Alcohol Withdrawal: Breathing Tube Patients At Risk?

Alcohol withdrawal can be a dangerous process, potentially causing severe symptoms such as seizures, delirium tremens, hallucinations, and anxiety. In severe cases, patients may be intubated and placed on a ventilator to manage symptoms and prevent harm to themselves or others. However, intubation carries its own risks, including pneumonia, delirium, and vocal cord damage. The severity of alcohol withdrawal symptoms varies depending on individual factors, and they can range from mild to life-threatening. Approximately 40% of hospital patients in the United States have an alcohol use disorder, and about half of them may experience withdrawal symptoms. Effective management of alcohol withdrawal in intensive care units (ICUs) is crucial to improving patient outcomes and reducing the length of stay.

Characteristics and values of severe alcohol withdrawal

Alcohol withdrawal symptoms

Withdrawal symptoms can be physical and psychological and range in severity from mild to severe. Initial symptoms may be felt within six hours of the last drink, with symptoms at their most severe within 48-72 hours after you stop drinking. However, some may linger for weeks or even months. The symptoms include:

• Tremors
• Sweating
• Severe anxiety
• Confusion
• Seizures
• Hallucinations
• Delirium tremens (DTs)

Delirium tremens is a severe indication of alcohol withdrawal and can be fatal. About 1%-1.5% of people with alcohol withdrawal will have DTs, which can continue for several days and are often most intense four to five days after the last drink. Severe alcohol withdrawal cases in hospitals are often responded to with heavy sedation, sometimes to the extent that the patient has to breathe through a tube on a ventilator. However, intubation introduces risks for additional potential complications, such as pneumonia, delirium, or damage to vocal cords, which can last long after the patient leaves the hospital.

It is important to note that withdrawal symptoms are not always the same for everyone, and some people may experience shortness of breath during alcohol withdrawal. This can be due to dehydration caused by excessive alcohol consumption, which can lead to higher urine production and considerable fluid loss. While dehydration does not commonly cause shortness of breath on its own, severe dehydration can lead to heavy fluid volume loss, resulting in hypotension, which can cause shortness of breath.

Treatment options

The treatment options for alcohol withdrawal vary depending on the severity of the withdrawal symptoms, which can range from mild to severe. Mild symptoms include headache, mild anxiety, and insomnia, while severe symptoms include hallucinations, seizures, severe anxiety, confusion, and tremors.

Mild Alcohol Withdrawal

If you are experiencing mild alcohol withdrawal, you may be able to recover on your own with rest and support. It is important to follow your doctor's advice, and it can be helpful to talk to a therapist or join a support group. Sticking to a daily routine and celebrating small accomplishments can also aid in recovery.

Moderate Alcohol Withdrawal

For moderate alcohol withdrawal, certain medications may be prescribed to help manage symptoms. Doctors will also want to monitor patients closely. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) is a commonly used tool to assess the severity of withdrawal symptoms and determine medication dosing.

Severe Alcohol Withdrawal

In cases of severe alcohol withdrawal, doctors may recommend a short-term detox program or inpatient treatment, where patients can receive 24/7 support and stronger medications. Benzodiazepines are often used to manage symptoms, but in severe cases, they may be less effective and require high doses, leading to potential complications. Dexmedetomidine has been suggested as an adjunct treatment for severe alcohol withdrawal, as it has been found to reduce benzodiazepine dosing and alcohol withdrawal severity scores.

Treatment Resources

There are various resources available for individuals seeking treatment for alcohol withdrawal and alcohol use disorder (AUD). SAMHSA's National Helpline offers free, confidential referrals to local treatment facilities, support groups, and community-based organizations. Alcohol Awareness also provides a free alcoholism hotline that can be called 24/7 to connect individuals with alcohol-related resources and support groups.

Intubation complications

Intubation is a standard medical procedure that involves inserting a flexible plastic tube down a person's throat. It is often performed before surgery or in emergencies to help a person breathe or to administer medication. While most people recover from intubation with no long-term effects, adverse events are more likely to occur if performed in an emergency.

