Traumatic Intubation Research Articles

National Survey of Airway Management Practices and Training Among Emergency Medicine Residency Programs in the United States.

As airway management becomes more complex with the adoption of new technologies and strategies, it is important to ensure that emergency medicine residents, the future of the specialty, receive extensive training. This study was designed to understand the prevailing airway management practices and training within emergency medicine residency programs. A survey consisting of 19 multiple-choice questions was sent to program directors of 258 emergency medicine residency programs in the United States. A total of 63 emergency medicine residency programs completed the airway survey, a response rate of 24%. Programs from all regions of the country are represented, most of them from university-based teaching hospitals (40%) and 3-year programs (78%). The majority of programs provide their residents with 50-100 intubations (50.8%) during their training. Pediatric intubations remain scarce with 54.1% of programs having only 5-10 pediatric intubations per resident. The emergency medicine team manages 93.6% of all trauma intubations, and residents complete 81% to 100% of all the department's intubations 88.9% of the time. Video laryngoscopy is on the rise, with GlideScope® (93.7%) and C-Mac® (55.6%) being the most common devices available. Overall, programs use both succinylcholine and rocuronium equally, but there is a trend toward using rocuronium more frequently than succinylcholine. By employing different teaching modalities, multiple times a year, residency programs expose residents to a variety of backup tools and surgical airway techniques. Emergency medicine residents are exposed to multiple advanced airway adjuncts and comprehensive airway curriculums as emergency airway management practices evolve and become more complex.

Expert opinion on factors associated with severe laryngeal injury after intubation in the pediatric population: a worldwide survey study.

To minimize post-intubation laryngeal injury it is important to identify the factors that contribute to the development of these lesions. Previous literature has been inconsistent. This survey aims to investigate experts' opinions on the various factors associated with severe laryngeal injury following intubation in the pediatric population and to determine whether these opinions influence the treatment of patients with one or more of these factors. A multiple-choice questionnaire with the possibility to provide open text answers was developed and sent by email, WhatsApp and Siilo to members of the scientific societies of anesthesiology, pediatric intensive care, emergency medicine and ear nose throat surgeons worldwide. Responses were analyzed thematically. A total of 363 physicians worldwide responded to the survey, mainly anesthesiologists (31%), intensivists (35%) and ENT surgeons (29%). The majority of the respondents (69%) had over 10years of experience in pediatric airway management. Overall, factors with the highest agreement (> 80% of respondents) were 'traumatic intubation', 'multiple intubation attempts', 'the use of oversized tubes', 'skill level of the intubator', 'repeated intubations' and 'period of intubation', specifically in small (weight < 2kg, age < 1year) children. The factors 'use of muscle relaxants' and 'biological sex' were not considered relevant. In accordance with their daily practice, physicians from different specialties reported varying factors as being relevant. These assumptions influence their routine decisions regarding intubation and extubation procedures. Although not extensively supported by literature, the majority of the experts indicate that factors such as 'traumatic intubation', 'multiple intubation attempts', 'oversized tubes', 'skill level of the intubator', 'repeated intubations' and 'period of intubation' are the most relevant factors in the development of post-intubation severe laryngeal injury in the pediatric population. Physicians from different specialisms also highlight specialism specific factors they consider most significant which influence their day-to-day clinical practice.

Development and Validation of a Bayesian Network Predicting Intubation Following Hospital Arrival Among Injured Children

BackgroundInadequate airway management can contribute to preventable trauma deaths. Current machine learning tools for predicting intubation in trauma are limited to adult populations and include predictors not readily available at the time of patient arrival. We developed a Bayesian network to predict intubation in injured children and adolescents using observable data available upon or immediately after patient arrival. MethodsWe obtained patient demographic, injury, resuscitation, and transportation characteristics from trauma registries from four American College of Surgeons-verified level 1 pediatric trauma centers from January 2010 through December 2021. We trained and validated a Bayesian network to predict emergent intubation after pediatric injury. We evaluated model performance using the area under the receiver operating and calibration curves. ResultsThe final model, TITAN (Timing of Intubation in Trauma Analysis Network), incorporated five factors: Glasgow Coma Scale, mechanism of injury, injury type (e.g., penetrating, blunt), systolic blood pressure, and age. The model achieved an area under the receiver operating characteristic curve of 0.83 (95% CI 0.80, 0.85) and had a calibration curve slope of 0.98 (95% CI 0.67, 1.29). TITAN had high specificity (98%), negative predictive value (97%), and accuracy (96%) at a binary probability threshold of 22.6%. ConclusionThe TITAN Bayesian network predicts the risk of intubation in pediatric trauma patients using five factors that are observable early in trauma resuscitation. Prospective validation of the model performance with patient outcomes is needed to assess real-life application benefits and risks. Level of EvidencePrognostic and Epidemiological, Level III.

