Bronchoscopy and Laryngoscopy Findings As Indications for Tracheotomy in the Burned Child

ORIGINAL ARTICLE Bronchoscopy and Laryngoscopy Findings as Indications for Tracheotomy in the Burned Child

Michael E. Prater, MD; Ronald W. Deskin, MD

Objective: To determine possible indications for tra- such as glottic webs, subglottic stenosis, and tracheoma- cheotomy in the burned child based on bronchoscopic lacia, were noted. and laryngoscopic findings. Results: Indications for tracheotomy included 6 for air- Design and Setting: A retrospective case study of all way obstruction, 6 for prolonged intubation, 6 for pul- patients admitted to a tertiary children’s burn center. monary cleansing, and 1 for endotracheal tube complications (subglottic stenosis). When examined by Participants: All children admitted with burn inhala- bronchoscopy and laryngoscopy, 17 of 19 children had tion injury between 1990 and 1995 (n = 211). significant airway edema, 10 had carbonaceous material in the airway, and 3 had ulcerations in the airway. Intervention: All patients underwent laryngoscopy and bronchoscopy and 19 underwent tracheotomy, with 5 tra- Conclusions: Tracheotomy is indicated in the burned child cheotomy tubes placed emergently. when significant airway edema is present. Failure to place a tracheotomy tube in these cases leads to a high incidence Main Outcome Measures: Observations during lar- of immediate tracheotomies (26%). There was no evidence yngoscopy and bronchoscopy included erythema, edema, of clinically significant infection attributable to tracheotomy. carbonaceous material, ulcerations, and bronchial mu- The number of airway complications due to tracheotomy cous casts. The supraglottis, glottis, and subglottis were was no higher than from endotracheal intubation. analyzed separately, when possible. Any sepsis resulting from tracheotomy was determined. Complications, Arch Otolaryngol Head Neck Surg. 1998;124:1115-1117

HERE REMAINS controversy Several studies have long been quoted in the literature regarding as reasons to avoid tracheotomy in the the timing and necessity of burned child. In separate studies in the tracheotomy in the burned early 1980s, Moylan5 and Lund and col- child. Miller and Gray1 ad- leagues6 both recommended avoiding a tra- vocateT serial bronchoscopies and early cheotomy, claiming an increase in long- tracheotomy (within 6-8 days) in the term sequelae, including tracheal stenosis, presence of persistent airway problems. laryngeal stenosis, tracheomalacia, and the Calhoun and Deskin2 report that no formation of granulation tissue. Gianoli variables relating to the initial airway and Miller7 reported a 13% incidence of care in burned children were associated early complications and a 38% incidence with the need for tracheotomy, and they of late complications in children younger suggest tracheotomy be reserved for than 1 year undergoing tracheotomy. Eck- patients who cannot be intubated or hauser and colleagues8 found increased who fail extubation. Herndon3 opines mortality from sepsis in those who under- that there are no specific rules govern- went tracheotomy, possibly due to seed- ing the necessity of a tracheotomy in ing of the trachea with bacteria. pediatric burn patients and suggests Endotracheal intubation, however, is each patient be judged individually. In not without controversy. In a prospec- clinical practice, the airway in burned tive study of 200 patients who were intu- 9 From the Department of children is primarily managed with bated for between 2 and 24 days, Whited Otolaryngology, University of endotracheal intubation, with trache- divided intubated patients into 3 catego- Texas Medical Branch, otomy reserved for airway obstruction ries: those intubated for 2 to 5 days, those Galveston. or pulmonary cleansing.2-4 intubated for 6 to 10 days, and those in-

