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Endotracheal tube stabilization using an orthodontic skeletal anchor in a patient with facial burns
Int. J. Oral Maxillofac. Surg. 2008; 37: 386–387 doi:10.1016/j.ijom.2007.12.003, available online at http://www.sciencedirect.com
Technical Note Trauma
Endotracheal tube stabilization using an orthodontic skeletal anchor in a patient with facial burns
T. Kanno1, M. Mitsugi1, Y. Furuki1, S. Kozato1,2 1 Division of Oral and Maxillofacial Surgery, Kagawa Prefectural Central Hospital, Kagawa, Japan; 2Kozato Dental and Orthodontic Clinic, Kagawa, Japan
T. Kanno, M. Mitsugi, Y. Furuki, S. Kozato: Endotracheal tube stabilization using an orthodontic skeletal anchor in a patient with facial burns. Int. J. Oral Maxillofac. Surg. 2008; 37: 386–387. # 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Stabilizing the endotracheal tube is of vital importance in patients suffering facial burns or trauma in the intensive care unit, as well as during a general anaesthetic procedure. Here is presented a secure method using a simple orthodontic skeletal anchorage system on the maxilla and 0.4-mm stainless steel wire that does not require any work or place any burden on the teeth or gingival tissue, and does not require extensive surgery.
Securing an endotracheal tube in patients with facial burns without jeopardizing the security of the airway can pose difficulty3. These patients usually present with burns on the face and neck, and frequently require prolonged ventilator support because of airway swelling, inhalation injury and general critical illness4,6. Several methods have been described that rely on straps, a single suture or wire, or complex devices that apply undesirable pressure to the face, which potentially makes facial wound care, including skin grafts and dressing, difficult2,3. In the past, tracheostomies were routinely used for initial airway management in many of these patients4,6. Recognition of the short duration of intubation required for many inhalation injuries, as well as the high rate of 0901-5027/040386 + 2 $30.00/0
complications associated with tracheostomies, have led to the more conservative approach currently practised4,6. Here is described a technique for fixing the endotracheal tube using a simple orthodontic skeletal anchorage system. Case report
A 63-year-old man sustaining severe systemic burns required orotracheal intubation during intensive care due to the requirement for prolonged ventilator-supported airway management, followed by skin grafting to the face under general anaesthesia, as well as daily burn care. It was necessary to stabilize the endotracheal tube to prevent accidental extubation, while allowing close attention to burn
Keywords: endotracheal tube; fixation; skeletal anchor. Accepted for publication 19 December 2007 Available online 4 March 2008
care. This involved the use of two 1.6-mm self-tapping simple rigid titanium screws (Dual Top Anchor System; Jeil Medical, Seoul, Korea). routinely used for orthodontic anchors and intermaxillary fixation in orthognathic surgery and to treat jaw fractures (Fig. 1a). No drilling was required, and damage to the teeth was avoided by inserting the screws between the roots. Then, 0.4-mm stainless steel wires were passed through the transverse holes in the screw heads to fix the endotracheal tube within 3 min (Fig. 1b). Oral hygiene was maintained with daily care by intensive care unit nurses, with no obstacle to using a tooth brush. The endotracheal tube was changed twice by simply untying the wires and retying or changing the wires to stabilize the new tubes; this
# 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Endotracheal tube stabilization using an orthodontic skeletal anchor in a patient with facial burns
387
Fig. 1. (a) Dual Top Anchor System. (b) An endotracheal tube secured to screws between the left upper central incisor and lateral incisor, and between the left upper canine and first premolar at the time of extubation (after 2 weeks of intubation in the intensive care unit).
was achieved without any difficulty after checking the tube position carefully before wire fixation. A wire cutter was kept next to the patient’s head in order to cope with any accident involving the endotracheal tube, such as tube obstruction, accidental dislodgement, accidental extubation or a leaking cuff. No problems occurred during the process of respiratory management and endotracheal suctioning. The patient successfully underwent systemic and local burn care several times, including a series of skin grafts to the face, without any complications, and was extubated safely after 2 weeks of intensive care. Discussion
Various techniques are used for fixing and stabilizing an endotracheal tube to the facial skeleton in patients with facial burns or trauma, or during craniomaxillofacial surgery, where the wound, injury, blood, saliva and disinfectant solutions interfere with tape adhesion2,3. Accessing the wound for cleaning and dressing can cause accidental extubation3,7. Methods of endotracheal tube stabilization include anchoring the tube with a circum-mandibular wire or standard dental arch bar, fixing a wire between the endotracheal tube and the cervix of a stable tooth, using a dental rubber dam clamp, or fixing a screw to the maxilla2,3,5,7. Such techniques require additional instruments, devices, drilling systems and time, and may require healthy teeth. Additional surgical intervention in
order to stabilize the endotracheal tube is often reported, such as a tracheostomy for airway management or fixation methods bypassing the endotracheal tube, involving the submental or submandibular regions1,4,6. Tracheostomy has a high risk of complications, especially in children, obese patients and patients with an enlarged thyroid gland, and often necessitates surgery extending into a burn wound, which can result in a greater incidence of wound infection4,6. A bypass method via submental or submandibular access has potential complications, such as the possibility of exposing the patient to hypoxia during the technique, the need for a specially designed tube with a connector, difficulty in making adjustments during accidental dislodgement of the tube and cosmetically less acceptable extended surgery, often involving the burn wound1. When it is anticipated that an artificial airway will be needed for more than 2 weeks, a late tracheostomy should be performed, taking into consideration the injury to the larynx and trachea, and the discomfort, as compared to the method reported here6. This simple self-tapping skeletal anchorage system using stainless steel wire is a secure method that appears to be effective, is easy to handle and involves no additional difficulty or labour. References 1. Anwer HMF, Zeitoun IM, Shehata EAA. Submandibular approach for tra-
2.