Traumatic nasogastric intubation as a suspected cause of laryngeal obstruction in a horse recovering from emergency laparotomy

AbstractAn 18‐year‐old mare, admitted for colic, underwent an exploratory laparotomy for right dorsal colon displacement. During recovery from anaesthesia, a severe acute onset laryngeal obstruction occurred at standing, requiring orotracheal re‐intubation, which relieved the obstruction. This was followed by secondary pulmonary oedema, treated with furosemide (2 mg/kg intravenously) and oxygen. At re‐extubation, attempted 30 minutes later, the horse re‐obstructed immediately and collapsed, prompting an emergency tracheostomy. Furosemide (2 mg/kg intravenously) and dexamethasone (0.1 mg/kg intravenously) were also administered. The horse stood up thereafter with a patent airway. In the history, to note, nasogastric intubation was particularly difficult at admission, and was identified as a potential cause of laryngeal trauma that may have precipitated laryngeal obstruction due to severe local inflammation. Dynamic laryngeal collapse probably also played a role due to high inspiratory negative pressure generated at the precise timing of standing, similar to exercise.

Micro-CT Imaging of Tracheal Development in Down Syndrome and Non-Down Syndrome Fetuses.

Down syndrome (DS) is associated with airway abnormalities including a narrowed trachea. It is uncertain whether this narrowed trachea in DS is a consequence of deviant fetal development or an acquired disorder following endotracheal intubation after birth. This study aimed to compare the tracheal morphology in DS and non-DS fetuses using microfocus computed tomography (micro-CT). Twenty fetal samples were obtained from the Dutch Fetal Biobank and divided into groups based on gestational age. Micro-CT images were processed to analyze tracheal length, volume, and cross-sectional area (CSA). Mean tracheal length and tracheal volume were similar in DS and non-DS fetuses for all gestational age groups. Mean, minimum, and maximal tracheal CSA were statistically significantly increased in the single DS fetus in the group of 21-24 weeks of gestation, but not in other gestational age groups. In 90% of all studied fetuses, the minimum tracheal CSA was located in the middle third of the trachea. Tracheal development in DS fetuses was similar to non-DS fetuses between 13 and 21 weeks of gestation. This suggests that the narrowed tracheal diameter in DS children may occur later in fetal development or results from postnatal intubation trauma. The narrowest part of the trachea is in majority of DS and non-DS fetuses the middle third. 3 Laryngoscope, 134:4389-4395, 2024.

Application of Neck Brace as an Alternative Method of Immobilization after Circular Tracheal Resection. Case Series

Introduction. Cicatricial tracheal stenosis comprises a severe complication of traumatic or prolonged intubation of the trachea. Circular resection of the trachea serves as a radical method of surgical treatment. The distension of the anastamosis can be prevented by immobilization of the neck and head in the thoracic adduction, as a rule, with the Grillo suture technique. This method of fixation creates severe discomfort for the patient, especially when eating. Rare cases involve neurological disorders due to compression of the neurovascular bundles of the neck and spinal cord. Materials and methods. The study enrolled 6 patients diagnosed with cicatricial tracheal stenosis upon admission to the thoracic surgery unit. All patients underwent a circular tracheal resection. Immobilization of the cervical spine was performed using a cervical collar (Schantz collar type). Results. Immobilization was performed within 7–13 days, followed by a control tracheobronchoscopy. No complications related to anastomotic failure and no specific complications when using these orthoses were revealed. Discussion. The postoperative period was reported as uneventful; anastomotic healing proceeded in accordance with the physiological timing indicated by the framework of other studies. The applied orthosis provides immobilization of the cervical spine, preventing from any movement in this area, which is actually similar to the use of the Mulliken-Grillo suture, but has a number of advantages: absence of cosmetic defects, possibility of quick fixation and removal. Significantly, this provides an opportunity to assess the risk of neurochemical damage in patients during preliminary fixation of the head in the hyperflexic position at the preoperative stage. Conclusion. Having such advantages as the absence of cosmetic defects and the possibility of quick removal, this method of neck fixation can be considered as an alternative to the classical fixation method.

