Laryngeal Complications in ICU🏥🗣️

Introduction

Laryngeal complications following tracheal intubation and tracheostomy are significant concerns in critically ill patients. These complications impact airway patency, vocalization, and swallowing, leading to dysphagia, dysphonia, and an increased risk of aspiration pneumonia.

🚨 The underlying critical illness, prolonged mechanical ventilation, and iatrogenic airway trauma exacerbate these complications, resulting in delayed extubation, decannulation failure, and prolonged hospital stay. 🏨

Speech and language therapists (SLTs) play a crucial role in the detection, assessment, and rehabilitation of these patients. 🗣️ The use of fibreoptic endoscopic evaluation of swallowing (FEES) is invaluable in assessing laryngeal dysfunction, guiding interventions, and improving patient outcomes. 🔍

Key Points 📌

✅ Pharyngolaryngeal injury post-intubation can delay extubation and decannulation, prolonging ICU stay.

✅ Early detection of dysphagia and dysphonia is crucial to prevent aspiration-related complications.

✅ Loss of vocalization during critical illness increases psychological distress, leading to anxiety, depression, and disengagement from rehabilitation.

✅ Multidisciplinary team (MDT) involvement, including SLTs, intensivists, and physiotherapists, is essential for optimizing recovery.

What Laryngeal Complications Are Associated with Intubation and Tracheostomy? 🤕

Laryngeal injury is common post-intubation, even after short-duration general anesthesia. These injuries can be classified based on onset and severity.

Complications of Tracheal Intubation 🏥

🔴 Early (Acute Phase) Complications:

• Laryngeal edema → Airway obstruction, stridor

• Vocal cord (VC) palsy or paresis → Hoarseness, breathy voice

• Laryngopharyngeal desensitization → Impaired cough, aspiration risk

• Aspiration pneumonia → Silent aspiration due to weak airway reflexes

• Dysphagia → Reduced airway protection

• VC ulceration, erythema, polyps → Pain, voice changes

🟠 Late Complications:

• Persistent laryngeal edema → Stridor, increased re-intubation risk

• VC atrophy or bowing → Vocal fatigue, reduced phonation

• Anterior glottic web formation → Airway narrowing

• Aspiration risk → Chronic aspiration leading to pneumonia

🔵 Very Late (Chronic) Complications:

• Glottic/subglottic stenosis → Fixed airway narrowing, dyspnea

• Laryngomalacia/tracheomalacia → Softened airway walls leading to collapse

Complications of Tracheostomy 🩺

• All complications of intubation, plus: Stoma infection, wound breakdown, granulation Incoordinated glottic closure → Ventilatory inefficiencyVC tremor and dysphonia → Impaired voice functionProlonged cuff inflation → Laryngeal desensitization, aspiration risk

These complications are influenced by duration of intubation, tube size, cuff pressure, patient-specific risk factors, and ICU management practices. ⚠️

Prevalence, Aetiology, and Risk Factors for Laryngeal Injury 📊

Laryngeal injury prevalence is high, with rates up to 83% post-intubation and 76% reporting dysphonia. 🔬 The severity of injury is influenced by multiple risk factors:

1️⃣ Patient-Related Factors:

• Age ≥50 years → 3-fold increased risk of VC paralysis

• Female sex → Smaller laryngeal anatomy increases susceptibility

• Obesity → Alters airway mechanics

• Diabetes, hypertension → Poor tissue healing, increased neuropathy risk

• Malnutrition, renal/hepatic failure → Delayed healing, poor immune response

• ICU-specific factors → Steroids, ECMO, propofol, midazolam → Contribute to laryngeal weakness

2️⃣ Intubation and Tube-Related Factors:

• Urgency of intubation → Increased trauma risk in emergency intubations

• Operator skill and technique → High-risk with difficult airways

• Bougie-assisted intubation → Can cause arytenoid cartilage injury

• Tracheal tube size & cuff pressure → Large diameter and high pressure = increased ischemic injury

3️⃣ Post-Intubation Factors:

• Duration of intubation →Risk of VC paralysis doubles at 3–6 hoursIncreases 15-fold if >6 hours

• Reintubation risk → 50% develop laryngeal injury

• Prolonged prone positioning → Contributes to upper airway edema

• Sedation, coughing, mouth care practices → Influence injury severity

Summary 📜

🔎 Laryngeal complications post-intubation and tracheostomy are frequent and multifactorial, leading to dysphagia, dysphonia, aspiration, and prolonged ICU stays. 🚨

✅ Early assessment, multidisciplinary management, and rehabilitation are critical in improving outcomes. 💡

📊 High-risk factors include age, comorbidities, intubation technique, duration, and post-extubation factors.

