Airway management, intubation, and tracheostomy in burn patients

Overview

Upper airway management is central to burn care, and establishing a secure airway is a critical task in the acute phase of facial and inhalation injury [1, 18]. Airway management is a load-bearing consideration in every burn resuscitation because the airway can be normal on arrival and obstructed hours later as edema develops, and because the same maneuvers that secure the airway can themselves injure it ^[19]. The clinical problem divides into four sequential decisions: whether to intubate, how to secure a technically difficult airway, when to extubate, and whether and when to perform tracheostomy.

The dominant theme across the modern literature is that burns are over-intubated. Many burn patients undergo unnecessary intubation driven by concern for inhalation injury, and the classic clinical examination findings that prompt those tubes correlate poorly with actual airway injury [20, 21]. The countervailing risk is real: thermal airway injury usually accompanies facial burns and can demand emergency control, and laryngeal edema can progress to obstruction ^[22]. The field has therefore moved toward objective criteria, direct laryngoscopic or bronchoscopic inspection, and early otolaryngology involvement, both to avoid placing tubes that are not needed and to limit the laryngotracheal damage caused by the tubes that are.

Indications for Intubation

When and whom to intubate is the most contested bedside decision in burn airway care. Multiple cohorts document a high rate of short-lived tubes: across adult burn intensive care units, more than 30 percent of patients arriving intubated are extubated within 2 days, a pattern labeled potentially unnecessary intubation ^[17]. In a 5-year regional burns-centre series, 30.8 percent of intubated patients were extubated within 48 hours, and intubation-related complications occurred in 37.5 percent of patients, with ventilator-associated pneumonia the most common at 27.5 percent ^[11]. Systematic review of pre-burn-center intubation found that these patients were more likely to have earlier extubation times, again pointing to potentially unnecessary intubation ^[6].

Facial burns are a weak trigger on their own. In a cohort of 335 facial-burn patients, 121 were intubated in the emergency department but only 73 (60.3 percent) were later confirmed to have inhalation injury on bronchoscopy, and conventional physical signs such as hoarseness and singed nostril hair were not predictive of inhalation injury or the need for a tube ^[9]. The authors of that series note that all patients with TBSA over 60 percent were intubated regardless of airway findings ^[9]. Predictors that do associate with inhalation injury before burn-center arrival include increasing percent TBSA burned, flame mechanism, enclosed-space exposure, face burns, hoarse voice, soot in the mouth, and shortness of breath ^[8].

Objective criteria are the response to over-intubation. Badulak and colleagues defined traditional criteria (suspected smoke inhalation, oropharyngeal soot, hoarseness, dysphagia, singed facial hair, oral edema, oral burn, non-full-thickness facial burns) and the ABA criteria, then found long-term intubation was strongly associated with ABA criteria (77.5 percent) over traditional criteria (22.5 percent) ^[10]. Adding suspected smoke inhalation and singed facial hair to the ABA criteria created the Denver criteria, which raised sensitivity for long-term intubation to 95 percent while specificity fell to 24 percent ^[10]. The authors state that intubation should be considered for patients displaying the Denver criteria, that the criteria include full-thickness facial burns, stridor, respiratory distress, swelling on laryngoscopy, upper-airway trauma, altered mentation, hypoxia or hypercarbia, hemodynamic instability, suspected smoke inhalation, and singed facial hair, and that patients lacking these criteria should not be intubated ^[10]. In an independent series, 72.5 percent of intubated patients met ABA criteria and 95 percent met Denver criteria, yet 30.8 percent were extubated within 48 hours, and the authors conclude that current criteria may overestimate the risk of airway compromise ^[11].

Liberal and restrictive criteria trade sensitivity against specificity. Comparing the two in adults with suspected inhalation injury, liberal criteria had higher sensitivity for prolonged intubation (0.98 vs 0.84) but markedly lower specificity (0.48 vs 0.96), and among patients who met liberal but not restrictive criteria, 65 percent were extubated within 48 hours and 90 percent did not have inhalation injury ^[4]. Adding objective gas-exchange data helps: arterial pH below 7.30 had 80 percent sensitivity and specificity for appropriate intubation, and adding pH and the P/F ratio to the ABA criteria improved sensitivity for appropriate intubations from 0.86 to 0.97 without altering specificity ^[23]. Provider background matters less than the criteria used; surgeons with acute-care-surgery training showed no difference from burn providers in emergent intubation rates, time to extubation, or bronchoscopic diagnosis of inhalation injury ^[20]. Prolonged mechanical ventilation, the downstream consequence of intubation, is independently associated with TBSA, age, full-thickness facial burn, and shock ^[24].