Postoperative sore throat: prophylaxis and treatment

Postoperative sore throat (POST) is one of the most reported complications after general anesthesia with an incidence of as high as 60% which may impact patient satisfaction and increase the cost of treatment. The aim of this review is to summarize the currently accepted approaches and new trends intended to reduce the risk and increase the treatment efficacy of POST. Difficult intubation, traumatic intubation, and several other factors contribute to the development of POST. Endotracheal intubation using a stylet-loaded tube exerts excessive pressure on the anterior tracheal wall predisposing to mucosal trauma and contributing to development of POST. Pharmacological interventions are aimed at prevention, amelioration of symptoms, and treatment of POST. Medications suggested for this purpose include corticosteroids, topical sprays and creams, non-steroidal anti-inflammatory drugs (NSAID), and N-methyl-D-aspartate (NMDA) receptor antagonists. The use of video-laryngoscopes (VL) for endotracheal intubation improves the glottic view and increases the success rates with less force required to ensure adequate laryngoscopic view. Nevertheless, despite advances in laryngoscopic devices, the incidence of POST remains high. A novel intubation technique with endotracheal tube (ETT) rotation 180 degrees (ETT 180°) has been suggested to overcome stylet related injury and, possibly, decrease the POST. To date, no clinical trials have been conducted to test the efficacy of ETT 180° in reducing the incidence of POST. Undoubtedly, the suggested method deserves further investigation to determine its role in patient care.

Abstract 129: Endovascular Therapy in Cerebral Venous Thrombosis: Nationwide Insights and Implications for Mortality

Introduction Cerebral Venous Thrombosis (CVT) is a rare cerebrovascular condition causing death or functional dependency in 10‐15%. Although Endovascular Therapy (EVT) is deployed variably across centers for managing CVT, the determinants and consequences of such use remain under‐explored. We examined the demographic and clinical correlates of EVT use in CVT and assessed its impact on patient outcomes utilizing a national database. Methods We identified CVT cases from 2015 to 2020 in the National Inpatient Sample, with EVT as the primary exposure. CVT and other diagnoses, and EVT and other procedures, were identified using standard ICD 10 codes. A backward stepwise regression model (at p&lt;0.05) was used to explore patient demographics, hospital characteristics, and comorbidities significantly associated with EVT use. We examined the association between EVT use and in‐hospital mortality using survey weighted unadjusted and adjusted logistic regression models. Covariates in the model one assessing inpatient mortality included age, insurance status, hospital teaching status, hospital volume size, central nervous system (CNS) infections, CNS cancer, other types of cancer, hematological disorder, traumatic head injuries, seizure, intubation, and transfer from an outside hospital. Model two additionally adjusted for female sex, NIH Stroke Scale (NIHSS), and Elixhauser mortality index. Results We identified 48,835 individuals with CVT, of whom 1,275 (2.6%) underwent EVT. The stepwise regression analysis revealed a higher likelihood of receiving EVT with older age (OR per year: 1.01, 95% CI: 1.01‐1.02, p&lt;0.001), presence of a hematological disorder (OR: 2.06, 95% CI: 1.58‐2.67, p&lt;0.001), seizure (OR: 1.54, 95% CI: 1.09‐2.16, p=0.014), intubation (OR: 3.85, 95% CI: 2.78‐5.34, p&lt;0.001), higher NIHSS (10.5[4‐18] versus 3[1‐8], p&lt;0.001), or admission to a teaching hospital (OR: 4.15, 95% CI: 1.93‐8.92, p&lt;0.001), high‐volume center (OR: 6.30, 95% CI: 2.29‐17.33, p&lt;0.001), or transfer from an outside hospital (OR: 1.89, 95% CI: 1.42‐2.51, p&lt;0.001). Conversely, there was a lower likelihood of EVT in those with CNS infections (OR: 0.19, 95% CI: 0.07‐0.48, p=0.001), CNS cancer (OR: 0.24, 95% CI: 0.06‐0.93, p=0.039), other types of cancer (OR: 0.47, 95% CI: 0.32‐0.69, p&lt;0.001), and traumatic head injuries (OR: 0.41, 95% CI: 0.25‐0.68, p&lt;0.001). Individuals with Medicare (OR: 0.39, 95% CI: 0.26‐0.59, p&lt;0.001) or Medicaid insurance (OR: 0.70, 95% CI: 0.50‐0.99, p=0.041), were also less likely to undergo EVT. EVT was associated with an increased odds of in‐hospital mortality (OR: 4.01, 95% CI 2.82‐5.68, p&lt;0.001), a relationship that persisted even after multivariable adjustment with model one (adjusted OR: 2.37 95% CI 1.50‐3.74, p&lt;0.001) and model two (adjusted OR: 7.32 95% CI 2.62‐20.5, p&lt;0.001). Conclusion We identified specific demographic and clinical factors associated with EVT use in CVT and found EVT use linked to higher mortality. The directionality of this relation is uncertain but could suggest more frequent use of EVT in individuals with very severe clinical presentations. These findings underscore the need for further prospective work to assess which individuals may benefit from therapy, in addition to optimal timing and approaches.

