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A Novel Rescue Technique for Difficult Intubation and Difficult Ventilation
Published on: January 17, 2011
Uncuffed endotracheal tubes should not be used in seriously burned children
1Burn Surgery Service, Shriners Hospital for Children, Boston, MA, USA.
Insights
Uncuffed endotracheal tubes can cause complications in severely burned children, necessitating urgent replacement due to air leaks. Early use of cuffed endotracheal tubes is recommended for these pediatric patients.
Area of Science:
- Pediatric Critical Care
- Burn Management
- Airway Management
Background:
- Uncuffed endotracheal tubes are commonly used in pediatric patients.
- Severely burned children often require prolonged mechanical ventilation.
- Complications can arise from inadequate airway management in this population.
Purpose of the Study:
- To document a complication associated with uncuffed endotracheal tube placement in critically burned children.
- To evaluate the necessity of urgent endotracheal tube replacement in this cohort.
- To provide recommendations for optimal airway management in pediatric burn patients.
Main Methods:
- Retrospective review of cases at a verified pediatric burn center.
- Analysis of acutely burned children requiring urgent replacement of uncuffed endotracheal tubes with cuffed tubes over a 5-year period.
- Identification of reasons for tube change, including uncontrollable air leak and worsening respiratory failure.
Main Results:
- Five children (3 boys, 2 girls) with an average age of 2.2 years and 41% body surface area burns required urgent tube change.
- Mechanical ventilation averaged 23.6 days, with tube changes occurring approximately 64 hours after burn unit arrival.
- Massive facial edema complicated tube changes, highlighting the potential danger; initial cuffed tube placement could have prevented this intervention.
Conclusions:
- Low-pressure cuffed endotracheal tubes should be used in critically burned children requiring significant mechanical ventilatory support, irrespective of age.
- This approach can prevent complications such as uncontrollable air leaks and the need for emergent tube replacement.
- Early appropriate airway management improves outcomes and potentially reduces the need for tracheostomy.
Objective:
To document a complication associated with placement of uncuffed endotracheal tubes in seriously burned children.
Design:
Retrospective review.
Setting:
Verified pediatric burn center.
Patients/Subjects:
Acutely burned children requiring urgent replacement of uncuffed endotracheal tubes with cuffed endotracheal tubes over a 5-yr period.
Interventions:
In all children, the reason behind the need for urgent tube change was uncontrollable air leak, despite properly sized uncuffed endotracheal tubes, as respiratory failure progressed and compliance worsened.
Results:
: These two girls and three boys had an average age of 2.2 +/- 1.0 yrs, burn size of 41% +/- 6.1% of the body surface, and subsequently required mechanical ventilation for an average of 23.6 +/- 6.3 days. Urgent tube change was required an average of 64.2 +/- 43.8 hrs after arrival in the burn unit (87.6 +/- 49.4 hrs after injury). Although successful in all children, massive facial edema rendered tube change potentially dangerous. The intervention would not have been necessary if cuffed endotracheal tubes had been placed initially. All children went on to survive their injury, without further tube change or tracheostomy.
Conclusion:
If children are critically burned and expected to require more than transient mechanical ventilatory support, low-pressure cuffed endotracheal tubes should be placed, regardless of the child's age.
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