized ETT, overinflated ETT cuff, and excessive ETT movement, surgery/anesthesia time (two-fold, 3-6 hours; 15-fold, over 6 hours), age (three-fold, over 50 years), and diabetes mellitus or hypertension (two-fold)

Swallowing impairment

� 254 patients who were intubatedendotracheally for >48 hours following cardiac surgery (41%)

� Risk : prolonged duration of � Risk : prolonged duration of endotracheal intubation, perioperativecerebrovascular events, and perioperative sepsis

� Resolves without intervention

Tracheal stenosis

� Cuff pressure exceeds the mean capillary pressure in the tracheal mucosa (approximately 20 cm H2O)

� Dyspnea within five weeks after � Dyspnea within five weeks after extubation

� Pulmonary function testing, bronchoscopy or laryngoscopy, spiral computed tomography

Tracheoesophageal fistula

� Recurrent aspiration pneumonia

� High ETT cuff pressure is the dominant risk factor

� High airway pressures, excessive � High airway pressures, excessive motion of the ETT, and prolonged duration of mechanical ventilation

Rare complication

� Epiglottis downfolding into the laryngeal inlet

� Case 1 laryngoscopy for oropharyngealpacking

� Case 2 Direct laryngoscopy was performed to rule out endobronchial intubation

� LMA, Fiberscope, stylet, endoscopic forceps

Uvula necrosis—an unusual

cause of severe postoperative

sore throat� Sore throat 40% with an average

duration of 16 ± 11 h(809 patients )� foreign body sensation or difficulty

swallowingswallowing

� long tracheal tube placed in the midline causing excessive compression of a long uvula, blind pharyngeal suctioning with a hard plastic sucker, and upper GI endoscopy, T.E.E.

Uvula necrosis.

C. J. Atkinson, and J. Rangasami Br. J. Anaesth. 2006;97:426-427

© The Board of Management and Trustees of the British Journal of Anaesthesia 2006. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Effects of steroids on Effects of steroids on Effects of steroids on Effects of steroids on reintubationreintubationreintubationreintubation

and postand postand postand post----extubationextubationextubationextubation stridorstridorstridorstridor in adultsin adultsin adultsin adults

� 40 mg of methylprednisolone four hours prior to extubationto extubation

� Cuff leak of less than 24 percent of the tidal volume

� post-extubation stridor (16 versus 39 percent) and reintubation (8 versus 30 percent)

The The The The endotrachealendotrachealendotrachealendotracheal tube cufftube cufftube cufftube cuff----leak leak leak leak

test as a predictor for test as a predictor for test as a predictor for test as a predictor for

postextubationpostextubationpostextubationpostextubation stridorstridorstridorstridor

� 462 patients studied, 20 (4.3%) developed PES

that required treatment; 7 of those 20 (1.5%)

required reintubationrequired reintubation

� defined by an absolute leak volume < or = 110

ml

� sensitivity was 0.50, and the specificity was 0.84

� ratio of ETT size to laryngeal diameter was >

45%, and patients intubated for > 6 d