Download PDF
Semin Plast Surg
DOI: 10.1055/s-0044-1786008
Review Article

Airway Management for Acute and Reconstructive Burns: Our 30-year Experience

Brita M. Mittal
1   Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas
,
Robert A. McQuitty
2   Department of Otolaryngology, University of Texas Medical Branch, Galveston, Texas
,
Mark Talon
1   Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas
3   Department of Anesthesiology, Shriners Children's Texas, Galveston, Texas
,
Alexis L. McQuitty
1   Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas
3   Department of Anesthesiology, Shriners Children's Texas, Galveston, Texas
› Author Affiliations
› Further Information
    Permissions and Reprints

Abstract

Airway management in both acute and reconstructive burn patients can be a major challenge for evaluation, intubation, and securing the airway in the setting of altered airway structure. Airway evaluation in both acute and reconstructive patients includes examination for evidence of laryngeal and supraglottic edema and structural changes due to trauma and/or scarring that will impact the successful approach to acquiring an airway for surgical procedures and medical recovery. The approach to acquiring a successful airway is rarely standard laryngoscopy and often requires fiberoptic bronchoscopy and a variety of airway manipulation techniques. Tracheostomy should be reserved for those with classic requirements of ventilatory and/or mechanical failure or severe upper airway burns. Even securing an airway for surgical procedures, especially with patients suffering injuries involving the head and neck, can be nonstandard and requires creative and flexible approaches to be successful. After much trial and error over the past 30 years in a large burn center, our multidisciplinary team has learned many valuable lessons. This review will focus on our current approach to safe airway management in acute and reconstructive burn patients.