An Innovative Single Staged Surgical Repair of Benign Tracheoesophageal Fistula - A Case Report.

The online version contains supplementary material available at 10.1007/s12070-022-03382-w.

Persistent Post-Extubation Stridor in an Intensive Care Unit: A Decision Dilemma

Stridor is a harsh, wheezing, often high-pitched sound produced by rapid, turbulent flow of air through a narrowed supraglottic region to proximal trachea and can be inspiratory, expiratory, or biphasic.[1] The incidence of post-extubation stridor varies from 2 to 42% in pediatric intensive care unit (ICU).[2] Factors like traumatic intubation, multiple attempts, prolonged intubation, use of cuffed or inappropriate sized tube, lower age, inadequate analgesia, and sedation are associated with significant risk of post-extubation stridor.[2] [3] Here, we report a case of persistent post-extubation stridor in a patient with traumatic brain injury, who was medically managed, thus avoiding reintubation. Informed consent for reporting this case was obtained from the child's parents.

Is a Difficult Airway Team Needed for Intubation at Removal of Mandibular Distraction Devices for Infants With Robin Sequence?

Difficult airway teams (DATs) are typically present to assist intubation at the initial mandibular distraction osteogenesis (MDO) operation for infants with Robin sequence (RS). In some institutions, the RS diagnosis triggers a "difficult airway" label for the infant, requiring DAT presence for future operations. By the time of distractor removal, however, breathing and airway anatomy are significantly improved. The objective of this study was to measure intubation difficulty and perioperative respiratory complications at MDO device removal as a proxy for the necessity for coordination with a DAT. This is a retrospective study including infants with RS from 2013 to 2021 who had MDO during infancy. Patients were excluded if they had a tracheostomy or MDO device failure. Predictor variables included demographic data, comorbidities, and apnea-hypopnea indices (AHIs) from pre- and immediate post-MDO polysomnograms. The primary outcome measures were number of intubation attempts, laryngoscopy grade, and perioperative respiratory events at the distractor removal operation. Descriptive statistics were computed including Fisher's exact, paired sample t-tests, and Wilcoxon rank tests, and P<.05 was considered statistically significant. The sample included 47 (60% male) patients with a mean age at MDO of 12.0±15.7weeks. Significant improvement in AHI was seen after MDO (pre-MDO: 26.8±18.4 events/hour; post-MDO 2.78±2.66 events/hour; P<.001). Average number of intubation attempts decreased from 2.09±1.36 to 1.30±0.75 (P<.001) and the most common post-MDO laryngoscopy grade was 1 (69%). There were no intraoperative and 2 (4%) minor postoperative respiratory events, both in patients with repaired congenital cardiac disease and not related to traumatic intubation. Neither difficult intubations nor perioperative respiratory events associated with intubation trauma were seen at distractor removal, suggesting that specialty airway assistance is not routinely needed after successful MDO. DAT presence should be determined on a case-by-case basis based on specific patient risk factors.

