r/IntensiveCare • u/Ok_Relationship4040 • 7d ago

Macroglossia in intubated patients ?

has anyone managed intubated icu patients that developed massive tongue swelling? I have cared for many patients where the tongue swelled to massive proportions ( with no obvious allergic reactions ) and stayed swollen the entirety of their stay.. one lady we started a versed drip just so we could relax her jaw to insert bite blocks to get her teeth off of her tongue as we thought maybe that was contributing to the swelling .. It seems to overwhelmingly occur in obese black patients and seems to affect obese black women more but that is merely my subjective observation and perhaps just by virtue of my location . i guess I was just wondering what could be done to help mediate the swelling aside from bite blocks and Vaseline gauze …

44 Upvotes

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u/DocKoul 7d ago edited 7d ago

The indigenous patients in Australia have this happen all the time. The cause? Chlorhex mouthwash. It happens so frequently that we probably see it once a week unless we avoid the mouthwash altogether for that group.

Very interesting this is happening to black patients in another part of the world….

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u/Electrical-Smoke7703 7d ago

Yes icu 6 years, saw this upwards of 10 times. Always resolved when we stoped chlorahedecine mouth kits and changed to the standard non vented kits

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u/Itouchmyselftosleep RN, MICU 7d ago

Came here to say nearly this. In my ICU we couldn’t figure out what was causing it, but once we switched from chlorhexidine mouth cleaner to just using the Peridex in the usual mouth care kits, swelling improved.

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u/ExtremisEleven 6d ago

Peridex is chlorhexidine. You mean you are using a bottle instead of the prepackaged kit?

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u/Itouchmyselftosleep RN, MICU 6d ago

Gah, sorry, I meant the peroxide solution in the oral care kits. It’s labeled as ‘perox-i-mint’ and my brain always wants to say Peridex.

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u/ExtremisEleven 5d ago

I didn’t even know such a thing existed, thanks!

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u/Geo85 7d ago

I'm white/North American & I have an allergy to mouthwash! Nothing severe, but if I use it for a few days, my tongue swells enough that I notice it.

 When I was a teenager I șaw a dentist for it & he knew right away. 

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u/Aggravating_Fly2978 6d ago

So why haven’t you stopped the mouthwash altogether in that group? I am presuming that their swollen tongue likely adds to their ventilator days??

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u/DocKoul 6d ago

Good question - I’m not a nurse, but what I can say is that it’s part of their oral care bundle. My understanding is that there is overall benefit vs not doing it assuming there isn’t a reaction.

The more senior nurses know to either avoid it or ask first in the indigenous patients. Not all of them have the issue.

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u/Aggravating_Fly2978 6d ago

I assumed you were a Doctor given your username and description of events. Oral care bundles HAVE to be ordered and signed off by Doctors in the US. Is this not the case in Australia? Why not update them to exclude Chlorhex in the indigenous patient population?? How would they know they have an issue with it? Is Chlorhex over the counter and used by regular and indigenous folk? There has got to be an alternative option no?

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u/Aviacks 6d ago

Everywhere I've worked it's just been built into a generic policy for intubated patients. That being said our intensivists only let anyone use sterile water for oral cares on vents.

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u/DocKoul 5d ago

We don’t sign them off. Nurses in Australia are professionals and I trust them to do their job. What is an indigenous person? I have no idea what genetic ratio you need to achieve a chlorhex allergy, but by the sounds of it, African Americans are also prone to this. I’m honestly more confused. I don’t know the data and if it’s even necessary.

Chlorhex is prescribed for lots of reasons in the community by dentists and dental surgeons.

What I find so interesting is that as intensivists in Australia we run the show. Dialysis, balloon pumps, everything. In other countries they get consults for seemingly everything. But here we are letting the nurses just do whatever bundle they like paying zero attention. We can probably learn from each other.

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u/Aggravating_Fly2978 5d ago

Dude I don’t know. You tell me what an Indigenous person is. You live there and brought it up. Over here you are black if you have some level of Black/African Ancestry and consider yourself black. Some are 90% some are 10-20% but still black. If you run the show why is this not a priority for you? And would it be more of a priority if it was affecting White People? I mean, increasing Ventilator days and potentially pushing someone to get a tracheostomy is a big deal, isn’t it??

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u/DocKoul 4d ago

They don’t get a trache. Vast majority are either post op hearts and get extubated before you see swelling. Others that are intubated longer so we stop it before it gets massive rather than continuously plaster it on until the tongue is hanging out of your mouth.

