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Getting warmed up with a multiple-choice question
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A 70-year-old man with oxygen-dependent COPD is admitted following a flash burn. He started smoking with his oxygen running, and the cigarette “exploded” in his face. Currently he is in the emergency department on four liters nasal cannula (twice his chronic oxygen prescription). He is mentating well with a saturation of 93% and a respiratory rate of 15 breaths/minute. He has first-degree burns on his lips and cheeks, with soot in his nares and singed nasal hairs. What is the best immediate management for this patient?
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(a) Immediate endotracheal intubation.
(b) Laryngoscopy to evaluate for upper airway, intubate if edema or blistering is seen.
(c) Bronchoscopy to evaluate entire airway, intubate if edema or blistering is seen.
(d) Admit for observation.
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Introduction
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Education about airway injury in burn patients typically focuses on patients with smoke inhalation injury (e.g. following entrapment in a burning building). Such patients are forced to inhale heated air, leading to a risk of delayed airway edema with difficult intubation. Consequently, the approach to airway management in such patients often involves pre-emptive airway examination with intubation if there are signs of airway involvement.
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Flash cigarette burns are entirely different. A flash cigarette burn is used here to refer to when a patient on home oxygen lights up a cigarette, leading to a very exuberant but self-limited combustion of the cigarette in their face. These fires are brief and self-contained, with primarily superficial damage. The injury often appears misleadingly severe (i.e. face covered in soot, with singed nasal hairs). Given a different mechanism of injury compared to other types of burns, the clinical approach should likely be different as well.
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The Evidence
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Amani H et al. Assessing the need for intubation in patients sustaining burn injury secondary to home oxygen therapy. Journal of Burn Care & Research 2012.
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This is a retrospective chart review study of 86 patients with burns associated with home oxygen between 2000-2010. 87% of these patients suffered burns while lighting a cigarette, with other causes including candles, sparks, and gas stoves. The percent total body surface area involved ranged from 0.5-15%.
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Most patients (61%) were not intubated. Among intubated patients, bronchoscopy revealed airway edema in 22%. Most intubations occurred in the field or outside hospital, with only eight patients intubated in the ED of the burn center and one patient intubated in the ICU (for an exacerbation of asthma).
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This study is limited because it evaluates a heterogeneous group of patients (combining flash cigarette burns with more serious burn injuries). Another limitation is that the indication for intubation in most cases was unclear, so it is unknown whether patients truly required intubation.
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Regardless, a few points are notable. Most patients didn’t require intubation, and the great majority had no airway edema. Perhaps more importantly, there was no evidence of delayed airway swelling: only one patient required intubation in the ICU due to asthma exacerbation. The authors came to the following conclusions:
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“Health care providers with limited or infrequent exposure to the treatment of burn patients with singed facial and nasal hair often interpret these physical findings to be consistent with the presence of a possible inhalation injury. This often results in unnecessary intubation in a patient who demonstrates no signs of respiratory distress or, as in a patient with COPD, no change in respiratory status from baseline.”
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Muehlberger T et al. Domiciliary oxygen and smoking: an explosive combination. Burns 1998.
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This is a retrospective chart review of 21 patients with burns due to lighting a cigarette on oxygen therapy between 1990-1997 at John Hopkins Hospital. Seventeen patients were using oxygen via nasal cannula, with four patients using a facemask. Seventeen patients had second-degree burns, four patients had full-thickness burns, and two patients required skin grafting. Nonetheless, no patients had an inhalational injury or required intubation.
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| Patient image from Muehlberger et al. |
This is a useful study because it examines only patients with flash cigarette burns. When managed at a referral center with extensive experience treating burns, none of these patients required intubation.
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Vercruysse GA et al. A rationale for significant cost savings in patients suffering home oxygen burns: Despite many comorbid conditions, only modest care is necessary. Journal of Burn Care & Research 2012.
