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CASE REPORT Table of Contents  
Ahead of print publication
Difficult airway following inhalational burn injury in a child


 Department of Anaesthesia and Critical Care, Government Medical College, Jammu, Jammu and Kashmir, India

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Date of Submission03-Jul-2022
Date of Acceptance22-Sep-2022
Date of Web Publication11-Nov-2022
 

  Abstract 


Airway management in a burn victim poses special challenges for the anaesthesiologist not only during the acute phase but also after delayed consequences have set in resulting in difficulty in airway management. We report a 5-year-old boy who was admitted to the Department of Paediatrics with biphasic stridor 2 months following inhalational burn injury. He presented with complaints of difficulty in swallowing solid food, hoarseness of voice for the past 1 month and occasional difficulty in breathing for the past 10 days. Laryngoscopy using a #2 Macintosh blade revealed pharyngeal stenosis with grossly distorted airway anatomy. The patient was finally intubated after great difficulty with a 3.5 mm internal diameter endotracheal tube using a fibrescope.

Keywords: Airway management, burns, difficult airway, pharyngeal stenosis


How to cite this URL:
Wakhloo R, Gurtoo H, Gandotra M, Gupta S. Difficult airway following inhalational burn injury in a child. Airway [Epub ahead of print] [cited 2022 Nov 28]. Available from: https://www.arwy.org/preprintarticle.asp?id=360983





  Introduction Top


Inhalational burn injury is one of the most challenging injuries for medical care providers. Airway management in a burn victim poses special challenge for the anaesthesiologist due to rapidly deteriorating changes in the airway during the acute phase requiring special management skills. Delayed consequences of inhalational burn injury can also result in structural airway changes that can cause difficulty in airway management.


  Case Report Top


A 5-year-old boy was admitted to the Department of Paediatrics in our hospital with biphasic stridor 2 months following inhalational burn injury. The patient had a history of inhalation of hot smoke through a chullah pipe 2 months earlier. At that time, the patient complained of a sudden bout of cough and burning sensation in the throat for which he was taken to a local dispensary in the village. He was given steam inhalation and a short course of steroid after which he felt some relief.

He presented now with complaints of difficulty in swallowing solid food, hoarseness of voice for the past 1 month and occasional difficulty in breathing for the past 10 days. On admission, the patient was conscious but the breathing was noisy with biphasic stridor which resolved spontaneously to recur in 24 h without any provocation. As his clinical condition did not improve, it was decided to do a diagnostic airway bronchoscopy. On preanaesthetic evaluation, the only positive finding was a few scattered crepitations over lung fields with no stridor. Oral examination revealed modified Mallampati Class II with a mouth opening of 2 fingers. There were no visible contractures or scars and neck movements were normal.

On arrival in the operating room, an intravenous (IV) line was secured with a 20 SWG cannula. The patient was premedicated with IV ondansetron 0.1 mg/kg and glycopyrollate 4 μg/kg. Monitoring was established with 3-lead electrocardiogram, noninvasive blood pressure and pulse oximeter. Preoxygenation was performed with 100% oxygen for 3 min at 8 l/min with appropriate-sized well-fitting face mask. Anaesthetic induction was done with titrated doses of IV ketamine (1 mg/kg) and propofol (2 mg/kg) till loss of consciousness. Once ventilation was possible, IV succinylcholine (2 mg/kg) was given.

When laryngoscopy was attempted with a #2 Macintosh blade, pharyngeal stenosis was identified. The entire airway anatomy was distorted due to fibrosis of all the surrounding structures. Only a small 5 mm opening was visible. The epiglottis was adherent and matted and appeared as a ball anteriorly. The faucial pillars were not identifiable separately [Figure 1]. On negotiating the fibrescope through the only pharyngeal opening, two small anteroposterior openings could be barely visualised which were presumed to be the trachea anteriorly and the oesophagus posteriorly. The trachea was confirmed after visualising the vocal cords using the fibrescope and an uncuffed 3.5 mm internal diameter endotracheal tube was advanced into the trachea under direct vision.
Figure 1: Fibrescopic view of pharyngeal stenosis with distorted anatomy

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Mechanical ventilation was started and maintained with a combination of oxygen:nitrous oxide in 50:50 ratio with halothane as inhalational agent. The patient was paralysed with atracurium 0.5 mg/kg. IV paracetamol (15 mg/kg) was used for analgesia. The intraoperative period was uneventful. A tracheostomy was performed at the end of surgery to bypass the pharyngeal stenosis and to decrease the work of breathing. It was anticipated that the child would subsequently need multiple surgeries to prevent the progression of oral fibrosis and assist the opening of pharynx. The anaesthetic was terminated and residual neuromuscular blockade was antagonised with neostigmine (50 μg/kg) and glycopyrollate (10 μg/kg).


