III_A. CONTINUED UPPER AIRWAY INJURY
Pathophysiology:
Upper airway and facial edema caused by the
heat-induced tissue and mucosal damage begins
to resolve between 2 and 4 days, with
superficial injuries. However, with
full-thickness burns, edema, both external and
in the oropharynx and larynx, will resolve
more slowly. Occasionally a release of deep
neck eschar is necessary to allow restoration
of venous drainage and edema resolution. The
upper airway mucosal damage leads to increased
production of oral secretions along with
secondary bacterial colonization of the
damaged tissue.
Treatment:
Continued airway maintenance with an
endotracheal tube may be required. Placement
of the patient in the head-elevated position
30o to 45o will allow
faster resolution of edema. Aggressive mouth
care to avoid mucosal infection, particularly
with anaerobes, is necessary because
aspiration of the infected saliva will lead to
airways infection.
The decision when to extubate is a difficult
one because there is no good test for
determining the adequacy of airway patency.
Laryngoscopy to determine the presence of cord
edema is helpful, as is deflation of the cuff
after suctioning of the oropharynx, to
determine if air moves around the tube. The
latter test is useful if an air leak is
present around the tube. However, the lack of
an air leak may simply reflect a large tube in
a small trachea. Edema of the false cords and
oropharynx as well as external compression
from a neck burn can also impair the airway
even if minimal cord edema is present.
Therefore one must be prepared to re-intubate
because no test of airway patency is
foolproof.
There is certainly a concern about maintaining
a tube in place too long because laryngeal
damage can result. However, loss of the airway
can be fatal if residual edema substantially
impedes re-intubation.
Previous
Nextd
|
