Editing Tracheal intubation (section)

==Complications==
Tracheal intubation is generally considered the best method for airway management under a wide variety of circumstances, as it provides the most reliable means of oxygenation and ventilation and the greatest degree of protection against regurgitation and pulmonary aspiration.<ref name=AHA2005-III/> However, tracheal intubation requires a great deal of clinical experience to master<ref name=Goedecke2007/> and serious complications may result even when properly performed.<ref name=Georgi2007/>

Four anatomic features must be present for orotracheal intubation to be straightforward: adequate mouth opening (full range of motion of the temporomandibular joint), sufficient pharyngeal space (determined by examining the [[hypopharynx|back of the mouth]]), sufficient submandibular space (distance between the thyroid cartilage and the chin, the space into which the tongue must be displaced in order for the larygoscopist to view the glottis), and adequate extension of the cervical spine at the atlanto-occipital joint. If any of these variables is in any way compromised, intubation should be expected to be difficult.<ref name=Georgi2007/>

Minor complications are common after laryngoscopy and insertion of an orotracheal tube. These are typically of short duration, such as sore throat, lacerations of the lips or [[gingiva|gums]] or other structures within the upper airway, chipped, fractured or dislodged teeth, and nasal injury. Other complications which are common but potentially more serious include [[tachycardia|accelerated]] or [[cardiac dysrhythmia|irregular]] heartbeat, [[hypertension|high blood pressure]], elevated [[intracranial pressure|intracranial]] and [[intraocular pressure|introcular]] pressure, and [[bronchospasm]].<ref name=Georgi2007/>

More serious complications include [[laryngospasm]], [[tracheobronchial injury|perforation of the trachea]] or [[esophagus]], pulmonary aspiration of gastric contents or other foreign bodies, fracture or dislocation of the cervical spine, [[temporomandibular joint]] or [[arytenoid cartilage]]s, decreased oxygen content, [[Hypercapnia|elevated arterial carbon dioxide]], and [[vocal cord paresis|vocal cord weakness]].<ref name=Georgi2007/> In addition to these complications, tracheal intubation via the nasal route carries a risk of dislodgement of adenoids and potentially severe nasal bleeding.<ref name=Delaney1988/><ref name=Mlinek1990/> Newer technologies such as flexible fiberoptic laryngoscopy have fared better in reducing the incidence of some of these complications, though the most frequent cause of intubation trauma remains a lack of skill on the part of the laryngoscopist.<ref name=Georgi2007/>

Complications may also be severe and long-lasting or permanent, such as vocal cord damage, esophageal perforation and [[retropharyngeal abscess]], bronchial intubation, or nerve injury. They may even be immediately life-threatening, such as laryngospasm and negative pressure [[pulmonary edema]] (fluid in the lungs), aspiration, unrecognized esophageal intubation, or accidental disconnection or dislodgement of the tracheal tube.<ref name=Georgi2007/> Potentially fatal complications more often associated with prolonged intubation or tracheotomy include abnormal communication between the trachea and nearby structures such as the [[Brachiocephalic artery|innominate artery]] (tracheoinnominate [[fistula]]) or esophagus ([[tracheoesophageal fistula]]). Other significant complications include airway obstruction due to [[tracheomalacia|loss of tracheal rigidity]], [[ventilator-associated pneumonia]] and [[Subglottic stenosis|narrowing]] of the glottis or trachea.<ref name=Rosenblatt2009/> The cuff pressure is monitored carefully in order to avoid complications from over-inflation, many of which can be traced to excessive cuff pressure [[ischemia|restricting the blood supply to]] the tracheal mucosa.<ref name=Sengupta2004/><ref name=Pousman2007/> A 2000 Spanish study of bedside percutaneous tracheotomy reported overall complication rates of 10–15% and procedural mortality of 0%,<ref name=Anon2000/> which is comparable to those of other series reported in the literature from the Netherlands<ref name=Polderman2003/> and the United States.<ref name=Hill1996/>

