Unilateral Vocal Fold Immobility After Prolonged Endotracheal Intubation | Critical Care Medicine | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network
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    Original Investigation
    December 19, 2019

    Unilateral Vocal Fold Immobility After Prolonged Endotracheal Intubation

    Author Affiliations
    • 1Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
    • 2Vanderbilt University School of Medicine, Nashville, Tennessee
    • 3Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
    • 4Tennessee Valley Veteran’s Affairs Geriatric Research Education and Clinical Center, Nashville
    • 5Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University, Nashville, Tennessee
    • 6Division of Laryngology, Vanderbilt University Medical Center, Nashville, Tennessee
    JAMA Otolaryngol Head Neck Surg. 2020;146(2):160-167. doi:10.1001/jamaoto.2019.3969
    Key Points

    Question  What is the incidence of unilateral vocal fold immobility after prolonged (>12 hours) endotracheal intubation, and what clinical factors are associated with this condition?

    Findings  In this single-center prospective cohort study, 7 of 100 patients intubated for more than 12 hours in a medical intensive care unit had unilateral vocal fold immobility at extubation. Hypotension requiring vasopressors, peripheral vascular disease, and coronary artery disease were associated with unilateral vocal fold immobility.

    Meaning  Unilateral vocal fold immobility after prolonged intubation is more common than previously observed and is associated with vascular risk factors; these results suggest an ischemic mechanism for neural injury in unilateral vocal fold immobility after prolonged endotracheal intubation.


    Importance  Endotracheal intubation and mechanical ventilation are life-saving treatments for acute respiratory failure but are complicated by significant rates of dyspnea and dysphonia after extubation. Unilateral vocal fold immobility (UVFI) after extubation can alter respiration and phonation, but its incidence, risk factors, and pathophysiology remain unclear.

    Objectives  To determine the incidence of UVFI after prolonged (>12 hours) mechanical ventilation in a medical intensive care unit and investigate associated clinical risk factors for UVFI after prolonged mechanical ventilation.

    Design, Setting, and Participants  This subgroup analysis of a prospective cohort study was conducted in a single-center medical intensive care unit from August 17, 2017, through May 31, 2018, among 100 consecutive adult patients who were intubated for more than 12 hours. Patients were identified within 36 hours of extubation and recruited for study enrollment. Those with an established tracheostomy prior to mechanical ventilation, known laryngeal or tracheal pathologic characteristics, or a history of head and neck radiotherapy were excluded.

    Exposure  Invasive mechanical ventilation via an endotracheal tube.

    Main Outcomes and Measures  The incidence of UVFI as determined by flexible nasolaryngoscopy.

    Results  One hundred patients (62 men [62%]; median age, 58.5 years [range, 19.0-87.0 years]) underwent endoscopic evaluation after extubation. Seven patients had UVFI, of which 6 cases (86%) were left sided. Patients with hypotension while intubated (odds ratio [OR], 10.8; 95% CI, 1.6 to ∞), patients requiring vasopressors while intubated (OR, 16.7; 95% CI, 2.4 to ∞), and patients with a preadmission diagnosis of peripheral vascular disease (OR, 6.2; 95% CI, 1.2-31.9) or coronary artery disease (OR, 5.1; 95% CI, 1.0-25.5) were more likely to develop UVFI.

    Conclusions and Relevance  Unilateral vocal fold immobility occurred in 7 of 100 patients in the medical intensive care unit who were intubated for more than 12 hours. Unilateral vocal fold immobility was associated with inpatient hypotension and preadmission vascular disease, suggesting that ischemia of the recurrent laryngeal nerve may play a role in disease pathogenesis.