Subcutaneous emphysema as a complication of otorhinolaryngological surgical procedures.

Subcutaneous emphysema (SE) represents, after bleeding and infections, a common complication in ENT surgery, given the intimate relationship between upper airways and anatomical area pertaining head and neck surgeon. Aim of this review is to analyze its characteristics, method of diagnosis and treatment to provide the specialist a useful tool for its early recognition. A narrative review was carried out in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. A total of 164 articles were collected and most of them were case reports. Of 273 articles taken into consideration, only 164 met inclusion criteria. Review of all cases of SE in relation to surgical ENT procedures allow to classify each etiology on the surgical procedure that could be complicated with SE: laryngo-tracheal procedures, thyroid surgery, nasal and otological surgery, adenotonsillectomies. Moreover, traumatic orotracheal intubation, as well as alveolar rupture because of positive pressure ventilation or rupture of a preexisting abnormality, must be always taken into account. All ENT surgery can be complicated by SE. Diagnosis is simple and usually based only on physical examination, but correct and quick diagnosis is required. Treatment is in most of the time exclusively conservative, but SE could also represent a surgical emergency, given the possible evolution in pneumothorax/pneumomediastinum with serious consequences for patient's health.

Emergeny Medicine Resident Trauma Intubation Success and Prior Intubation Experience

BackgroundEmergency medicine residents are often involved in the management of trauma airways. There are few data on the correlation between prior intubation experience and first-pass trauma intubation success for emergency medicine residents. ObjectivesWe attempted to elucidate a relationship between prior resident intubation experience and first-pass success for trauma patient intubation. MethodsWe combined two data sets to assess for correlation between prior intubation experience for postgraduate year 2 and 3 residents and first-pass success for trauma patient intubation. Prior intubation experience was gathered from resident procedure logs and trauma intubation data were collected as part of a quality-monitoring program. A univariable logistic regression analysis for all available variables was performed, with first-pass intubation success as the outcome of interest. ResultsWe included 295 consecutive trauma patients intubated at a Level I trauma center where we could link the resident prior intubation experience (total intubations) with intubation attempt quality data. First-pass success for all emergency medicine residents was 82.3% (233/283). Overall successful intubation rate for emergency medicine residents was 90.4% (256/283). The combination of airway management by both the resident and emergency medicine attending provided an overall success rate of 97.3% (287/295). There was no statistically significant association between first-pass success and prior resident intubation experience or any of the other measured variables. ConclusionWe did not demonstrate any significant correlation between first-pass intubation success and number of prior intubations performed by the emergency medicine resident.

A difficult trauma intubation without the usual landmarks.

A difficult trauma intubation without the usual landmarks.

Uvular Necrosis after Oral Bronchoscopy with Bronchoalveolar Lavage: A Case Report with Review of Evidence

Uvular Necrosis is a relatively rare and unfortunate postprocedural circumstance that can occur following a traumatic oropharyngeal insertion of medical instruments. These medical instruments cause compression of the uvula decreasing vascular supply and leading to necrosis and subsequently sloughing off of the affected area. We present here possibly the first-ever case reported as a rare complication of oral bronchoscopy with bronchoalveolar lavage (BAL) that leads to uvular necrosis. The patient complained of persistent sore throat, odynophagia, and dysphagia one day after the procedure. Uvular necrosis is more commonly reported during nasopharyngeal endoscopies and traumatic blind intubations but is rarely associated with bronchoscopies. Though the inciting event is unclear on this patient whether it was the BAL or the bronchoscope itself, the uvular necrosis was a certainty. With appropriate management, the patient’s symptoms started resolving and the area of necrosis diminished. While symptoms from uvular necrosis typically self-resolve within two weeks with conservative management, it is important to recognize the concern to the provider of life-threatening oropharyngeal edema that can be a sequel of this event.