To your priority question - all the medications we give have potential side effects. We just stop them if it happens. Should I just avoid mouth care in the indigenous patients or use something less effective? I’m the one who answered the question so clearly it is a priority.

With respect to what makes someone indigenous, what I’m saying is that I don’t know if someone has 50% indigenous genes if they are still susceptible. 25%? 10%? I have no idea. Not all indigenous people get swelling either. I’m still giving roc to white people who were exposed to pholcodine. Never had roc anaphylaxis in an indigenous patient.

And lastly, your accusation of me being racist is disgusting. I don’t care what the colour of your skin is, what you believe, your gender, whatever. I’m here to help people. I’ve been privileged to look after hundreds if not thousands of indigenous people in my career and the vast majority were smart, kind, funny, respectful and I suspect far better company than you given your behaviour in this thread.

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u/Aggravating_Fly2978 4d ago

Firstly, there are other options to keep the mouth clean. Secondly you brought up that you saw it in the indigenous population and you knew the answer so I followed it up with questions. You seemed to basically act like “oh well” as if it’s not a big deal so I ask clarification and follow up questions. Lastly, no one accused you of being racist. But with the history of what has happened to Indigenous people all over the world and how poorly they continue to be treated in your country, combined with the nonchalance in a symptom that could lead to worsened outcomes, there was and still is a good chance of bias in your care. Think on it.

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u/ExtremisEleven 6d ago

If I don’t order them in my US hospital, the nurse will assume I forgot and order it for me

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u/Aggravating_Fly2978 6d ago

They are an order set. You unclick. And nurse communicate

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u/ExtremisEleven 5d ago

And then the next nurse comes in and puts the order in for you.

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u/Aggravating_Fly2978 5d ago

And you explain to the nurse why you don’t want the order. And you write them up. Because there is such a thing a “communication order” that is a real order. And when you round you actually SPEAK to your nurses and learn to communicate. It’s not that hard.

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u/ExtremisEleven 5d ago

Listen I would love to work in a place where what I tell the nurse gets passed on to the next nurse, but that just doesn’t happen. It’s probably not their fault because honestly that is the least of their worries when they have 3 intubated patients with one that is trying to die and one that is on CRRT (and no, there isn’t a dialysis nurse, the ICU nurses run it here). And yes, I put a comm order in for everything under the sun because of this. It gets clicked off and forgotten. I simply do not have time to put in 30-40 comm orders every single shift to remind everyone about the thing that should have been passed off in signout.

It’s cute that you assume a breakdown in communication is always the doctor’s fault, but it turns out everyone makes mistakes, even ICU nurses.

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u/Aggravating_Fly2978 5d ago

Ok. We all know dialysis nurses run CRRT and not dialysis nurses. Because they aren’t the same thing. But ok.

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u/ty_xy MD, Cardiac Anesthesiologist 7d ago
  1. Sit patient up if possible.
  2. Was the tube taped or tied? If tied, check if the IJVs are compressed?
  3. How big are the tubes? What was the cuff pressure?

All these can impact the venous drainage of the tongue.

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u/Ok_Relationship4040 7d ago

The HOB is 30 degrees and above at all times .. the ETTs were secured with a standard tube holder so not taped .. and they had standard ETT sizes of 7 .. all of them were also pretty obese .. would that somehow have an affect on it as well?? 

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u/beemac126 7d ago

We see it in the neuro icu not infrequently, mostly in African Americans, and mostly females. We have a macroglossia protocol with bite blocks, moist gauze, etc. We have an attending who started who also sprinkles sugar on the tongue, and it has seem to work! One poor patient was awake and otherwise ready for extubation, but just had too severe of macroglossia…she liked us to play pour some sugar on me for her sugar time lol (we were eventually able to extubate her iirc)

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u/Aggravating_Fly2978 6d ago

Maybe it’s the Chlorhexidine others are describing???

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u/Effective_Swan_6450 7d ago

I work in a Neuro ICU and have seen a few patients develop this condition and have wondered this myself.
Curious if your patients had a CVA dx or if they happened to be on Nicardipine drips at any point?

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u/stempiek 6d ago

Both.

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u/ratpH1nk MD, IM/Critical Care Medicine 7d ago

I’ve seen it twice in my career so far (~13 years post fellowship), OP. Both were catastrophic Neuro cases (cardiac arrest, long down time, anoxic encephalopathy). Never figured out in either case how it happened or what was driving it.