  Discussion Top


Unanticipated difficult airway has a low but consistent incidence in general anaesthesia which can be a major cause of anaesthesia-related morbidity and mortality. The reported incidence of difficult intubation in general anaesthesia is 5.85%; cannot intubate situation is 0.35% and cannot ventilate-cannot intubate situation is 0.02%.[1] Three basic considerations before induction of general anaesthesia in a burn injury are - whether to consider awake intubation, whether to use a percutaneous technique or maintain spontaneous ventilation.[2] Fibreoptic bronchoscopy has been the gold standard for difficult intubations as it has the advantage of being flexible and steerable while allowing continuous visualisation of structures.[3] It also has a high success rate and reduces the incidence of intubation trauma in cases of anticipated difficult intubation with minimal use of general anaesthetics.[4],[5]

Inhalational burn injury mainly involves the structures of the airway above the carina. This is due to the combination of efficient heat dissipation in the upper airway, low heat capacity of air and reflex closure of the larynx.[6] The most commonly affected area in inhalational burn injury is the supraglottic region leading to upper airway oedema, obstruction, difficult visualisation and difficult intubation. Those patients who present early with symptoms such as hoarseness of voice, stridor, upper airway oedema, singed nasal hair and other signs of hypoxaemia should be intubated as early as possible to decrease further risk of complications. Inhalation of toxic fumes and chemicals usually result in injury to subglottic area due to cytokine-mediated inflammatory response initiating a cascade of hyperaemia, bronchospasm and disruption of the mucociliary barrier. The systemic effects occur in two distinct phases, a burn shock (ebb) phase followed by a hypermetabolic (flow) phase, first described by Cuthbertson in 1942.[7]

A thorough airway assessment should be done in every patient of inhalational burn injury as damage may be present even in the absence of outer cutaneous findings. Acute burn injury must be managed as per Advanced Trauma Life Support protocol and difficult airway should be anticipated in all burn patients. In many cases, clinical manifestations could be delayed for several days following exposure to an inhalation injury. Many patients present later on with scars, contractures and difficult mobility of the airway making further performance of any other surgical procedure difficult. In view of their lengthy recovery and prolonged rehabilitation, careful perioperative anaesthetic management assumes utmost importance. A retrospective study was conducted involving a difficult airway response team constituted by anaesthesiologists, otorhinolaryngologists and trauma surgeons working together as a multidisciplinary team.[8] Such a team-based approach resulted in the ability to secure the airway more often without the need for an emergency cricothyrotomy.


  Conclusion Top


This case underscores the importance of anticipating a difficult airway following any inhalational burn injury. Even if external manifestations are not present, there is a possibility of distorted airway anatomy as encountered in our patient. One must conduct a thorough clinical examination including a focused airway examination to identify airway-related problems. Being prepared for a possible difficult intubation and planning a strategy accordingly will ultimately result in patient safety.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that the name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Crosby ET, Cooper RM, Douglas MJ, Doyle DJ, Hung OR, Labrecque P, et al. The unanticipated difficult airway with recommendations for management. Can J Anaesth 1998;45:757-76.  Back to cited text no. 1
    
2.
Caplan CA, Benumof JL, Berry FA, Blitt CD, Bode RH, Cheney FW, et al. Practice guidelines for management of the difficult airway: An updated report by the American society of anesthesiologists task force on management of the difficult airway. Anesthesiology 2003;98:1269-77.  Back to cited text no. 2
    
3.
Bokhari A, Benham SW, Popat MT. Management of unanticipated difficult intubation: A survey of current practice in the Oxford region. Eur J Anaesthesiol 2004;21:123-7.  Back to cited text no. 3
    
4.
Mathur R, Jain PK, Chakotiya PS, Rathore P. Anaesthetic and airway management of a post-burn contracture neck patient with microstomia and distorted nasal anatomy. Indian J Anaesth 2014;58:210-3.  Back to cited text no. 4
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5.
Ovassapian A, Tuncbilek M, Weitzel EK, Joshi CW. Airway management in adult patients with deep neck infections: A case series and review of the literature. Anesth Analg 2005;100:585-9.  Back to cited text no. 5
    
6.
Pruitt BA Jr., Flemma RJ, DiVincenti FC, Foley FD, Mason AD Jr., Young WG Jr. Pulmonary complications in burn patients. A comparative study of 697 patients. J Thorac Cardiovasc Surg 1970;59:7-20.  Back to cited text no. 6
    
7.
Cuthbertson DP, Angeles Valero Zanuy MA, León Sanz ML. Post-shock metabolic response. 1942. Nutr Hosp 2001;16:176-82.  Back to cited text no. 7
    
8.
Hillel AT, Pandian V, Mark LJ, Clark J, Miller CR, Haut ER, et al.. A novel role for otolaryngologists in the multidisciplinary difficult airway response team. Laryngoscope 2015;125:640-4.  Back to cited text no. 8
    

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Correspondence Address:
Megha Gandotra,
6D/92 Upper Shiv Nagar, Jammu - 180 005, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None



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