3. 4.
5.
6.
7.
cheal intubation in patients with facial fractures. Br J Anaesth 2007: 98: 835– 849. Arora S, Nagdeve NG, Makkar JK, Sharma RK. Fixation of an oral tracheal tube to the maxilla in maxillofacial surgery. Anesth Analg 2006: 103: 1620. Davis C. Endotracheal tube fixation to the maxilla in patients with facial burns. Plast Reconstr Surg 2004: 113: 982–984. GRAVVANIS AI, TSOUTSOS DA, ICONOMOU TG, PAPADOPOULOS SG. Percutaneous versus conventional tracheostomy in burned patients with inhalation injury. 2005; 29: 1571–1575. Honig JF, Merten HA, Braun U. Intraoral dental fixation of an endotracheal tube using a cofferdam clamp. Anaesthesist 1990: 39: 422–423. Jones WG, Madden M, Finkelstein J, Yurt RW, Goodwin CW. Tracheostomies in burn patients. Ann Surg 1989: 209: 471–474. Perrotta VJ, Stern JD, Lo AK, Mitra A. Arch bar stabilization of endotracheal tubes in children with facial burns. J Burn Care Rehabil 1995: 16: 437–439.
Address: M. Mitsugi Division of Oral and Maxillofacial Surgery Kagawa Prefectural Central Hospital 5-4-16 Bancho Takamatsu Kagawa 760-8557 Japan Tel.: +81 87 835 2222 Fax: +81 87 837 6210. E-mail: [email protected]
Technical Note Trauma
Endotracheal tube stabilization using an orthodontic skeletal anchor in a patient with facial burns
T. Kanno1, M. Mitsugi1, Y. Furuki1, S. Kozato1,2 1 Division of Oral and Maxillofacial Surgery, Kagawa Prefectural Central Hospital, Kagawa, Japan; 2Kozato Dental and Orthodontic Clinic, Kagawa, Japan
T. Kanno, M. Mitsugi, Y. Furuki, S. Kozato: Endotracheal tube stabilization using an orthodontic skeletal anchor in a patient with facial burns. Int. J. Oral Maxillofac. Surg. 2008; 37: 386–387. # 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Stabilizing the endotracheal tube is of vital importance in patients suffering facial burns or trauma in the intensive care unit, as well as during a general anaesthetic procedure. Here is presented a secure method using a simple orthodontic skeletal anchorage system on the maxilla and 0.4-mm stainless steel wire that does not require any work or place any burden on the teeth or gingival tissue, and does not require extensive surgery.
Securing an endotracheal tube in patients with facial burns without jeopardizing the security of the airway can pose difficulty3. These patients usually present with burns on the face and neck, and frequently require prolonged ventilator support because of airway swelling, inhalation injury and general critical illness4,6. Several methods have been described that rely on straps, a single suture or wire, or complex devices that apply undesirable pressure to the face, which potentially makes facial wound care, including skin grafts and dressing, difficult2,3. In the past, tracheostomies were routinely used for initial airway management in many of these patients4,6. Recognition of the short duration of intubation required for many inhalation injuries, as well as the high rate of 0901-5027/040386 + 2 $30.00/0
complications associated with tracheostomies, have led to the more conservative approach currently practised4,6. Here is described a technique for fixing the endotracheal tube using a simple orthodontic skeletal anchorage system. Case report
A 63-year-old man sustaining severe systemic burns required orotracheal intubation during intensive care due to the requirement for prolonged ventilator-supported airway management, followed by skin grafting to the face under general anaesthesia, as well as daily burn care. It was necessary to stabilize the endotracheal tube to prevent accidental extubation, while allowing close attention to burn
Keywords: endotracheal tube; fixation; skeletal anchor. Accepted for publication 19 December 2007 Available online 4 March 2008
care. This involved the use of two 1.6-mm self-tapping simple rigid titanium screws (Dual Top Anchor System; Jeil Medical, Seoul, Korea). routinely used for orthodontic anchors and intermaxillary fixation in orthognathic surgery and to treat jaw fractures (Fig. 1a). No drilling was required, and damage to the teeth was avoided by inserting the screws between the roots. Then, 0.4-mm stainless steel wires were passed through the transverse holes in the screw heads to fix the endotracheal tube within 3 min (Fig. 1b). Oral hygiene was maintained with daily care by intensive care unit nurses, with no obstacle to using a tooth brush. The endotracheal tube was changed twice by simply untying the wires and retying or changing the wires to stabilize the new tubes; this
# 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Endotracheal tube stabilization using an orthodontic skeletal anchor in a patient with facial burns
387
Fig. 1. (a) Dual Top Anchor System. (b) An endotracheal tube secured to screws between the left upper central incisor and lateral incisor, and between the left upper canine and first premolar at the time of extubation (after 2 weeks of intubation in the intensive care unit).