Impact of Dysphagia and Dysphonia After Prolonged Intubation and Tracheostomy

Laryngeal complications, particularly dysphagia (difficulty swallowing) and dysphonia (voice disorders), have a major impact on patients recovering from critical illness. Prolonged intubation and tracheostomy alter swallow function, cough strength, and airway protection, leading to a higher risk of aspiration pneumonia, malnutrition, and delayed rehabilitation. 🚨

1️⃣ Prevalence and Clinical Impact

• Laryngeal injury is highly prevalent 📊:Dysphonia: 76%Pain: 76%Hoarseness: 83%Dysphagia: 49%

• Post-extubation dysphagia is reported in 60% of ICU patients and 50% of cardiac surgery patients.

• Severe dysphagia persists in one-third of patients even after hospital discharge. 🏨

• Dysphagia and aspiration increase the risk of pneumonia, contributing to ventilator-associated pneumonia (VAP) and prolonged ICU stay.

2️⃣ Mechanisms of Dysphagia & Dysphonia Post-Intubation

🚧 Mechanical factors:

• Laryngeal edema and VC inflammation impair airway protection.

• Reduced translaryngeal gas flow (due to tracheostomy) leads to laryngeal desensitization and disuse atrophy.

• Vocal cord paralysis or weakness → Ineffective phonation, poor cough.

• Glottic incompetence → Increased risk of silent aspiration.

🧠 Neurological & Cognitive Contributions:

• Cognitive dysfunction, delirium, and prolonged sedation impair swallowing coordination.

• Residual effects of medications (e.g., neuromuscular blockers, steroids, and sedatives) lead to laryngeal weakness.

• Sepsis-associated polyneuropathy further worsens swallowing and airway protection.

💡 Key Consequences:

• Delayed oral intake, malnutrition, weight loss 🍽️

• Increased aspiration pneumonia risk 🦠

• Failed extubation and prolonged tracheostomy dependence

• Severe psychological distress from communication impairments 😥

Diagnosis and Detection of Laryngeal Injury 🔍🩺

Early and accurate diagnosis of laryngeal dysfunction is crucial in preventing prolonged complications and mortality.

1️⃣ Bedside Clinical Assessments

✅ Cuff-Leak Test 💨

• Assesses airway patency before extubation.

• Absence of a cuff leak suggests laryngeal edema or vocal cord dysfunction.

• Sensitivity: 88.6%, Specificity: 90% compared to direct laryngoscopy.

✅ Speech and Language Therapy (SLT) Evaluation 🗣️

• SLTs assess voice, swallow, cough strength, and secretion clearance.

• SLT screening post-extubation is recommended in all ICU patients.

2️⃣ Instrumental Assessments

📹 Fibreoptic Endoscopic Evaluation of Swallowing (FEES)

• Gold-standard bedside test using a flexible endoscope to evaluate airway patency, vocal cord mobility, and aspiration risk.

• Accurately detects silent aspiration, informs treatment decisions, and monitors therapy response.

🩻 Videofluoroscopy (VFS)

• Modified barium swallow test done in radiology.

• Assesses dynamic swallowing function but requires patient transport.

📡 Laryngeal Ultrasound (LUS)

• Emerging non-invasive bedside technique for assessing laryngeal edema and vocal cord mobility.

🎶 Laryngeal Videostroboscopy

• Gold standard for vocal cord vibration analysis.

• Helps differentiate structural vs. neurogenic vocal cord injuries.

🧠 Laryngeal Electromyography (EMG)

• Assesses neuromuscular function of the vocal cords and laryngeal muscles.

🦠 Sialometry & Saliva Secretion Analysis

• Evaluates salivary pooling, secretion rate, and aspiration risk.

Therapeutic Strategies & Multidisciplinary Team Management 🏥👩⚕️

1️⃣ Laryngeal Edema Management

✅ Dexamethasone (Corticosteroids) 📉

• Reduces airway inflammation and laryngeal swelling.

• Must balance risk of hyperglycemia, muscle weakness, and delirium.

✅ Anti-Reflux Therapy (PPIs)

• If laryngopharyngeal reflux contributes to edema, high-dose proton pump inhibitors (PPIs) (e.g., omeprazole) are recommended.

2️⃣ Secretion Management 💦

✅ Pharmacological Agents:

• Glycopyrrolate, atropine, or hyoscine patches reduce excessive salivation.

• Botulinum toxin injections into salivary glands for persistent drooling.

• Salivary gland radiotherapy (in severe cases).

✅ Subglottic Suctioning & Secretion Clearance

• Reduces pooled secretions, preventing ventilator-associated pneumonia (VAP).

3️⃣ Restoring Translaryngeal Gas Flow for Rehabilitation 💨

✅ Cuff Deflation & One-Way Speaking Valves

• Early trials of cuff deflation help restore normal airflow and voice.

• Passy Muir Valves facilitate speech and airway protection.

✅ Above-Cuff Vocalization (ACV) 🎤

• Retrograde airflow technique allowing vocalization despite a cuffed tracheostomy.

• Improves laryngeal function, communication, and quality of life.

4️⃣ Voice and Swallowing Rehabilitation 🗣️🍽️

✅ SLT-Led Exercises

• Targeted voice and swallow exercises aid in laryngeal muscle recovery.