Immediate Complications

• Emergencies: Can’t Intubate, Can’t Oxygenate (CICO)
• Laryngospasm
• Airway Obstruction
• Surgical Cricothyroidotomy Conditions
• Airway in C-Spine Injury
• Airway management in major trauma
• Angioedema
• Coroner’s Clot
• Intubation of the GI Bleeder
• Hypoxia
• Post-intubation Care
• Unplanned Extubation

Short-term Complications

• Tracheal stenosis
• Laryngotracheal injury
• Ulcers on the posterior aspect of the true vocal cords
• Excessive cuff pressure requirements
• Self-extubation
• Inability to seal the airway
• Patient discomfort
• Difficulty in suctioning tracheobronchial secretions

Long-term Complications

• Pneumonia
• Delirium
• Damage to vocal cords
• Laryngeal granuloma
• Stomal infection
• Stomal haemorrhage
• Subcutaneous emphysema
• Pneumomediastinum

Alcohol withdrawal can be potentially fatal and may require intubation if symptoms are severe. Symptoms of alcohol withdrawal include tremors, sweating, severe anxiety, confusion, seizures, and shortness of breath. Shortness of breath can be caused by dehydration due to alcohol's diuretic effects, resulting in fluid loss and potential hypotension. Treatment for severe alcohol withdrawal may involve heavy sedation and intubation to manage symptoms and prevent harm to the patient or others. However, intubation carries the risks of the aforementioned complications, which can be long-lasting or even permanent.

Scoring severity

The severity of alcohol withdrawal symptoms varies from person to person. The symptoms are at their most severe within 48-72 hours after the last drink. However, symptoms may begin as early as six hours after the last drink.

The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) has been a traditional method for assessing the severity of a patient's withdrawal symptoms. However, this method has its limitations. For instance, ordering a CIWA alone can lead to many encounters with a maximum CIWA-Ar (Alcohol Revised) score of 0, which likely reflects patients who do not have withdrawal symptoms. The CIWA-Ar scale has a cutoff point of 24, beyond which the patient is considered to have severe alcohol withdrawal syndrome (SAWS). The American Society of Addiction Medicine (ASAM) and the American Thoracic Society (ATS) have defined different severities of AWS using the CIWA-Ar scale, with ASAM and ATS cutoff scores for SAWS of 19 and 15, respectively.

Another scale used to assess the severity of alcohol withdrawal is the Alcohol Withdrawal Clinical Assessment (AWCA) scale.

Alcohol withdrawal symptoms can include tremors, sweating, severe anxiety, confusion, and seizures. Additionally, alcohol withdrawal can also lead to shortness of breath or rapid breathing. This is often due to dehydration caused by the diuretic effects of alcohol, resulting in increased urine production and fluid loss. Severe dehydration can lead to heavy fluid volume loss, causing hypotension and subsequent shortness of breath. Additionally, dehydration can thicken the mucus lining in the airways, further contributing to breathing difficulties.

Alcohol withdrawal syndrome (AWS) can progress to more severe and complicated forms, such as delirium and seizures, which may require mechanical ventilation and prolonged hospitalization. Patients with a history of recent heavy alcohol use and other acute medical conditions, such as pneumonia, cardiac dysfunction, or alcohol-related liver disease, are at a higher risk for a higher degree of AWS and require higher levels of care.

Prevention and rehabilitation

Alcohol withdrawal can be a life-threatening condition that requires immediate medical attention. While the symptoms of alcohol withdrawal can be severe, there are effective treatments available to help patients manage their symptoms and prevent complications.

Alcohol withdrawal prevention focuses on reducing the severity of withdrawal symptoms and preventing complications. This involves a combination of medical interventions and behavioural therapies.

For severe alcohol withdrawal cases, hospitals typically administer heavy sedation to control symptoms and prevent harm to the patient or others. This often requires intubation and mechanical ventilation, which can introduce risks for additional complications, such as pneumonia, delirium, and vocal cord damage. Therefore, medical professionals aim to minimise the use of intubation and instead focus on symptom management.

One effective approach is the use of specific medications, such as starting with lorazepam (a sedative), closely monitoring the patient, and adjusting dosages as needed. This may also involve switching to other sedatives, such as phenobarbital, until the patient's symptoms are effectively managed.

Additionally, early detection and intervention are crucial in preventing severe alcohol withdrawal. The Alcohol Withdrawal Clinical Assessment (AWCA) scale is a valuable tool for assessing the severity of withdrawal symptoms and guiding treatment decisions. By using this scale, medical professionals can provide targeted interventions and medication dosing, improving patient outcomes.

Furthermore, addressing underlying alcohol use disorders is essential for long-term prevention and rehabilitation. Behavioural therapies, such as cognitive-behavioural therapy, can help individuals manage cravings, develop coping strategies, and reduce the risk of relapse. Support groups, youth support groups, and family counselling can also play a vital role in the recovery process by providing emotional support and addressing the social and occupational issues associated with alcohol use.

Overall, the key to successful prevention and rehabilitation lies in early intervention, accurate assessment, targeted medication use, and comprehensive behavioural therapies. By addressing both the physical and psychological aspects of alcohol withdrawal, individuals can effectively manage their symptoms, reduce complications, and work towards long-term recovery.

Frequently asked questions