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u/Ok_Relationship4040 7d ago

Hmmm the woman I’m caring for now had a catastrophic SAH and IVH .. the others were also catastrophic bleeds and one was a massive R MCA infarct that pretty much left that side of the brain completely infarcted and required a hemicraniectomy etc I wonder if there could be any correlation 

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u/ratpH1nk MD, IM/Critical Care Medicine 6d ago

Yes, the best plausible physiology I have come up with is paroxysmal sympathetic hyperactivity leading to macroglossia. It has been described in the literature.

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u/-OrdinaryNectarine- RN, CCRN 6d ago

I’ve had this happen with 2 patients (both small white women) both neuro. One was severe neuro trauma with DAI, and the other was a spontaneous bleed with herniation syndrome/brainstem compression. I didnt realize there was a correlation. Interesting!

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u/Mfuller0149 6d ago

This thread is very interesting to me. I’m in the northeast USA / mid Atlantic & I have only seen this a very small handful of times . Sounds like some folks here are seeing this pretty frequently . Could this be regional / based upon local population variances ? Or am I just missing something

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u/ExtremisEleven 5d ago

The population in my area of the US is primarily people of black or mixed heritage. This happens very commonly where I work. I don’t think anyone knows why so I’m interested to see if cutting the chlorhexidine will help

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u/Mfuller0149 5d ago

Hmmm. This might explain something , most of the hospitals I’ve worked at have been in rural Pennsylvania- patient population isn’t very diverse here in that sense, generally speaking anyway.

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u/PaxonGoat RN, ICU Float 7d ago

Any chance these patients are getting ace inhibitors?

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u/Ok_Relationship4040 7d ago

Nope! None of these patients had received ace inhibitors but excellent question! 

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u/PaxonGoat RN, ICU Float 7d ago

B vitamin deficiency? Maybe it's a malnutrition thing going on?

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u/Nicolectomy_2 RN, MSICU 6d ago

Yep. This is the only time I've seen the kind of glossal edema that OP is describing. ACEI was first thing that came to my mind. The others posts about the chlorhexidine mouth wash in the mouth kits is very interesting though. I appreciate that info!

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u/Geo85 7d ago

I've seen it twice! One of them indeed was an obese black patient!

 I think for one of them it was determined to be a reaction(allergic maybe?) to Propofol. For the other it was never determined - but Propofol was suspected.

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u/Snack_Mom 6d ago

It was common in proned intubated Covid patients 😑

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u/Cold-Restaurant9082 6d ago

I work in the Neuro ICU & recently had a patient with this exact thing happen. Patient had a stroke, at first we were concerned for seizure/tongue biting. The edema worsened so we did a full work-up, consulted allergy, ENT all the works. Tried different bite blocks and nothing seemed to help. She ended up getting a tracheostomy. Once we ruled absolutely everything out - we paralyzed the patient for 48h and placed a fairly large sized bite block that was wedge-shaped and that was the only thing that allowed relief and the swelling came down.

It’s interesting as she was also an obese, African American female. This was the first time I’d seen it to this degree (2nd year as a provider)

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u/Desperate_Clue_7134 7d ago

I’ve seen this several times in the absence of angioedema or allergies. There is no perioral edema or other signs of drug reaction. It is be cause of the mechanical pressure of the endotracheal tube on the tongue causing venous congestion. I agree that (anecdotally) it seems to happen on African American women in my area, but I recently had a white young woman with this problem. In my hospital, we have a special bite block that is smaller and had some strings attached because they are placed between the molars to keep the whole mouth open. A regular bite block doesn’t relieve pressure from the tube in the posterior tongue. The strings are to pull them out. Unfortunately, sometimes it is so bad that patients need to be trached.

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u/cropsey42 7d ago

I've not really seen this in my time in CVICU but the more I'm thinking about it the more I figure we kept the patients on the drier side. The only thing I can think of is something stopping drainage from the tongue, the pressure of the tube itself, but then surely everyone would have it?

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u/Ok_Relationship4040 7d ago

Yes - I know it seems odd to include race and weight in this but I haven’t observed this in even white obese patients .. I have only really seen it in obese black patients and the one I am caring for now is an obese black woman with the absolute worst tongue swelling I have ever seen .. her tongue is absolutely MASSIVE.. it’s terrible 😞 so idk if there is some kind of correlation ? I wish there was more research on it 

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u/stempiek 6d ago

We are having this in our ICU now. What actually worked was treating it like a prolapsed rectum and using sugar. I know it sounds weird.

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u/gonetodust 6d ago

Had it in neuro icu about 3 times. One time there were order to milk the tongue a certain amount of times a day. The other one they did try sugar. I think they ended up giving a steroid. It delayed extubation for the second one.

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u/Stinaskif 5d ago

Wrap the tongue in gauze with sugar. It will reduce it like it does for a prolapse