What is the most appropriate route for securing the airway in a patient with face, neck, and upper chest burns, inhalation injury, and airway obstruction, presenting with hypoxemia (oxygen saturation less than 90%)?

Airway Management in a Burn Patient with Inhalation Injury and Airway Obstruction

Orotracheal intubation is the most appropriate route for securing the airway in this critically ill burn patient with face, neck, and upper chest burns, inhalation injury, airway obstruction, and hypoxemia. 1

Assessment of the Situation

• The patient presents with classic features of thermally-induced airway obstruction including inhalation injury, airway obstruction, and hypoxemia (SpO2 < 90%), which are clear indications for urgent intubation 1
• The presence of face, neck, and upper chest burns suggests potential for progressive airway edema and worsening obstruction, making immediate definitive airway management essential 1
• The patient is already in "bad condition" with an existing airway tube, indicating the need for a definitive airway solution 1

Rationale for Orotracheal Intubation

• Orotracheal intubation is considered the gold standard for airway control in emergency situations and allows for:

  • Assured airway patency
  • Easy removal of secretions from the tracheobronchial tree
  • Protection against aspiration
  • Regulated ventilation 2

• Modified rapid sequence intubation (RSI) is the most appropriate technique for securing the airway in burn patients with inhalation injury 1

• Important considerations for orotracheal intubation in this scenario:

  • Use of an uncut tracheal tube to allow for subsequent facial swelling
  • Videolaryngoscopy if available to increase intubation success
  • Use of a bougie to facilitate intubation if direct laryngoscopy is used 1

Why Not Other Options?

• Nasotracheal intubation: Not recommended in this scenario due to:

  • Potential for bleeding in the setting of facial burns
  • Risk of creating false passages in the presence of nasal trauma or edema
  • Need for subsequent conversion to oral tube 1

• Surgical cricothyroidotomy: Should be reserved as a rescue technique when orotracheal intubation fails, not as a first-line approach 1

  • Surgical airway is more difficult to perform and has higher complication rates compared to orotracheal intubation
  • Should only be considered if orotracheal intubation is impossible or fails 3, 4

• Tracheostomy: Not appropriate as an emergency first-line procedure due to:

  • Technically more challenging and time-consuming than orotracheal intubation
  • Higher risk of bleeding and other complications in the emergency setting
  • Should be considered as a planned procedure after initial stabilization if prolonged ventilation is anticipated 1, 4

Special Considerations

• Carbon monoxide and cyanide poisoning may be present, which can worsen tissue hypoxia despite normal oxygen saturation readings 1
• Large volume fluid resuscitation will worsen airway swelling, making early definitive airway management crucial 1
• After securing the airway, insert a gastric tube as this may become difficult later due to facial swelling 1
• Avoid succinylcholine from 24 hours post-injury to avoid hyperkalemia 1

Management Algorithm

1. Position patient appropriately (head-up if possible) 1
2. Pre-oxygenate thoroughly 1
3. Proceed with modified RSI for orotracheal intubation 1
4. Use videolaryngoscopy if available and operator is skilled 1
5. Have rescue devices and surgical airway equipment immediately available as backup 1
6. If orotracheal intubation fails after a maximum of two attempts, do not delay in proceeding to surgical airway (cricothyroidotomy) 3, 4

In this critically ill burn patient with signs of inhalation injury and airway obstruction, prompt orotracheal intubation represents the safest and most effective approach to secure the airway and improve oxygenation, with surgical techniques reserved only for rescue situations when orotracheal intubation fails.