Airway in the Acute Burn — Intubate Early
⏱️ Why "early" is the whole message
- Progressive oedema of the face, tongue, pharynx and larynx develops over hours as resuscitation fluid is given — a airway that is manageable now may be impossible in two hours.
- If there are features of inhalation injury (facial/neck burns, singed nasal hair, carbonaceous sputum, hoarseness, stridor, enclosed-space fire), secure the airway early with an oral endotracheal tube while it is still achievable.
- Use an uncut, appropriately large ETT — the face will swell, and a cut tube can retract; a larger tube also allows later bronchoscopy/toilet.
- Anticipate a difficult airway: senior help, difficult-airway cart, videolaryngoscope and flexible scope ready; avoid burning bridges (maintain spontaneous ventilation if severe distortion).
Airway in the Healing / Contracted Burn
Weeks to months later, the same patient returns for grafting or contracture release. Now the problem is scarring and contracture, and the airway concerns dominate the pre-anaesthetic assessment (straight from Dr. Tanya's notes):
Why it is difficult
- Neck contractures → fixed flexion, ↓ neck extension → poor laryngoscopy view & difficult mask seal
- Peri-oral / facial contractures & microstomia → ↓ mouth opening → device won't fit
- Facial burns → difficult mask ventilation (no seal)
- Distorted anatomy from previous grafts
The plan
- Formulate an explicit airway plan A → B → C, and always have alternatives ready
- Difficult-airway cart: videolaryngoscope, flexible intubating scope, supraglottic devices, bougie, exchange catheter, range of tube sizes
- Prefer inhalational induction ≫ IV induction (maintain spontaneous ventilation) when a difficult airway is anticipated — Dr. Tanya's note: "inhalational induction >> IV induction"
- Awake fibreoptic intubation for the most severe fixed contractures/microstomia; surgical contracture release under LA/ketamine may first improve mouth opening & neck movement before the definitive graft under GA
- Difficult venous cannulation → plan access early (scarred skin)
Sequencing pearl: for a neck contracture, the surgeon can sometimes release the band under local anaesthetic / ketamine sedation first — this restores neck extension and mouth opening, converting a feared airway into a routine one for the main grafting procedure.