was achieved without any difficulty after checking the tube position carefully before wire fixation. A wire cutter was kept next to the patient’s head in order to cope with any accident involving the endotracheal tube, such as tube obstruction, accidental dislodgement, accidental extubation or a leaking cuff. No problems occurred during the process of respiratory management and endotracheal suctioning. The patient successfully underwent systemic and local burn care several times, including a series of skin grafts to the face, without any complications, and was extubated safely after 2 weeks of intensive care. Discussion
Various techniques are used for fixing and stabilizing an endotracheal tube to the facial skeleton in patients with facial burns or trauma, or during craniomaxillofacial surgery, where the wound, injury, blood, saliva and disinfectant solutions interfere with tape adhesion2,3. Accessing the wound for cleaning and dressing can cause accidental extubation3,7. Methods of endotracheal tube stabilization include anchoring the tube with a circum-mandibular wire or standard dental arch bar, fixing a wire between the endotracheal tube and the cervix of a stable tooth, using a dental rubber dam clamp, or fixing a screw to the maxilla2,3,5,7. Such techniques require additional instruments, devices, drilling systems and time, and may require healthy teeth. Additional surgical intervention in
order to stabilize the endotracheal tube is often reported, such as a tracheostomy for airway management or fixation methods bypassing the endotracheal tube, involving the submental or submandibular regions1,4,6. Tracheostomy has a high risk of complications, especially in children, obese patients and patients with an enlarged thyroid gland, and often necessitates surgery extending into a burn wound, which can result in a greater incidence of wound infection4,6. A bypass method via submental or submandibular access has potential complications, such as the possibility of exposing the patient to hypoxia during the technique, the need for a specially designed tube with a connector, difficulty in making adjustments during accidental dislodgement of the tube and cosmetically less acceptable extended surgery, often involving the burn wound1. When it is anticipated that an artificial airway will be needed for more than 2 weeks, a late tracheostomy should be performed, taking into consideration the injury to the larynx and trachea, and the discomfort, as compared to the method reported here6. This simple self-tapping skeletal anchorage system using stainless steel wire is a secure method that appears to be effective, is easy to handle and involves no additional difficulty or labour. References 1. Anwer HMF, Zeitoun IM, Shehata EAA. Submandibular approach for tra-
2.
3. 4.
5.
6.
7.
cheal intubation in patients with facial fractures. Br J Anaesth 2007: 98: 835– 849. Arora S, Nagdeve NG, Makkar JK, Sharma RK. Fixation of an oral tracheal tube to the maxilla in maxillofacial surgery. Anesth Analg 2006: 103: 1620. Davis C. Endotracheal tube fixation to the maxilla in patients with facial burns. Plast Reconstr Surg 2004: 113: 982–984. GRAVVANIS AI, TSOUTSOS DA, ICONOMOU TG, PAPADOPOULOS SG. Percutaneous versus conventional tracheostomy in burned patients with inhalation injury. 2005; 29: 1571–1575. Honig JF, Merten HA, Braun U. Intraoral dental fixation of an endotracheal tube using a cofferdam clamp. Anaesthesist 1990: 39: 422–423. Jones WG, Madden M, Finkelstein J, Yurt RW, Goodwin CW. Tracheostomies in burn patients. Ann Surg 1989: 209: 471–474. Perrotta VJ, Stern JD, Lo AK, Mitra A. Arch bar stabilization of endotracheal tubes in children with facial burns. J Burn Care Rehabil 1995: 16: 437–439.
Address: M. Mitsugi Division of Oral and Maxillofacial Surgery Kagawa Prefectural Central Hospital 5-4-16 Bancho Takamatsu Kagawa 760-8557 Japan Tel.: +81 87 835 2222 Fax: +81 87 837 6210. E-mail: [email protected]