Inability to secure the airway, with subsequent failure of oxygenation and ventilation is a life-threatening complication which if not immediately corrected leads to [[hypoxemia|decreased oxygen content]], brain damage, [[Circulatory collapse|cardiovascular collapse]], and death.<ref name=Georgi2007/> When performed improperly, the associated complications (e.g., unrecognized esophageal intubation) may be rapidly fatal.<ref name=Katz2001/> Without adequate training and experience, the incidence of such complications is high.<ref name=AHA2005-III/> The case of Andrew Davis Hughes, from Emerald Isle, NC is a widely known case in which the patient was improperly intubated and, due to the lack of oxygen, sustained severe brain damage and died. For example, among [[paramedic]]s in several United States urban communities, unrecognized esophageal or [[hypopharynx|hypopharyngeal]] intubation has been reported to be 6%<ref name=Jones2004/><ref name=Pelucio1997/> to 25%.<ref name=Katz2001/> Although not common, where basic [[emergency medical technician]]s are permitted to intubate, reported success rates are as low as 51%.<ref name=Sayre1998/> In one study, nearly half of patients with misplaced tracheal tubes died in the emergency room.<ref name=Katz2001/> Because of this, the [[American Heart Association]]'s ''Guidelines for Cardiopulmonary Resuscitation'' have de-emphasized the role of tracheal intubation in favor of other airway management techniques such as bag-valve-mask ventilation, the laryngeal mask airway and the Combitube.<ref name=AHA2005-III/>  Higher quality studies demonstrate favorable evidence for this shift, as they have shown no survival or neurological benefit with endotracheal intubation over supraglottic airway devices (Laryngeal mask or Combitube).<ref name="pmid30293843">{{cite journal | vauthors = White L, Melhuish T, Holyoak R, Ryan T, Kempton H, Vlok R | title = Advanced airway management in out of hospital cardiac arrest: A systematic review and meta-analysis | journal = Am J Emerg Med | volume = 36 | issue = 12 | pages = 2298–2306 | date = December 2018 | pmid = 30293843 | doi = 10.1016/j.ajem.2018.09.045 | s2cid = 52931036 | url = https://espace.library.uq.edu.au/view/UQ:4f65350/UQ4f65350_OA.pdf }}</ref>

One complication—unintentional and unrecognized intubation of the esophagus—is both common (as frequent as 25% in the hands of inexperienced personnel)<ref name=Katz2001/> and likely to result in a deleterious or even fatal outcome. In such cases, oxygen is inadvertently administered to the stomach, from where it cannot be taken up by the [[circulatory system]], instead of the lungs. If this situation is not immediately identified and corrected, death will ensue from cerebral and cardiac anoxia.

Of 4,460 claims in the [[American Society of Anesthesiologists]] (ASA) Closed Claims Project database, 266 (approximately 6%) were for airway injury. Of these 266 cases, 87% of the injuries were temporary, 5% were permanent or disabling, and 8% resulted in death. Difficult intubation, age older than 60 years, and female gender were associated with claims for perforation of the esophagus or pharynx. Early signs of perforation were present in only 51% of perforation claims, whereas late [[sequelae]] occurred in 65%.<ref name=Domino1999/>

During the [[Severe acute respiratory syndrome coronavirus|SARS]] and [[COVID-19 pandemic]]s, tracheal intubation has been used with a [[ventilator]] in severe cases where the patient struggles to breathe. Performing the procedure carries a risk of the caregiver becoming infected.<ref>{{cite journal |last1=Zuo |first1=Mingzhang |last2=Huang |first2=Yuguang |last3=Ma |first3=Wuhua |last4=Xue |first4=Zhanggang |last5=Zhang |first5=Jiaqiang |last6=Gong |first6=Yahong |last7=Che |first7=Lu |title=Expert Recommendations for Tracheal Intubation in Critically ill Patients with Noval Coronavirus Disease 2019 |journal= Chinese Medical Sciences Journal|date=2020 |volume=35 |issue=2 |pages=105–109 |doi=10.24920/003724 |pmid=32102726 |pmc=7367670 |quote=high-risk aerosol-producing procedures such as endotracheal intubation may put the anesthesiologists at high risk of nosocomial infections|doi-access=free }}</ref><ref>{{cite web |title=World Federation Of Societies of Anaesthesiologists - Coronavirus |url=https://www.wfsahq.org/resources/coronavirus |website=www.wfsahq.org |date=25 June 2020 |quote=Anaesthesiologists and other perioperative care providers are particularly at risk when providing respiratory care and tracheal intubation of patients with COVID-19}}</ref><ref>{{cite web |title=Clinical management of severe acute respiratory infections when novel coronavirus is suspected: What to do and what not to do |url=https://www.who.int/csr/disease/coronavirus_infections/InterimGuidance_ClinicalManagement_NovelCoronavirus_11Feb13u.pdf |publisher=[[World Health Organization]] |page=4 |quote=The most consistent association of in-creased risk of transmission to healthcare workers (based on studies done during the SARS outbreaks of 2002–2003) was found for tracheal intubation.}}</ref>