Airway complications in patients with closed-head injuries

The neurologic deficits in the closed-head injury population present special problems when managing the airway. Many of these closed-head injury patients require long-term intubation with endotracheal tube or tracheostomy to treat their central respiratory problems and control oral and pulmonary secretions. Four hundred sixty-seven closed-head injury patients were seen over a five-year period. Seventy-two of these patients required long-term endotracheal intubation, tracheostomy, or both. A prospective study by direct endoscopic examination prior to decannulation showed 23 of these 72 patients (32%) had important laryngeal or tracheal findings. The principal abnormalities observed were vocal cord paralysis, tracheal stenosis, subglottic stenosis, glottic stenosis, and tracheomalacia. This study suggests also that severely mentally impaired patients (cognitive function II and III) should retain their tracheostomy because of the high morbidity and mortality among these patients (31%) when they are decannulated. This mortality was directly related to poor pulmonary toilet, with pneumonia and sepsis being the major causes of death. This study did not show that the use of steroids or ventilators in the initial management adversely effected airway complications.