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This is a retrospective study of 64 patients admitted with burns sustained while using home oxygen therapy between 1997-2010. 92% of burns were due to cigarettes. Intubation predominantly occurred prior to transfer to the burn center, with 28% of transferred patients arriving intubated. An additional two patients were intubated in the emergency department prior to evaluation by the burn service. Among all intubated patients, 80% were extubated within eight hours of admission and 100% were extubated within 24 hours of admission.
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This is an interesting study. Given that most patients were extubated very rapidly, it is unlikely that they truly required intubation. Furthermore, for a patient intubated pre-emptively, this data suggests that it is safe to pursue rapid extubation.
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Answering to the introductory question
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Choice (D) may be best (observation). For patients with severe smoke inhalation injury (e.g. due to being trapped in a burning building), there is a risk of delayed airway edema with subsequent airway crisis. Therefore, an aggressive approach to the airway is typically recommended with airway inspection and pre-emptive intubation if there is evidence of airway edema or blistering. However, patients with flash cigarette burns do not appear to develop delayed airway edema. Therefore, there is no indication for airway inspection or pre-emptive intubation.
Choice (D) may be best (observation). For patients with severe smoke inhalation injury (e.g. due to being trapped in a burning building), there is a risk of delayed airway edema with subsequent airway crisis. Therefore, an aggressive approach to the airway is typically recommended with airway inspection and pre-emptive intubation if there is evidence of airway edema or blistering. However, patients with flash cigarette burns do not appear to develop delayed airway edema. Therefore, there is no indication for airway inspection or pre-emptive intubation.
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Conclusions
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Flash burns due to rapid combustion of a cigarette (sometimes with ignition of the patient’s nasal cannula as well) are typically relatively benign. Skin grafting is only rarely required, with topical care usually being sufficient for management of the burn. The rate of airway edema is low, and there does not appear to be a risk of delayed airway swelling or airway loss.
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Pre-emptive intubation of these patients is not indicated. Although these patients invariably have singed nasal hairs and soot in their nares, this is not an indication for intubation. Airway management should be approached in these patients as it would be in other patients with chronic respiratory failure, with intubation only if clinically warranted (e.g. due to acute respiratory failure). If the patient has already been intubated prophylactically, evidence supports aggressively weaning and extubating these patients.
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| More on the anxiety-COPD vortex of badness here. |
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Most patients on home oxygen therapy have COPD, so a flash fire may cause bronchospasm with exacerbation of the patient’s lung disease. Aggressive management with bronchodilators and perhaps low-dose corticosteroids may be helpful with this (e.g. prednisone 40 mg PO for five days). Patients often have pain and anxiety related to their burns, which may cause tachypnea with worsening of gas trapping thereby aggravating their dyspnea (figure above). Cautious use of opioids can be helpful to alleviate pain and anxiety. Although facial burns will typically prevent application of noninvasive ventilation, the use of high-flow nasal cannula may be considered in selected patients with elevated work of breathing who do not require intubation (with very careful observation).
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Overall, these patients may be approached with a focus on serial clinical assessment and common sense. Surgical consultation is important to determine the need for skin grafting or other burn management. From an airway and pulmonary standpoint, these patients should likely be approached similarly to other patients with chronic lung disease and respiratory dysfunction. All efforts should be made to treat the lung disease, with intubation only if clinically warranted.
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- Patients who have limited facial burns following a flash burn (from rapid combustion of a cigarette) typically do well with conservative therapy. Skin grafting or intubation are only rarely required.
- There is no role for pre-emptive intubation or routine airway examination for a patient with a limited flash burn. If the patient has already been intubated pre-emptively, they should be aggressively weaned and extubated.
- Patients with a COPD exacerbation following a flash burn may be managed similarly to other patients with COPD exacerbation. Attentive pain control will often go a long ways towards making these patients feel and look better.
Josh is the creator of PulmCrit.org. He is an associate professor of Pulmonary and Critical Care Medicine at the University of Vermont.
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