Non conventional way of securing endotracheal tube in a case of facial burns.

Dear Editor,

We read with interest your article about “Non conventional way of securing endotracheal tube in bearded individuals”.[12]

We administered anesthesia to a 30-year-old female patient, with 80% burns. She had burns all over her face. Intubation was difficult as she had microstomia due to perioral burns; mouth opening was 1 finger breadth. Neck was fixed due to burns on neck, she could not flex her neck, and minimal movement was possible side to side. Because of burns, nasal openings were reduced in size. Temporarily securing the oral endotracheal tube in such a patient with a burned face is a challenge as the adhesive tape, used commonly, cannot stick on such patients.

The main goal of reliable fixation in patients with facial burns is to eliminate the possibility of the tracheal tube being dislodged as these patients are often very difficult to re-intubate. Also it should be easy to adjust when the tracheal tube position needs to be changed.[2]

Different methods have been tried, such as tying with standard or umbilical tape, oxygen tubing, or encircling tube with front maxillary incisors using either heavy braided silk suture[2] or dental wires,[3] orthodontic brackets bonded to the maxillary incisors by wire encircling the tube,[4] fixation of tube to a previously inserted maxillary arch bar,[5] or use of maxillary screws.[6]

Many of these methods unfortunately have problems. Tying around neck may lead to venous return obstruction in neck veins and it is sometimes not optimal from a surgical standpoint. Orthodontic brackets and dental resin require the patient is at least partially dentulous as well as specialized dental skills for their placement and management. Wire can cause damage to teeth. Wires around the tracheal tube are difficult to adjust after they are placed and require wire cutters. If the wires are cut during an adjustment, it may be difficult to control the fragments with the possibility that sections are lost into the upper airway. Wires around the front incisors may damage the dental enamel and interfere with dental hygiene.

Hence, we used innovative and non-invasive way of fixing the ET tube using IV fluid bottles which are easily available in OT as was published in your esteemed journal for fixation of endotracheal tube in bearded patient.[1]

A 500 ml plastic bottle of an intravenous fluid was cut open into a rectangular piece. A centre slit approximating the diameter of the endotracheal tube was cut. Two side holes were cut near the longitudinal margin ensuring that they were not near the margin as they could cut through the plastic. After tracheal intubation, the tube was temporarily secured with the bandage. Thereafter, the tube was engaged into the slit of the rectangular piece. A sterile gauze pad was placed below the rectangular plastic to avoid trauma to the burnt face. The tube was further secured using tape over the plastic rectangle. Next, the whole unit consisting of the rectangular piece and tube was secured using the bandage tied to the side holes on the rectangular piece. Bandage was tied above ears, thus avoiding risk of venous obstruction at neck.

We made two modifications: Firstly we cut an additional hole for passing suction catheter for intraoral suction [Figure 1]. Secondly, a sterile gauze pad was placed below the rectangular plastic to avoid trauma to the burnt face [Figure 2]. The rectangular shaped plastic served as a smooth surface over the burn area to secure the tube.

Figure 1

Rectangular plastic with holes for endotracheal tube and suction

Figure 2

The intubated patient of facial burns

In summary, by this method dental damage is avoided, tube can be easily adjusted while maintaining a high degree of security and intraoral suction is possible. Only limitation is that perioral debridement is not possible as the area is covered.