Case reportUse of high flow nasal cannula on a pediatric burn patient with inhalation injury and post-extubation stridor
Introduction
Inhalation injuries remain a substantial cause of immediate and delayed morbidity and mortality in burn patients [1]. In addition, prolonged endotracheal intubation is associated with a number of complications including ventilator associated pneumonia, airway injury, and the risk of reintubation. Reintubation is a particular problem in children because of their small airway size, their inability to cooperate with periextubation maneuvers, and their relatively high sedation requirements.
Stridor due to upper airway obstruction occurs in 2.4–63.6% of patients in pediatric intensive care units [2], [3], [4], [5]. Nearly 10% of pediatric patients with post-extubation stridor require reintubation, making stridor one of the most common indications for reintubation in this population [5]. The propensity for post-extubation stridor is reportedly dependant on patient age, duration of intubation, size of the endotracheal tube, and absence of air leak at the time of extubation. In a recent prospective cohort study of pediatric trauma patients, mechanism of injury and the absence of air leak at the time of extubation were felt to be the strongest predictors of post-extubation stridor and risk of reintubation [2]. In addition, the smaller airway size of pediatric patients predisposes them to more frequent obstructive airway injuries after intubation, including airway edema and temporary vocal cord paralysis. In a recent study that evaluated the airway of pediatric patients immediately post-extubation, only 10.2% had a normal endoscopy, 24.2% had at least a moderate airway lesion and 10.7% had at least one severe airway lesion. Independent risk factors for a worse endoscopic evaluation included reintubation and endotracheal tube changes [5].
Given these serious consequences, a number of pharmacologic interventions designed to decrease post-extubation stridor and reintubation have been evaluated, including systemic or aerosolized steroids, aerosolized racemic epinephrine, and Heliox. While these therapies hold promise, there is limited data to support their use. A different strategy is the use of noninvasive positive pressure devices such as CPAP, which has had some limited success in preterm infants, older children and adults. Unfortunately, pediatric patients are usually unable to cooperate with the mask equipment necessary to apply noninvasive positive pressure, and masks that fit this population are generally unavailable.
A new technology that administers high flow oxygen with molecular water vapor delivered via high flow nasal cannula has recently been introduced. This specialized nasal cannula device is designed to comfortably deliver humidified oxygen at flow rates that are theoretically high enough to mimic CPAP. A few reports describing the use of this technology in a variety of patient populations have been published. To our knowledge, this is the first reported use of high flow nasal cannula in a pediatric patient with inhalation injury, post-extubation stridor, and potential extubation failure. This case report study was approved by the University of North Carolina School of Medicine Institutional Review Board.
Section snippets
Case summary
The patient is a 12-month-old female with 8% total body surface area partial thickness flame burn involving the upper torso, forehead and cheeks with an associated inhalation injury following a house fire. The child, who had been intubated in the field, was admitted with a 3.5 cuffless endotracheal tube and placed on high frequency percussive ventilation (VDR®) to assist with secretion clearance and maintenance of gas exchange. After 14 days, the patient was switched to conventional
Discussion
Several strategies have been developed in an attempt to address stridor as a cause for extubation failure, some preventative and some immediately therapeutic. The foremost strategy is the air leak test to avoid extubating a child who most likely will fail. The air leak test has become standard practice in intubated pediatric patients to determine if airway edema is present. This test measures the pressure required to produce an audible sound around the tip of the endotracheal tube. Most centers
Conflict of interest
The authors have no financial or personal conflicts of interest.
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