Incidence of Acute Laryngeal Injury Following Endotracheal Intubation

In the United States, 55 000 patients receive care in more than 6 000 intensive care units (ICUs) each day. The most common reason for ICU admission is respiratory failure and the need for a mechanical ventilator. Although 50% to 70% of patients survive their acute illness, the remainder are left with massive impairments in health and overall functioning. One of the most severe post-ICU complications is airway scaring directly resulting from endotracheal intubation.

Scarring of the vocal cords or trachea after intubation results from mucosal injury by an endotracheal tube (i.e. breathing tube). The initial mucosal injury ultimately heals with pathologic fibrotic contracture. This fibrosis physiologically restricts ventilation, and produces life-threatening dyspnea and airway obstruction. Acute and chronic airway injury following intubation is largely unappreciated owing to the fact that the long-term sequelae of intensive respiratory support is rarely managed by practitioners providing acute care. Treatments for chronic airway injury are suboptimal. They are largely surgical and offer marginal improvement in breathing while causing permanently worsened voice. Preventative efforts to preserve laryngeal and tracheal function (through identification of modifiable risk factors) could reduce the incidence of this devastating complication of medical care. Additionally, early identification of acute laryngeal injury after intubation may prevent the development of chronic complications. Patients with acute post-intubation airway injury treated with early endoscopic surgery require significantly fewer procedures, and may avoid an invasive open surgical reconstruction compared with patients treated with chronic fibrotic scars.

The development of airway fibrosis and ventilatory obstruction has been linked to inflammatory processes. Macrolide antibiotics such as azithromycin has been shown to reduce mucosal airway inflammation. IN addition the combination of a macrolide antibiotic and budesonide an inhaled corticosteroid has been shown to work synergistically to reduce inflammation and modify the disease process of tracheal stenosis in rabbit models.

The purpose of this investigation is to delineate the incidence of acute and chronic laryngeal injury following intubation within our health system. In addition, this study seeks to identify risk factors for airway injury that may provide information to help reduce the incidence of injury or increase the speed of diagnosis through hospital based process measures. Finally, in patients with acute laryngeal injury, this study seeks to investigate the effects of azithromycin and budesonide to improve objective and subjective breathing measures in patients with Acute Laryngeal injury (ALgI) following endotracheal intubation.

Overview: Patients will be recruited from adult patients in the surgical and medical intensive care units of Vanderbilt Medical Center who were intubated for greater than 48 hours. Following informed consent and study enrolment, data will be stored in a secure REDCap database housed within a server located behind the Vanderbilt University Medical Center (VUMC) firewall. Data analysis will be performed by KSP at VUMC.