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Pulmonary
Problems in the Early Post-Resuscitation
Period
(Day
2-6)
There are
five major abnormalities that can be seen
during this period that will impair
pulmonary function. Recognition of these
potential problems will allow preventive
measures to be initiated before severe
dysfunction results. A major impediment to
an aggressive surgical approach to the burn
wound during this period is pulmonary
dysfunction.
Major
Pulmonary Abnormalities
- Continued
Upper Airway Obstruction
- Decreased
Chest Wall Compliance
- Tracheobronchitis
from Inhalation Injury
- Pulmonary
Edema
- Surgery
- and Anesthesia-Induced Lung
Dysfunction
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CONTINUED
UPPER AIRWAY OBSTRUCTION
Pathophysiology:
- Continued
airways edema
- Mucosal
damage with slough
- Increased
oral secretions
- Bacterial
colonization
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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, excision
of deep neck eschar is necessary to allow
expansion of the underlying soft tissue,
which then restores venous drainage and
allows 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
endotracheal intubation until
edema resolves
- Head
elevated position
- Avoid
excessive tube motion
- Vigorous
oral hygiene (add Nystatin if
on antibiotics)
- Avoid
cuff over-inflation (< 25cm
H20)
- Consider
tracheostomy thru unburned
tissue or neck graft if airway
safety of concern
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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. Given this fact,
extubation should not be performed unless
re-intubation is feasible.
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.
WHEN
TO EXTUBATE
- Direct
evidence of mucosal edema
resolution (visualization)
- Evidence of
adequate facial edema
resolution to allow for
re-intubation
- Evidence of
adequate cough and ability to
protect the airway
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Click
the Image to Enlarge
Persistent
Facial Edema precludes safe re-intubation if
needed
  
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