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©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 Findings on Bronchoscopy and Laryngoscopy SUBJECTS AND METHODS No. of Tubes No. of No. Who Placed The records of all children admitted between 1990 Site and Finding Patients Died Emergently and 1995 to the Shriners Burns Institute were re- Edema viewed, and those with inhalation injury were ex- Supraglottis and glottis 3 0 2 amined. All patients who had a tracheotomy tube Supraglottis, glottis, 14 4 3 placed were studied. Data recorded included name, and subglottis age, percentage of total body surface area burned, per- Soot or casts centage area of third-degree burns, whether the pa- Supraglottis and glottis 4 0 0 tient was intubated, length of intubation, whether tra- Supraglottis, glottis, 64 0 cheotomy was performed, length of tracheotomy and subglottis intubation, whether the patient underwent decan- Ulcerations nulation, complications due to tracheotomy, com- Found 3 2 0 plications due to endotracheal intubation, infection Not found 16 2 0 resulting from tracheotomy, bronchoscopic findings of edema, ulceration, and carbon in the supra- glottic, glottic, and subglottic areas (performed by vari- ous clinicians, including anesthesiologists and AIRWAY MANAGEMENT otolaryngologists), the indication for tracheotomy, and whether the patient died. Sixteen (84%) of the 19 children requiring tracheotomy were initially endotracheally intubated. Two of the remaining 3 eventually required an immediate tracheotomy due to airway obstruction and an inability to pass an endotracheal tube. The indications for tra- tubated for 11 to 24 days. He found significant short- and cheotomy were airway obstruction from edema (6 long-term sequelae in all 3 groups, but much more pro- [32%]; 5 of these were placed emergently); predicted nounced in those intubated longer than 10 days. Com- long-term intubation (6 [32%]); pulmonary cleansing mon complications included subglottic stenosis, poste- (6 [32%]); and complications of intubation (subglottic rior laryngeal stenosis, and granulation tissue formation. stenosis, 1 [5%]). Complications ranged from 2% of those intubated for a short period to 14% for those intubated longer than 10 FINDINGS ON DIRECT LARYNGOSCOPY days.9 In a more recent study, Tom and Miller10 report AND BRONCHOSCOPY that some of the complications thought secondary to tracheotomy, including laryngeal and even subglottic ste- Findings on bronchoscopy were divided into 3 anatomi- nosis, may in fact be long-term sequelae of intubation. cal regions: the supraglottis, the glottis, and the subglot- The purpose of this study was to determine pos- tis. Bronchoscopic findings were categorized as normal; sible indications for tracheotomy in the severely erythematous and/or edematous; ulcerated and/or ne- burned child by examining findings on bronchoscopy crotic; and carbonaceous and/or with casts. Seventeen and laryngoscopy. The medical records of all children (89%) of 19 patients had initial findings of inflamma- admitted to the Shriners Burns Institute, Galveston, tion and edema, 3 (16%) had ulcerations, and 10 (53%) Tex, with inhalation injury between 1990 and 1995 had carbon in the airway. Four died, all with edema and were retrospectively studied, with an emphasis on carbonaceous deposits in all 3 regions in the airway the comparison between bronchoscopic findings (Table). (routinely performed on all inhalation victims) and the subsequent placement of a tracheotomy tube. To AIRWAY COMPLICATIONS address questions in the literature regarding an increased incidence of airway sequelae and infection There were 7 children with a total of 9 complications following tracheotomies compared with endotracheal secondary to airway management. Six of the complica- intubation, the number of airway complications and tions were due to endotracheal entubation (2 cases infections due to tracheotomy and endotracheal intu- of subglottic stenosis and 4 cases of pneumomediasti- bation were compared for this population. num or pneumothorax) and 3 to the tracheotomy (2 cases of tracheomalacia and 1 of pneumomediasti- RESULTS num). In no instance was sepsis or infection docu- mented to be caused by the tracheotomy. Both cases of OVERALL subglottic stenosis required surgical intervention, whereas both cases of tracheomalacia resolved during Of the 211 patients admitted to the Shriners Burns In- observation. All instances of pneumothorax and pneu- stitute with inhalation injury, 19 (9%) underwent tra- momediastinum were related to high airway pressures. cheotomy. The average age was 4.2 years, the average to- Three children were not decannulated (2 due to tal body surface area burned was 61%, and the average anoxic brain injury and 1 due to recurrent aspiration area of third-degree burn was 53%. pneumonia).

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©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 VOICE ASSESSMENT Accepted for publication July 9, 1998. Presented at the 1998 annual meeting of the Ameri- All voices and airways were subjectively assessed by the can Society of Pediatric Otolaryngology, under the aus- child’s caregiver. All results were described as normal or pices of the Combined Otolaryngology Spring Meeting, Palm near normal. Beach, Fla, May 13, 1998. Reprints: Ronald W. Deskin, MD, Department of Oto- COMMENT laryngology, University of Texas Medical Branch, 7.104 Sealy Annex, Rte 0521, Galveston, TX 77555. Surgeons generally prefer to manage the airway of burned children with an endotracheal tube and reserve REFERENCES tracheotomy for those who cannot be intubated or 2,3 who fail extubation. However, this study shows that 1. Miller RP, Gray SD. Airway reconstruction following laryngotracheal thermal trauma. those children with significant airway edema or car- Laryngoscope. 1988;98:826-829. bonaceous deposits seen during bronchoscopy and 2. Calhoun KH, Deskin RW. Long term airway sequelae in a pediatric burn popu- laryngoscopy and managed with an endotracheal tube lation. Laryngoscope. 1988;98:721-725. 3. Herndon DN. Total Burn Care. Philadelphia, Pa: WB Saunders Co; 1996. are at risk for immediate tracheotomy (26%). The 4. Wilson D, Deskin RW. Pediatric tracheotomy. In: Quinn FB. Dr. Quinn’s Online immediate tracheotomy is usually performed due to Textbook of Otolaryngology. Available at: http://www.utmb.edu/oto. Accessed accidental extubation and an inability to reinsert the June 1997. endotracheal tube. This finding suggests that trache- 5. Moylan J. Inhalation and burn injury. Surg Clin North Am. 1980;60:1533-1540. otomy is indicated in those children with significant 6. Lund T, Goodwin C, McManus W. Upper airway sequelae in burn patients. Ann Surg. 1985;201:374-382. airway edema seen on initial bronchoscopy and laryn- 7. Gianoli GJ, Miller RH. Tracheotomy in the first year of life. Ann Otol Rhinol Laryn- goscopy. Bacterial inoculation of the trachea due to gol. 1990;99:896. the tracheotomy did not lead to clinically significant 8. Eckhauser FE, Billote S, Burke F. Tracheotomy complicating massive burn in- infection in this population. The number of cases of jury. Am J Surg. 1977;127:418-423. 2 9. Whited PE. A prospective study of laryngotracheal sequelae in long term intu- tracheomalacia due to tracheotomy and the number bation. Laryngoscope. 1984;94:367-377. of cases of subglottic stenosis due to the endotracheal 10. Tom LWC, Miller L. Endoscopic assessment in children with tracheotomies. Arch tube2 were identical. Otolaryngol Head Neck Surg. 1993;119:321-324.

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