Keywords

airway management - bronchoscopy - airway evaluation - pediatric burn


Publication History

Article published online:
26 April 2024

© 2024. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Apfelbaum JL, Hagberg CA, Connis RT. et al. 2022 American Society of Anesthesiologists practice guidelines for management of the difficult airway. Anesthesiology 2022; 136 (01) 31-81
    CrossrefPubMedGoogle Scholar
  • 2 Crawley SM, Dalton AJ. Predicting the difficult airway. BJA Educ 2015; 15 (05) 253-258
    CrossrefPubMedGoogle Scholar
  • 3 Rafique NB, Khan FA. Comparison of Mallampati test, thyromental distance and distance from tragus to nares for predicting difficult intubation in pediatric patients. Open J Anesthesiol 2014; 04 (04) 104-109
    CrossrefPubMedGoogle Scholar
  • 4 Sinha A, Jayaraman L, Punhani D. Predictors of difficult airway in the obese are closely related to safe apnea time!. J Anaesthesiol Clin Pharmacol 2020; 36 (01) 25-30
    CrossrefPubMedGoogle Scholar
  • 5 Whitten C. 10 common pediatric airway problems—and their solutions. Anesthesiology News 2019;August 20:Airway Management:51–69
    PubMedGoogle Scholar
  • 6 Mishra D, Chakole V, Dev P. Difficult airway management in a patient with post-burn contracture neck. Cureus 2022; 14 (10) e30011
    PubMedGoogle Scholar
  • 7 Han SH, Oh AY, Jung CW, Park SJ, Kim JH, Nahm FS. The effect of the jaw-thrust manoeuvre on the ability to advance a tracheal tube over a bronchoscope during oral fibreoptic intubation. Anaesthesia 2013; 68 (05) 472-477
    CrossrefPubMedGoogle Scholar
  • 8 Matten EC, Shear T, Vender JS. Chapter 15 - nonintubation management of the airway: airway maneuvers and mask ventilation. In: Hagberg CA. ed. Benumof and Hagberg's Airway Management. 3rd ed.. Philadelphia: W.B. Saunders; 2013: 324-339.e1
    Google Scholar
  • 9 Galvagno Jr SM, Nahmias JT, Young DA. Advanced trauma life support® update 2019: management and applications for adults and special populations. Anesthesiol Clin 2019; 37 (01) 13-32
    CrossrefPubMedGoogle Scholar
  • 10 American College of Surgeons. 2021 . Accessed April, 2024 at https://www.facs.org/quality-programs/trauma/education/advanced-trauma-life-support/
    PubMed
  • 11 Advanced Burn Life Support Course, Provider Manual by ABLS Advisory Committee. American Burn Association 2017–2018. . Accessed April, 2024 at https://ameriburn.org/wp-content/uploads/2019/08/2018-abls-providermanual.pdf
    PubMedGoogle Scholar
  • 12 Orozco-Peláez YA. Airway burn or inhalation injury. Colombian Journal of Anesthesiology 2018; 46: 26-31
    CrossrefPubMedGoogle Scholar
  • 13 Bittner EA, Shank E, Woodson L, Martyn JA. Acute and perioperative care of the burn-injured patient. Anesthesiology 2015; 122 (02) 448-464
    CrossrefPubMedGoogle Scholar
  • 14 Cai AR, Hodgman EI, Kumar PB, Sehat AJ, Eastman AL, Wolf SE. Evaluating pre burn center intubation practices: an update. J Burn Care Res 2017; 38 (01) e23-e29
    CrossrefPubMedGoogle Scholar
  • 15 Romanowski KS, Palmieri TL, Sen S, Greenhalgh DG. More than one third of intubations in patients transferred to burn centers are unnecessary: proposed guidelines for appropriate intubation of the burn patient. J Burn Care Res 2016; 37 (05) e409-e414
    CrossrefPubMedGoogle Scholar
  • 16 Eastman AL, Arnoldo BA, Hunt JL, Purdue GF. Pre-burn center management of the burned airway: do we know enough?. J Burn Care Res 2010; 31 (05) 701-705
    CrossrefPubMedGoogle Scholar
  • 17 Hogg G, Goswamy J, Khwaja S, Khwaja N. Laryngeal trauma following an inhalation injury: a review and case report. J Voice 2017; 31 (03) 388.e27-388.e31
    CrossrefPubMedGoogle Scholar
  • 18 Dingle LA, Wain RAJ, Bishop S. et al. Intubation in burns patients: a 5-year review of the Manchester regional burns centre experience. Burns 2021; 47 (03) 576-586
    CrossrefPubMedGoogle Scholar
  • 19 Mayglothling J, Duane TM, Gibbs M. et al; Eastern Association for the Surgery of Trauma. Emergency tracheal intubation immediately following traumatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012; 73 (5, Suppl 4): S333-S340
    CrossrefPubMedGoogle Scholar
  • 20 Badulak JH, Schurr M, Sauaia A, Ivashchenko A, Peltz E. Defining the criteria for intubation of the patient with thermal burns. Burns 2018; 44 (03) 531-538
    CrossrefPubMedGoogle Scholar
  • 21 Huang RY, Chen SJ, Hsiao YC. et al. Positive signs on physical examination are not always indications for endotracheal tube intubation in patients with facial burn. BMC Emerg Med 2022; 22 (01) 36
    CrossrefPubMedGoogle Scholar
  • 22 Bai C, Huang H, Yao X. et al Application of flexible bronchoscopy in inhalation lung injury. Diagn Pathol 2013; 8 (174) 1-5
    PubMedGoogle Scholar
  • 23 Robinson L, Miller RH. Smoke inhalation injuries. Am J Otolaryngol 1986; 7 (05) 375-380
    CrossrefPubMedGoogle Scholar
  • 24 Moshrefi S, Sheckter CC, Shepard K. et al. Preventing unnecessary intubations: a 5-year regional burn center experience using flexible fiberoptic laryngoscopy for airway evaluation in patients with suspected inhalation or airway injury. J Burn Care Res 2019; 40 (03) 341-346
    CrossrefPubMedGoogle Scholar
  • 25 Ahuja RB, Gibran N, Greenhalgh D. et al; ISBI Practice Guidelines Committee, Steering Subcommittee, Advisory Subcommittee. ISBI practice guidelines for burn care. Burns 2016; 42 (05) 953-1021
    CrossrefPubMedGoogle Scholar
  • 26 Hemmes SN, Serpa Neto A, Schultz MJ. Intraoperative ventilatory strategies to prevent postoperative pulmonary complications: a meta-analysis. Curr Opin Anaesthesiol 2013; 26 (02) 126-133
    CrossrefPubMedGoogle Scholar