Four Different Reasons of Subcutaneous Emphysema With or Without Pneumomediastinum and Pneumothorax After Facial Bone Surgery.

In the present study, the authors report rare case series with subcutaneous emphysema with or without pneumomediastinum and pneumothorax after orthognathic and facial bone contouring surgery, compare their clinical and radiologic findings, and suggest precautions. Four patients who showed subcutaneous emphysema on follow up chest X-ray and computed tomography after orthognathic and facial bone contouring surgery were included in the study. In all cases post-op subcutaneous emphysema were detected, however, the aspect and mechanisms of post-op air spread were all different. After the conservative management with administering the O 2 by nasal cannula or endotracheal tube, the symptoms were relieved except 1 patient who needed chest tube insertion and further supra-sternal incision. In conclusion, subcutaneous emphysema with or without pneumomediastinum and pneumothorax after orthognathic and facial bone contouring surgery can be occurred by cervical fascia injury or alveolar ruptures. To preventing those complications, traumatic naso-tracheal intubation, excessive positive pressure ventilation, intermaxillary fixation immediate after the surgery, and increase of intra-alveolar pressure of the patients should be avoided.

Survey of current trends in the management of traumatic subcutaneous emphysema in dogs.

Subcutaneous emphysema (SCE) is a common occurrence in emergency veterinary practice, but published information regarding treatment and management strategies is lacking. This study examined trends in diagnostic and treatment recommendations. An internet-based survey with cross-sectional analysis. There were 129 respondents: board-certified and nonboard-certified veterinarians in private practice and university settings. Significant differences in the choice of diagnostics and treatment were found based on the etiology and severity of SCE and between respondent groups. Computed tomography (CT) was selected more frequently for SCE resulting from blunt or penetrating traumas by the board-certified veterinarians practicing in a teaching hospital (VTH group; P<0.001). All veterinarians were more likely to select tracheobronchoscopy as part of their workup for SCE as a result of endotracheal intubation trauma (P=0.0093 [penetrating traumas]; P=0.0002 [blunt force traumas]). Intermittent SC drainage and ventral cervical exploratory surgery were more likely to be chosen as treatments when SCE was classified as severe generalized (P<0.0001). There is significant variation in the treatment of SCE in veterinary medicine as well as associated diagnostics to determine severity and treatment options. Further studies are indicated to determine the optimal approach and provide guidance to clinicians.

Assessment of Acoustic Voice Parameters After Anterior Cervical Discectomy and Fusion.

BackgroundAnterior cervical discectomy and fusion (ACDF) is a surgical treatment approach for cervical spine diseases. Alteration in voice quality is a commonly encountered concern after perilaryngeal neck surgeries. Vocal cord paralysis is a known complication of ACDF. In this study, we aimed to investigate the effect of ACDF on acoustic voice parameters and to compare ACDF with posterior cervical discectomy and fusion (PCDF).MethodologyIn this study, we investigated 52 patients admitted to the hospital with symptoms related to cervical spinal cord compression and underwent spine surgery in the Neurosurgery Clinic (26 underwent ACDF and 26 underwent PCDF). For standardization, 25 healthy age and gender-matched volunteers were evaluated as the control group. The voices of the patients were analyzed digitally preoperatively and at first and third months postoperatively. As acoustic parameters, jitter, shimmer, basal frequency, and normalized noise energy were recorded. All patients were examined preoperatively and postoperatively for laryngeal pathology and were asked to fill the Voice Handicap Index-10 (VHI-10).ResultsThe changes in four of the five acoustic parameters from baseline to postoperative first-month assessment in the ACDF group were significant (p < 0.05). These parameters almost approached normal values in the analysis performed at three months. In the PCDF group, no significant differences were seen in the acoustic analysis of the patients in comparison to the preoperative and the first and third-month assessments. The VHI-10 values were not significantly different among the patients who underwent ACDF or PCDF or control patients at any postoperative time point.ConclusionsOur study demonstrated that voice parameters in patients who underwent ACDF worsened significantly after the surgery compared with patients who underwent PCDF; however, these changes recovered within three months postoperatively. The possible causes for these findings include the retraction of the vagus and the recurrent laryngeal nerve, postoperative edema of strap muscles, intubation trauma to the vocal folds, and other laryngeal structures.

