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Incidence and Outcomes of Acute Laryngeal Injury After Prolonged Mechanical Ventilation*

Shinn, Justin R. MD1; Kimura, Kyle S. MD1; Campbell, Benjamin R. MD1; Sun Lowery, Anne BS2; Wootten, Christopher T. MD1,3; Garrett, C. Gaelyn MD1,4; Francis, David O. MD, MS5; Hillel, Alexander T. MD6; Du, Liping PhD7; Casey, Jonathan D. MD8; Ely, E. Wesley MD, MPH7,9,10; Gelbard, Alexander MD1,4

doi: 10.1097/CCM.0000000000004015
Clinical Investigations
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SDC

Objectives: Upper airway injury is a recognized complication of prolonged endotracheal intubation, yet little attention has been paid to the consequences of laryngeal injury and functional impact. The purpose of our study was to prospectively define the incidence of acute laryngeal injury and investigate the impact of injury on breathing and voice outcomes.

Design: Prospective cohort study.

Setting: Tertiary referral critical care center.

Patients: Consecutive adult patients intubated greater than 12 hours in the medical ICU from August 2017 to May 2018 who underwent laryngoscopy within 36 hours of extubation.

Interventions: Laryngoscopy following endotracheal intubation.

Measurements and Main Results: One hundred consecutive patients (62% male; median age, 58.5 yr) underwent endoscopic examination after extubation. Acute laryngeal injury (i.e., mucosal ulceration or granulation tissue in the larynx) was present in 57 patients (57%). Patients with laryngeal injury had significantly worse patient-reported breathing (Clinical Chronic Obstructive Pulmonary Disease Questionnaire: median, 1.05; interquartile range, 0.48–2.10) and vocal symptoms (Voice Handicap Index-10: median, 2; interquartile range, 0–6) compared with patients without injury (Clinical Chronic Obstructive Pulmonary Disease Questionnaire: median, 0.20; interquartile range, 0–0.80; p < 0.001; and Voice Handicap Index-10: median, 0; interquartile range, 0–1; p = 0.005). Multivariable logistic regression independently associated diabetes, body habitus, and endotracheal tube size greater than 7.0 with the development of laryngeal injury.

Conclusions: Acute laryngeal injury occurs in more than half of patients who receive mechanical ventilation and is associated with significantly worse breathing and voicing 10 weeks after extubation. An endotracheal tube greater than size 7.0, diabetes, and larger body habitus may predispose to injury. Our results suggest that acute laryngeal injury impacts functional recovery from critical illness.

1Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN.

2Vanderbilt University School of Medicine, Nashville, TN.

3Department of Pediatric Otolaryngology, Vanderbilt University Medical Center, Nashville, TN.

4Division of Laryngology, Vanderbilt University Medical Center, Nashville, TN.

5Division of Otolaryngology – Head and Neck Surgery, University of Wisconsin-Madison, Madison, WI.

6Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, MD.

7Center for Quantitative Sciences, Department of Biostatistics, Vanderbilt University, Nashville, TN.

8Division of Allergy, Pulmonary, and Critical Care, Vanderbilt University Medical Center, Nashville, TN.

9Tennessee Valley Veteran’s Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN.

10Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN.

*See also p. 1802.

This work was performed at the Vanderbilt University Medical Center.

Drs. Shinn, Kimura, and Campbell, Ms. Lowery, and Dr. Gelbard had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs. Shinn, Du, and Gelbard were involved with statistical analysis. All authors provided revisions and approved the final article.

Trial Registration: Clinical Trials ID# NCT03250975.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s websites (http://journals.lww.com/ccmjournal).

Supported, in part, by a Vanderbilt Institute for Clinical and Translational Research grant to purchase video laryngoscopy recording capabilities.

Dr. Shinn received funding from Vanderbilt Institute for Clinical and Translational Research grant (to purchase video laryngoscopy recording capabilities). The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: alexander.gelbard@vumc.org

Copyright © 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.