Upper Airway and Laryngeal Injury

The larynx bears the brunt of upper-airway thermal injury and is the structure whose edema most often forces airway control. Laryngeal inhalation injury carries a significant increase in mortality and often indicates immediate airway evaluation, and laryngeal injuries form a distinct subset with minor-to-severe laryngotracheal delayed sequelae, particularly after thermal injury in enclosed spaces ^[19]. Laryngeal pathology after inhalation injury includes edema and erythema, laryngeal granulation, vocal-cord palsy or paresis, and laryngeal contracture ^[25]. The three major injury classes described for the burned airway are supraglottic, subglottic, and systemic ^[26]. In an animal laryngeal-burn model, granulation tissue appeared at 3 days and early epiglottic and subglottic fibrosis appeared by 7 days and matured by 14 days, with massive supraglottic edema concentrated around the arytenoids extending transglottically ^[27].

Whether the airway is evaluated before or after intubation shapes what is found and what follows. In a systematic review of laryngeal inhalational injuries, airway stenosis was more common in patients intubated immediately than in those evaluated first (50.0 percent vs 5.2 percent), posterior glottic involvement was identified only in patients intubated before airway evaluation, and every case in which intervention preceded laryngeal evaluation occurred in a closed-space setting ^[19]. The review authors note that early otolaryngology referral may mitigate or treat these effects ^[19]. Long-term laryngotracheal complications after inhalation injury are under-recognized, and described risk factors include high-grade injury, elevated initial inflammatory responses, prolonged translaryngeal intubation, and a history of tracheostomy ^[5]. Early surgical management of thermal airway injury has been reported to produce rapid abatement of mucosal inflammation, resolution of granulation tissue, and return of laryngeal function ^[28].

Difficult Airway and Intubation Technique

Fiberoptic bronchoscopy is the reference tool both for diagnosing inhalation injury and for guiding intubation, established as a simple, safe, and accurate method that identifies the anatomic level and severity of large-airway injury ^[29]. Beyond diagnosis, direct inspection prevents tubes: in one series, all 51 patients who underwent flexible fiberoptic laryngoscopy met traditional intubation criteria on examination, yet 98 percent were safely monitored without intubation based on the scope findings ^[21]. Nasolaryngoscopy carries the same message in asymptomatic patients; none of 130 asymptomatic patients with negative nasolaryngoscopy were intubated, and the presence of erythema or edema in asymptomatic patients was of questionable clinical significance [9, 30]. Pediatric fiberoptic laryngoscopy in referred facial-burn children had a sensitivity of only 29 percent for clinical findings, comparable to reliance on clinical examination alone ^[31]. Direct visual inspection via nasolaryngoscopy can guide appropriate airway-management decisions ^[32].

When intubation is required, post-burn contracture of the face and neck creates an anticipated difficult airway that distorts the standard approach. Reported features include restricted mouth opening, fixed neck flexion, microstomia, scar hyperplasia, and tracheal stenosis, and both anesthesiologists and surgeons report difficulty in this setting ^[33]. The recurring recommendation across these reports is to secure the airway with the patient awake: authors describe awake fiberoptic-guided intubation, intubating laryngeal mask airway, and intubation without neuromuscular blockade as the safe approaches in moderate-to-severe post-burn contracture necks [12, 13]. Awake flexible fiberoptic intubation is described as the reference for anticipated difficult tracheal intubation, though serious facial burns and dysmorphic anatomy can make it difficult or impossible, and video-laryngoscopic devices such as the Pentax Airway Scope and King Vision have been used as alternatives [34, 35]. In severe glottic narrowing, oxygenation delivered through the working channel of the fiberscope during awake tracheal intubation has been used to prolong safe apnea time ^[36]. Fixation of the endotracheal tube on burned facial skin is itself a challenge; reports describe intermaxillary fixation screws, trans-alveolar wiring, and dental-unit fixation techniques to secure the tube without further tissue damage [18, 37].

Extubation

Extubation timing and failure are distinct problems from intubation, because the burned airway can fail liberation for reasons the standard indices miss. There is no consensus on an acceptable extubation-failure rate, and conventional indices do not accurately predict extubation outcomes in burn patients; in one analysis the extubation-failure incidence was 12.3 percent, and a sodium trending higher before extubation was associated with more successes, possibly reflecting lower volume status ^[38]. Higher heart rate and lower serum pH were associated with extubation failure, while the presence of inhalation injury was associated with extubation success in that matched analysis ^[38].

Unplanned extubation is the inverse hazard. In a burn-unit review, unplanned extubation occurred in 4.7 percent of patients (0.7 events per 100 ventilator days), inhalation injury was independently associated with increased risk (odds ratio 4.68), and no patient with a bite block had an unplanned extubation ^[39]. Accidental loss of the tube can be fatal because reintubation is technically hard in the edematous or contracted burn airway; in one tracheal-reconstruction series, six of the eight accidentally extubated patients in the conventionally treated group died from reintubation difficulties ^[65]. Distinct from these is palliative extubation, the deliberate termination of mechanical ventilation to allow a natural death when ventilator support no longer aligns with the patient's goals ^[40].

