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

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 evaluation; airway management; bronchoscopy; pediatric burn.

Fig. 1

( A ) An acute burn patient was admitted several days after flame burns to the face and neck. Note the severe orbital and oral edema, an indicator of laryngeal edema identified by nasopharyngoscopy. ( B ) A patient presented to our hospital with severe facial contractures, mandating a nasal fiberoptic intubation for reconstructive surgery.

Fig. 2

Severe facial and airway edema in an acute burn patient during the first operative debridement. (see also Fig. 9 ). This image is provided courtesy of Assi et al 2018.

Fig. 3

A patient with severe head and neck contractures, which developed after a 95% flame burn. A nasal ETT, placed by fiberoptic intubation and ketamine-only sedation, is in place. Prior to the widespread availability of ultrasound for peripheral intravenous catheter placement, this patient required intramuscular medications followed by a central venous catheter. After many successful anesthetics and surgeries for burn scars, he was able to attend college.

Fig. 4

The ability to perform jaw-thrust maneuver improves the anatomic view for fiberoptic intubation. This is not attainable with severe neck and mandibular contractures. ( A ) Only the vallecular space above the epiglottis is seen. ( B ) A jaw-thrust improves vocal cord visualization.

Fig. 5

Fiberoptic nasopharyngoscopy images of ( A ) normal airway and ( B ) edematous airway requiring urgent intubation. This image is provided courtesy of Toussaint and Singer 2014.

Fig. 6

LMA placement in a post-commissuroplasty patient who presented with severe microstomia. The bronchoscope adaptor facilitated a tracheal assessment of prior inhalation injury. Note the soft skin without contractures overlying the lateral neck and mandible (allowing easy mask ventilation). Anticipating airway obstruction postoperatively, an ETT adaptor attached to a nasal trumpet is in place.

Fig. 7

Umbilical (twill) cotton ties or white surgical tape can be wrapped around the head, above and below the ears, and tied around the ETT.

Fig. 8

A heavy braided suture, such as 0-silk, is placed circumferentially around the lingual base of the teeth.

Fig. 9

ETT fixation using intermaxillary fixation screw in a patient with severe facial and cervical burns.

Fig. 10

An oral ETT can be secured to a loop created by a red rubber (Rob-Nel) catheter or nasogastric tube, usually 6 or 8 French, passed through the nose, and brought out of the mouth. This image is provided courtesy of Woodson et al 2018.

Fig. 11

A nasotracheal tube can be safely secured with a loop of umbilical (twill) tape around the bony nasal septum. ( A ) Red rubber catheters have been passed through each naris and pulled from the oropharynx with McGill forceps. One end of the tape is tied to each of the catheters. When the catheters are pulled from the nose, the tape can be tied in a loop around the septum. ( B ) ETT, nasogastric tube, and a nasoduodenal feeding tube are all secured in place after being tied to the septal tie. This image is provided courtesy of Woodson et al 2018.