Airway Management

Goal: Avoid airway obstruction due to inhalation injury or burn-induced swelling.

- Patients with smoke inhalation injury may present with a range of symptoms in terms of severity.
- Patients with severely symptomatic smoke inhalation injury (e.g., respiratory distress, stridor) require immediate definitive airway (cuffed tube in trachea) because they are at risk of immediate airway loss. Oxygenate and ventilate.
- All patients with burns covering >40% TBSA should be intubated because total-body swelling will tend to obstruct the airway. Patients with facial burns around the mouth may require intubation (Figure 1).
- Best: Rapid-sequence intubation by skilled provider, followed by continuous sedation and airway maintenance, supplemental oxygen, portable ventilator.
- Better: Cricothyroidotomy followed by continuous sedation and airway maintenance, supplemental oxygen via an oxygen concentrator, portable ventilator.
- Minimum: Cricothyroidotomy, ketamine, ambu bag with positive end-expiratory pressure (PEEP) valve.

Figure 1: Severe Facial Burns With Airway Secured

Notes:

- Patients with mild symptoms of smoke inhalation injury (e.g., some cough, no respiratory distress) can be observed.
- Burns or explosions in a closed space are associated with higher risk of inhalation injury than burns occurring in open areas.
- Supraglottic airway (e.g., laryngeal mask airway [LMA], King LT [Ambu, http://www.ambuusa.com/], or Combitube [Medtronic Minimally Invasive Therapies, http://www.medtronic.com/covidien]) is not appropriate because edema will continue to increase over 48 hours and these tubes do not overcome vocal-cord edema.
- Endotracheal tube must be secured circumferentially around the neck using cotton ties or similar. Tape does not stick to the face well enough in burn patients.
- Place nasogastric (or orogastric) tube to decompress stomach in intubated patients.
- Perform frequent endotracheal suction of intubated patients to ensure tube patency and remove mucus/debris (approximately once an hour or more frequently if oxygen saturation [SpO2] drops).
- If there is evidence of inhalation injury, use 3–5mL of endotracheal saline to facilitate suctioning and prevent tube insipation and obstruction.
- Monitoring end-tidal CO2 is an important capability for all intubated patients. A rising end-tidal CO2 could indicate clogging of endotracheal tube or poor ventilation from another cause (e.g.,bronchospasm, tight eschar across chest).
- Use PEEP on all intubated patients.
- Perform a surgical escharotomy of the chest for tight, circumferential, full-thickness burns that impair breathing. Incision goes through the full thickness of the burn and into the fat (Appendix A). Expect some pain and bleeding.
- Use bronchodilators (e.g., albuterol inhaler) for intubated patients with inhalation injury, if available.
- Ventilator management of burn patients can be complicated and evolve as pulmonary conditions change due to volume overload/edema and acute respiratory distress syndrome (ARDS). Telemedicine consultation with skilled providers is recommended.