• Swallow strengthening therapy reduces aspiration risk.

✅ Pharyngeal Electrical Stimulation (PES) ⚡

• Promotes neuromuscular recovery in severe dysphagia.

• Involves targeted nasogastric stimulation to improve swallow reflex.

5️⃣ Adjunctive Therapies

✅ Expiratory Muscle Strength Training (EMST)

• Improves cough strength, swallow coordination, and voice quality.

✅ Biofeedback Surface EMG

• Enhances motor learning for laryngeal function rehabilitation.

6️⃣ Surgical Interventions for Severe Cases 🏥🔪

• Vocal cord medialization procedures for unilateral vocal cord paralysis.

• Tracheal reconstruction or dilation for stenosis.

• Laryngeal framework surgery for chronic dysphonia.

Summary 🎯

✅ Dysphagia and dysphonia are highly prevalent post-intubation complications, requiring early intervention.

✅ Diagnosis relies on clinical assessment, FEES, videofluoroscopy, laryngeal ultrasound, and stroboscopy.

✅ Multidisciplinary management (SLT, ICU, ENT) is crucial for optimizing voice and swallow recovery.

✅ Innovative therapies like ACV, PES, EMST, and laryngeal EMG are emerging to expedite recovery.

Post-Extubation Screening for Dysphagia and Dysphonia 🔍🩺

Routine post-extubation screening for dysphagia and dysphonia is essential to identify high-risk patients and implement early interventions. 🚨

1️⃣ Screening for Dysphagia After Extubation 🍽️

• Nurse-Led Swallow Screening Protocols 🚑

• Limitations of Clinical Swallow Assessments

2️⃣ Screening for Dysphonia After Extubation 🎤

• Voice Handicap Index-10 (VHI-10)A patient-reported tool that helps quantify dysphonia severity and its impact on quality of life.

• ENT and SLT ReferralPersistent dysphonia requires videostroboscopy or laryngeal ultrasound to evaluate vocal cord function.

3️⃣ Dysphagia Screening in Tracheostomy Patients 🩹

• 50% of tracheostomized patients aspirate, often silently.

• FEES-guided assessment is recommended for safe progression to oral intake.

Laryngeal Complications and COVID-19 🦠🏥

The COVID-19 pandemic significantly impacted laryngeal complications, primarily due to prolonged intubation, frequent proning, and high cuff inflation pressures.

1️⃣ Unique Laryngeal Complications in COVID-19

✅ Severe Laryngeal Edema → Increased rates of reintubation and tracheostomy

✅ Persistent Dysphonia & Dysphagia → Up to 90% of patients experience severe voice changes post-extubation

✅ Direct SARS-CoV-2 Injury → The virus may cause airway edema, inflammation, and post-viral laryngitis.

✅ Increased Laryngeal Stenosis Risk → Due to prolonged intubation durations in ICU COVID patients.

2️⃣ Post-COVID Dysphagia and Dysphonia Recovery

• Post-ICU follow-up clinics should actively screen for airway dysfunction.

• SLT interventions, vocal rehabilitation, and early ACV therapy are critical for long-term recovery.

Future Directions and Research Needs 📚🔬

Despite advancements in early detection and management, several gaps remain in the literature on post-intubation laryngeal complications. 🚀

1️⃣ Understanding the Impact of Specific ICU Practices

• How do interventions like prone positioning and subglottic suction tubes influence laryngeal outcomes?

• What is the optimal timing for tracheostomy to minimize laryngeal damage?

2️⃣ Innovations in Laryngeal Rehabilitation

• Above-Cuff Vocalization (ACV) Therapy: Can it be optimized for faster speech recovery?

• Pharyngeal Electrical Stimulation (PES): Is it cost-effective and scalable for routine use?

3️⃣ Long-Term Follow-Up of ICU Survivors

• How many patients develop persistent dysphagia or airway stenosis beyond 1 year?

• What is the psychological burden of post-extubation dysphonia?

Conclusions 🎯💡

🔎 Laryngeal complications are common and significantly impact recovery, requiring early identification and multidisciplinary management.

✅ SLT involvement, FEES-based assessment, and innovative therapies (ACV, PES, EMST) improve rehabilitation outcomes.

📊 COVID-19 has exacerbated laryngeal complications, necessitating long-term follow-up for survivors.

🚀 Future research should focus on optimizing ICU practices and long-term airway rehabilitation strategies.

A proactive, multidisciplinary approach is the key to minimizing morbidity and enhancing recovery in critically ill patients. 💙

Final Thought 💭

👉 How can we improve post-extubation dysphagia screening and make SLT involvement a universal ICU practice?

Let’s continue the conversation on early laryngeal rehabilitation and its role in ICU survivorship. 🗣️💬

Reference 📖

Wallace S, McGrath BA. Laryngeal complications after tracheal intubation and tracheostomy. BJA Education.2021;21(7):250-257. doi: 10.1016/j.bjae.2021.02.005.