A Newborn with Congenital Stridor.

A Newborn with Congenital Stridor.

IATROGENIC MACROGLOSSIA FOLLOWING TRAUMATIC INTUBATION

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Acute onset macroglossia is a rare yet life-threatening complication that may result from numerous etiologies including patient positioning while under anesthesia, oropharyngeal packing, local trauma, postoperative from surgery in the oral cavity, or secondary to allergic or nonallergic angioedema. Several management strategies have been described including utilization of reduction glossectomy. We present a rare case of acute onset macroglossia likely caused by traumatic intubation with multiple attempts and further potentiated by prone positioning. CASE PRESENTATION: Patient is a 55-year-old female with a past medical history of hypertension, COPD, OSA, HFpEF who presented with a one-week history of worsening shortness of breath. Vital signs showed T 97.6, BP 140/89, RR 24, O2 saturation 96% on 40% FiO2 on BiPAP. Physical exam demonstrated decreased air entry bilaterally with faint wheezing and crackles. Imaging suggested findings of pulmonary edema.Patient was treated for a working diagnosis of COPD and HF exacerbation with nebulizer treatments, steroids, and diuretics. Initial ABG showed pH 7.287, pCO2 77, pO2 124. However, her requirements on BiPAP worsened and a repeat ABG showed pH 7.156, pCO2 105.9, pO2 91 on 60% FiO2. Due to the underlying acidosis and deteriorating mental status, decision was made to intubate. Patient underwent a difficult intubation by anesthesia with at least three failed attempts due to patient's airway being hypertrophied and anterior. They were finally able to place a 6 Fr ETT over a bougie. Hospital course was further complicated by deteriorating respiratory status with ARDS and patient underwent multiple proning sessions. Around Day 7, patient was noted to have a protruding tongue that was undergoing excessive swelling. At its worse, the tongue was protruding three to four inches. The tongue was kept wet and covered with gauze. After stabilization, patient finally underwent tracheostomy about three weeks after intubation. Her status stabilized and she was transferred to another hospital for OMFS and ENT evaluation. Patient was treated with lingual compressive wraps as well as dexamethasone to normalization in a couple weeks. DISCUSSION: A review of literature did not show any cases that attributed multiple failed intubation attempts correlating with development of macroglossia. However, there have been some case reports attributing macroglossia to prone positioning. Typically, when macroglossia is of this magnitude, it requires reduction glossectomy by OMFS. However, our patient was treated conservatively with lingual compression wraps and steroids with return of tongue to baseline size making our case unique. CONCLUSIONS: Macroglossia is an extremely rare, yet almost forgotten complication that may be seen in intubated patients. The potential for it to be detrimental for the patient should always be in the back of our minds. REFERENCE #1: D. Saah, I. Braverman, J. Elidan, and B. Nageris, "Traumatic macroglossia," Annals of Otology, Rhinology & Laryngology, vol. 102, no. 9, pp. 729-730, 1993. REFERENCE #2: J. M. DePasse, M. A. Palumbo, M. Haque, C. P. Eberson, and A. H. Daniels, "Complications associated with prone positioning in elective spinal surgery," World Journal of Orthopaedics, vol. 6, no. 3, pp. 351–359, 2015. REFERENCE #3: R. Shanti, H. Braidy, and V. Ziccardi, "Application of maxillomandibular fixation for management of traumatic macroglossia: a case report," Craniomaxillofacial Trauma and Reconstruction, vol. 08, no. 04, pp. 352–355, 2015. DISCLOSURES: No relevant relationships by mohammed halabiya, source=Web Response No relevant relationships by William Meng, source=Web Response No relevant relationships by Richard Miller, source=Web Response No relevant relationships by Sushant Nanavati, source=Web Response No relevant relationships by Shawn Pate, source=Web Response No relevant relationships by Rutwik Patel, source=Web Response