  • 27 Chhabada S, Licina L, Markakis D. Getting with the times: cuffed endotracheal tubes are safe in pediatric patients. Society for Pediatric Anesthesia. Acessed April, 2024 at http://www3.pedsanesthesia.org/newsletters/2018summer/procon-pro.html
    PubMedGoogle Scholar
  • 28 Chambers NA, Ramgolam A, Sommerfield D. et al. Cuffed vs. uncuffed tracheal tubes in children: a randomised controlled trial comparing leak, tidal volume and complications. Anaesthesia 2018; 73 (02) 160-168
    CrossrefPubMedGoogle Scholar
  • 29 Holzapfel L, Chevret S, Madinier G. et al. Influence of long-term oro- or nasotracheal intubation on nosocomial maxillary sinusitis and pneumonia: results of a prospective, randomized, clinical trial. Crit Care Med 1993; 21 (08) 1132-1138
    CrossrefPubMedGoogle Scholar
  • 30 Park DH, Lee CA, Jeong CY, Yang HS. Nasotracheal intubation for airway management during anesthesia. Anesth Pain Med 2021; 16 (03) 232-247
    CrossrefPubMedGoogle Scholar
  • 31 Lee MH, Kim HJ. Application of high-flow nasal oxygenation as a rescue therapy in difficult videolaryngoscopic intubation. SAGE Open Med Case Rep 2021 ;9:2050313X211010015
    PubMedGoogle Scholar
  • 32 Patel A, Nouraei SA. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia 2015; 70 (03) 323-329
    CrossrefPubMedGoogle Scholar
  • 33 Hodgson KA, Owen LS, Kamlin COF. et al. Nasal high-flow therapy during neonatal endotracheal intubation. N Engl J Med 2022; 386 (17) 1627-1637
    CrossrefPubMedGoogle Scholar
  • 34 Iglesias NJ, Prasai A, Golovko G, Ozhathil DK, Wolf SE. Retrospective outcomes analysis of tracheostomy in a paediatric burn population. Burns 2023; 49 (02) 408-414
    CrossrefPubMedGoogle Scholar
  • 35 Saffle JR, Morris SE, Edelman L. Early tracheostomy does not improve outcome in burn patients. J Burn Care Rehabil 2002; 23 (06) 431-438
    CrossrefPubMedGoogle Scholar
  • 36 Sabri A, Dabbous H, Dowli A, Barazi R. The airway in inhalational injury: diagnosis and management. Ann Burns Fire Disasters 2017; 30 (01) 24-29
    PubMedGoogle Scholar
  • 37 Lubianca Neto JF, Castagno OC, Schuster AK. Complications of tracheostomy in children: a systematic review. Rev Bras Otorrinolaringol (Engl Ed) 2022; 88 (06) 882-890
    PubMedGoogle Scholar
  • 38 Fernandez-Bussy S, Mahajan B, Folch E, Caviedes I, Guerrero J, Majid A. Tracheostomy tube placement: early and late complications. J Bronchology Interv Pulmonol 2015; 22 (04) 357-364
    CrossrefPubMedGoogle Scholar
  • 39 Rodeberg DA, Easter AJ, Washam MA, Housinger TA, Greenhalgh DG, Warden GD. Use of a helium-oxygen mixture in the treatment of postextubation stridor in pediatric patients with burns. J Burn Care Rehabil 1995; 16 (05) 476-480
    CrossrefPubMedGoogle Scholar
  • 40 Herman J, Baram M. In the midst of turbulence, heliox kept her alive. Ann Am Thorac Soc 2017; 14 (03) 452-455
    CrossrefPubMedGoogle Scholar
  • 41 Han TH, Teissler H, Han RJ, Gaines JD, Nguyen TQ. Managing difficult airway in patients with post-burn mentosternal and circumoral scar contractures. Int J Burns Trauma 2012; 2 (02) 80-85
    PubMedGoogle Scholar
  • 42 Kumar B, Vadaje K, Sethi S, Singh A. Failed intubating laryngeal mask airway-guided blind endotracheal intubation in a severe postburn contractured neck patient. Acta Anaesthesiol Belg 2011; 62 (02) 95-99
    PubMedGoogle Scholar
  • 43 Khundkar SH. 4.5 - neck burn reconstruction. In: Chang J. ed. Global Reconstructive Surgery. London: Elsevier; 2019: 255-262
    Google Scholar
  • 44 Sheridan RL, Ingelfinger JR. Fire-related inhalation injury. N Engl J Med 2016; 375 (05) 464-469
    CrossrefPubMedGoogle Scholar
  • 45 Kupas DF, Kauffman KF, Wang HE. Effect of airway-securing method on prehospital endotracheal tube dislodgment. Prehosp Emerg Care 2010; 14 (01) 26-30
    CrossrefPubMedGoogle Scholar
  • 46 Whitley AB, Nygaard RM, Endorf FW. Reduction of pressure-related complications with an improved method of securing endotracheal tubes in burn patients with facial burns. J Burn Care Res 2018; 39 (01) 117-120
    PubMedGoogle Scholar
  • 47 Xue FS, Luo MP, Liao X. Intra-oral stabilisation of the reinforced tracheal tubes using the surgical suture. Anaesthesia 2008; 63 (09) 1017-1019
    CrossrefPubMedGoogle Scholar
  • 48 Jensen NF, Kealey GP. Securing an endotracheal tube in the presence of facial burns or instability. Anesth Analg 1992; 75 (04) 641-642
    CrossrefPubMedGoogle Scholar
  • 49 O'Hara D, Oakey S, Shelley O. Securing tracheal tubes in facial burns. Br J Anaesth 2009; 103 (03) 458-459
    CrossrefPubMedGoogle Scholar
  • 50 Assi P, Quiroga L, Gerold K, Caffrey J. Endotracheal tube fixation in patients with facial burns, what are the options?. Eplasty 2018; 18: ic19
    PubMedGoogle Scholar
  • 51 Woodson L, Sherwood E, Kinsky M. et al. Anesthesia for burned patients. In: DN H. ed. Total Burn Care. 5th ed:. Elsevier Inc; 2018: 131-154
    Google Scholar
  • 52 Bhat VR, Venkateshwaran G. A secure method of nasotracheal tube fixation using an infant feeding tube. Anesth Analg 2004; 99 (05) 1352-1354
    CrossrefPubMedGoogle Scholar
  • 53 Rooney KD, Poolacherla R. Use of the nasal bridle to secure fixation of an endotracheal tube in a child with facial blistering secondary to toxic epidermal necrolysis. Burns 2010; 36 (08) e143-e144
    CrossrefPubMedGoogle Scholar
  • 54 Toussaint J, Singer AJ. The evaluation and management of thermal injuries: 2014 update. Clin Exp Emerg Med 2014; 1 (01) 8-18
    CrossrefPubMedGoogle Scholar
  • 55 Gray RM, Rode H. Intra-operative endotracheal tube stabilisation for facial burns. Burns 2010; 36 (04) 572-575
    CrossrefPubMedGoogle Scholar