Adverse Effects and Complications of Endotracheal Intubation and Invasive Mechanical Ventilation-Part 3

Late Adverse Effects/Complications (Manifest Within Weeks-Months After Intubation)

Laryngotracheal Stenosis (see Tracheal Stenosis)


  • Generally Occurs Weeks-Months After Intubation
  • Incidence: 1-21% (Ann Otol Rhinol Laryngol, 2007) [MEDLINE]
  • Risk Factors (Ann Otol Rhinol Laryngol, 2007) [MEDLINE]
    • Prior Irradiation for Oropharyngeal/Laryngeal Tumor
    • Prior Non-Airway Surgery
    • Prolonged Intubation >7 Days
      • Laryngotracheal Stenosis Rarely Occurs in Patients Intubated for <3 Days


  • Laryngeal (Glottic) Stenosis: due to pressure from the endotracheal tube itself with local ischemia, inflammation, tissue necrosis, and scarring
    • Usual Location is the Posterior Glottis and Interarytenoid Regions (Where the Endotracheal Tube Exerts the Most Pressure)
  • Tracheal Stenosis
    • Due to High Endotracheal Tube Cuff Pressure (at 20 cm H20, Cuff Pressure Will Exceed the Mean Capillary Pressure in the Mucosa), with Obstruction of Capillary Blood Flow and Associated Ischemia, Inflammation, Mucosal Erosion, Tissue Necrosis, Distorted Tracheal Architecture, and Scarring
    • Usual Location/Appearance of Endotracheal Intubation-Associated Tracheal Stenosis is a Web-Like Stenosis at the Endotracheal Tube Cuff Site
      • In Contrast, Tracheostomy-Associated Tracheal Stenosis Associated Typically Occurs Around the Tracheal Stoma (see Tracheostomy)



  • Failure to Wean from Mechanical Ventilation (in Patients on Mechanical Ventilation)
  • Subacute/Progressive Dyspnea (see Dyspnea)
    • Usually Becomes Symptomatic Approximately 5 Weeks to Months After Extubation


  • Rigid Bronchoscopy with Dilation/Laser Resection/Stenting (see Bronchoscopy)
    • May Be Required for Tracheal Stenosis
  • Mitomycin C (see Mitomycin)
    • Has Been Used to Prevent Tracheal Restenosis After Local Procedures
  • Surgical Resection
    • May Be Required for Refractory Cases of Tracheal Stenosis

Laryngotracheomalacia (see Tracheobronchomalacia)


  • Well-Known Complication of Prolonged Endotracheal Intubation (Aust N Z J Surg, 1976) [MEDLINE]
  • Generally Occurs Weeks-Months After Endotracheal Intubation


  • Thinning and/or Destruction of Tracheal Cartilage Due to Increased Endotracheal Tube Cuff Pressure

Tracheoarterial Fistula (see Tracheoinnominate Artery Fistula)


  • Although Tracheoarterial Fistula is More Commonly Observed with Tracheostomy, Cases Have Been Reported with Prolonged Endotracheal Intubation (see Tracheostomy)


  • Erosion Through Tracheal Wall into Innominate Artery


  • Tracheoinnominate Artery Fistula: usually

Tracheoesophageal Fistula (see Tracheoesophageal Fistula)


  • While Tracheoesophageal FistulaRarely Occurs with Endotracheal Intubation, Reported Cases Have Been Observed in Patients with Prolonged Intubation (Aust N Z J Surg, 1976) [MEDLINE]
    • Risk Factors (Chest Surg Clin N Am, 1996) [MEDLINE]
      • Corticosteroids (see Corticosteroids)
        • Possible Risk Factor
      • Diabetes Mellitus (see Diabetes Mellitus)
        • Possible Risk Factor
      • Excessive Mobility of the Endotracheal Tube
      • High Airway Pressure
      • High Endotracheal Tube Cuff Pressure
        • Main Risk Factor
      • Prolonged Duration of Mechanical Ventilation
      • Use of Nasogastric Tube (see Nasogastric-Orogastric Tube)
        • Possible Risk Factor


  • Erosion of the Endotracheal Tube Tip/Cuff into the Posterior Wall of the Trachea, Fistulizing into the Esophagus


  • Air Leak from Ventilator Circuit (“Lost Volume”)
  • Gastric Distention (see Gastric Distention)
  • Presence of Tube Feedings in Tracheal Secretions
  • Recurrent Aspiration Pneumonia (see Aspiration Pneumonia)


Acalculous Cholecystitis (see Acalculous Cholecystitis)

Acute Kidney Injury (AKI) (see Acute Kidney Injury)

Arrhythmia/Cardiac Arrest (see Cardiac Arrest)

Arytenoid Cartilage Dislocation

Aspiration Pneumonia (see Aspiration Pneumonia)

Auto-Positive End-Expiratory Pressure (Auto-PEEP or Intrinsic PEEP) (see Invasive Mechanical Ventilation-General)

Bronchospasm (see Bronchospasm)

Constipation (see Constipation)

Decubitus Ulcer (see Decubitus Ulcer)

Deep Venous Thrombosis (DVT) (see Deep Venous Thrombosis)

Dental/Lingual/Orolabial/Pharyngeal/Laryngeal Mucosal Injury

Diarrhea (see Diarrhea)

Endotracheal Tube Cuff/Ventilator Circuit Leak

Endotracheal Tube Tip Malpositioning

Erosive Esophagitis (see Esophagitis)

Esophageal Injury

Gastrointestinal Stress Ulceration (see Peptic Ulcer Disease)

Ileus (and Gastrointestinal Hypomotility) (see Ileus)

Gastrointestinal Ulceration (see Peptic Ulcer Disease)

Impaired Mucociliary Motility

Increased Intracranial Pressure (see Increased Intracranial Pressure)

Induction of Inflammatory Response

Insulin Resistance

Intensive Care Unit (ICU)-Acquired Weakness (see Intensive Care Unit-Acquired Weakness)

Joint Contracture

Laryngeal Injury

Laryngotracheal Stenosis (see Tracheal Stenosis)

Laryngotracheomalacia (see Tracheobronchomalacia)

Neurologic Complications

Oxygen Toxicity (see Oxygen)

Patient-Ventilator Dyssynchrony

Pharyngitis (see Pharyngitis)

Positive Pressure-Induced Artifacts Introduced into the Measurement of Hemodynamic Pressures

Post-Intubation Hypoxemia (see Hypoxemia)

Post-Intubation Hypotension (see Hypotension)

Sleep Disruption

Swallowing/Speech Impairment (see Dysphagia)

Tracheoarterial Fistula (see Tracheoinnominate Artery Fistula)

Tracheoesophageal Fistula (see Tracheoesophageal Fistula)

Translocation of Tracheal Bacteria into the Bloodstream

Ventilator-Induced Diaphragmatic Dysfunction (VIDD)

Ventilator-Induced Lung Injury (VILI)/Barotrauma

Vocal Cord Granuloma

Vocal Cord Paralysis

Vocal Cord Ulceration