Our patient was safely switched from oral to nasal intubation using a tracheal tube guide. Although nasotracheal intubation was a suitable option, there were concerns regarding upper airway edema due to the large burn area and facial burns. Since the patient was in the acute phase of a burn injury, a tracheal tube guide was used considering the risk of difficult airway management. A tracheal tube can be safely managed for 2 weeks without tracheostomy in pediatric patients with facial burns.
In children, nasal intubation is not only used in otolaryngological and dental surgery but also used in the PICU for post-cardiac surgery management, since unplanned extubation is reported to be less frequent with nasal intubation than with oral intubation [1]. Nasotracheal intubation is generally associated with less stimulation of pharyngeal reflex and less discomfort than endotracheal intubation; in addition, with the former, oral care is easier, and the tubes are less likely to bend and are less likely to be bitten. With endotracheal intubation, it is difficult to secure the tracheal tube, and there is a risk of accidental extubation due to tongue movement. Hence, nasotracheal intubation is beneficial for children in whom it is difficult to maintain the tracheal tube position [5].
In burn patients, tracheal intubation should be considered in cases of airway burns, burn area of more than 40%, or burns of the face or neck [6, 7]. In children, fatality rates have been reported to increase when the burn area exceeds 60% [8]. In adults, tracheostomy should be considered for patients with severe burns, as in the present case, because prolonged ventilatory management is expected. However, few studies have shown the benefits of tracheostomy in children [9]. Regardless of the indications, tracheostomy is not recommended for children because it can lead to delayed language development [10]. In addition, if there are burns on the anterior neck, tracheotomy should be performed after skin grafting [11]; hence, airway management techniques without tracheostomy are needed for pediatric patients with severe burns, including facial and cervical burns.
Various methods for switching from oral to nasal intubation have been reported [12,13,14,15]. Many methods involve bronchoscopy [12, 15] or a short period of airway loss. Children are more prone to obstruction by airway edema than adults; therefore, an appropriate method of tracheal tube replacement is required for such pediatric patients [5]. The method adopted in our patient’s case can be performed using a McGrath™ laryngoscope, which allows images to be shared with the carers; unlike bronchoscopy, tracheal tube replacement can be performed in a limited workspace because the McGrath™ is small and does not require a separate monitor. In addition, by using a tracheal tube guide, a stable airway can be maintained until just before replacement, with virtually no loss of airway security.
Various tube fixation methods for facial burns have been reported [2,3,4]. In the current case, nasotracheal intubation was considered less likely to cause unplanned extubation than oral intubation; however, the method of fixation required ingenuity. As the tape could not be fixed to the skin due to the burns, a string was used for fixation, and a thread was applied to the nasal wings to prevent the tracheal tube from moving.
The child with severe burn injury was safely switched from oral to nasotracheal intubation, and ventilatory management was continued for 2 weeks, despite burns to the face and neck. Safe tracheal tube replacement is possible with a tracheal tube guide and video laryngoscope without the use of a bronchoscope. This method may allow a safe transition from oral intubation in patients requiring nasal intubation, especially pediatric patients with facial burns, and help prevent unexpected extubation.
