Airway management of recovered pediatric patients with severe head and neck burns: a review

Abstract

There are approximately 10,000 pediatric burn survivors in the United States each year, many of whom will present for reconstructive surgery after severe burns in the head and neck (1). These recovered burn victims, who are beyond the acute phase of injury, often have significant scarring and contractures in the face, mouth, nares, neck, and chest, which can make airway management challenging and potentially lead to a 'cannot intubate, cannot ventilate' scenario (2). Although numerous cases have been presented in the literature on this topic (3-17), there are no comprehensive review articles on the unique challenges of airway management in the recovered pediatric burn patient with distorted airway anatomy. This article aims to provide a comprehensive review of airway management in such patients, focusing on challenges encountered during mask ventilation and tracheal intubation, as well as the role of surgical release of neck contractures to facilitate tracheal intubation. Lessons learned from all reported cases identified in a thorough literature search are incorporated into this review.

A Case of Severe Head and Neck Post-Burn Contractures: Fiberoptic Intubation through an I-Gel Laryngeal Mask Maintaining Spontaneous Ventilation

“…In this particular case, the patient experienced extreme anxiety facing medical procedures making impossible an awake approach. However, anesthesia induction may carry the risk of airway collapse due to loss of pharyngeal tone, negative intraluminal pressure and hypercapnia [1]. Inability to extend the neck and limitations on chin-lift and jaw thrust may compromise the possibility to overcome airway obstruction after induction.…”

“…Difficult intubation should also be expected. Maintenance of spontaneous ventilation during induction and intubation and avoidance of muscle relaxants is a better and safer option in these cases [1,4].…”

“…Careful evaluation in the post-burn patient with head and neck contractures is crucial since anatomical variations may be significant [1]. In the acute burn injury phase particular attention is paid to external and airway soft tissue damages [2].…”

“…In the acute burn injury phase particular attention is paid to external and airway soft tissue damages [2]. During the postburn phase, contractures in the face, neck and chest may result in upper airway obstruction, microstomia, subglottic stenosis, tracheomalacia, granuloma formation, fixation of the neck in a flexed position [1][2][3]. Severe facial and neck scars may predict difficult mask ventilation.…”

“…As literature on fiberoptic intubation through a laryngeal mask airway in these patients is scarce [1], we analyzed the airway management of an adolescent with severe post burn head and neck contractures. The patient was admitted at our hospital for elective reconstructive surgery of the upper limb.…”