Tracheostomy

Tracheostomy is the most common and effective strategy for maintaining airway patency in burn patients who need prolonged control, and it is indicated when prolonged mechanical ventilation is anticipated [16, 41]. Indications and timing have historically been experience-driven and sometimes controversial, and severe burn patients often need prolonged ventilation because of their critical condition, sedation management, and repeated operating-room visits [41, 42]. Predictive tools have been developed to formalize the decision: a nomogram predicts the need for tracheostomy in burned patients, and a classification formula combining clinical factors reached an AUC of 0.972, with hours after injury the only indicator for emergency tracheotomy (cut-off 32.4 hours) [41, 43].

The historical comparison of tracheostomy with translaryngeal intubation favors leaving the tube where possible. In the Lund series, sequelae were more frequent and more severe after tracheostomy than after translaryngeal intubation, duration of tube placement and the presence of a tracheal stoma were the dominant etiologic factors, and the authors favored translaryngeal (nasotracheal) tubes for initial respiratory support for periods up to 3 weeks ^[3]. More recent matched data temper that concern: in one cohort, complications occurred equally in tracheotomized burn patients and matched controls, and tracheostomy was linked neither to dysphagia nor to inpatient mortality, with the authors concluding it is safe ^[43].

Technique selection centers on percutaneous versus open approaches. Percutaneous techniques are associated with a lower risk of infection than surgical tracheostomy, and in burned patients with inhalation injury the bedside percutaneous approach has been reported with no significant perioperative complications, one-fifth the cost of conventional tracheostomy, and a lower incidence of pulmonary sepsis (45 percent vs 68 percent) [44, 45]. One series found no difference in complications between percutaneous dilational and open surgical tracheostomy and supported early tracheostomy to reduce dysphagia in patients without neck burns ^[46]. A semi-open modification has been described to combine the minimally invasive percutaneous advantages with the surgical control of the open technique, and ultrasound-guided percutaneous dilational tracheostomy has been used to open the airway quickly in head-and-neck burns with upper-airway obstruction [47, 48]. In a patient who arrested from complex upper-airway obstruction after burns and repeated intubation attempts, emergency Griggs percutaneous tracheostomy was life-saving ^[49].

Airway Complications

The tubes and stomas that secure the burned airway produce a characteristic set of late complications. After intubation or tracheostomy, four patients in the Lund series developed tracheal stenosis and five had significant tracheal scar-granuloma formation ^[3]. In moderate and severe inhalation injury followed long-term, the tracheostenosis rate reached 100 percent, with granuloma formation and vocal-cord paralysis more frequent in severe injury ^[50]. Complex post-tracheostomy tracheal stenosis with cartilage destruction and tracheomalacia is a severe complication described in burn patients, and post-corrosive and post-tracheostomy tracheal stenosis can produce life-threatening but potentially reversible airway obstruction at the bedside [51, 52]. Reconstruction can be difficult; a full-length laryngotracheal stenosis required multiple costal-cartilage graft reconstruction after laser dilatation and resection failed ^[53].

Tracheocutaneous fistula is a common complication after decannulation of a long-term tracheostomy, with incidence correlating with cannulation duration, and persistent fistulas have been closed with multilayered local-tissue rearrangement ^[54]. Acquired tracheoesophageal fistula is uncommon but can occur as a delayed, life-threatening complication of inhalation injury; in one report a massive tracheoesophageal fistula developed on postburn day 14 and caused refractory respiratory failure managed with venovenous extracorporeal membrane oxygenation to permit surgical repair ^[55]. Pathologic study of severe laryngeal burns shows epidermal necrosis, gland and chondrocyte necrosis, vascular congestion, and granulation with cartilaginous metaplasia, changes implicated as the substrate of laryngostenosis [27, 56]. For refractory hypoxemic respiratory failure that the airway alone cannot rescue, extracorporeal membrane oxygenation is described as salvage therapy, though roughly half of burn centers use it, patient volumes are very low, and overall mortality has remained unchanged across decades despite increasing venovenous use [57, 58].

Dysphagia and Voice

Swallowing impairment is a frequent and under-appreciated consequence of the burned airway, driven by intubation, ventilation, and facial wounds. Dysphagia is identified in roughly half of older burn patients during admission, and one in every two patients aged 75 or older admitted with burn injury demonstrates dysphagia [14, 15]. Dysphagia is associated with burn size, pre-existing cognitive impairment, mechanical ventilation, duration of enteral feeding, hospital length of stay, in-hospital complications, and mortality, while burn location and mechanism are not associated ^[15]. Cognitive impairment is the most sensitive predictor at 100 percent sensitivity ^[14]. Intubation duration is a recurring driver: in one cohort all dysphagia patients had an orotracheal-intubation history averaging 18 days, versus 8.5 days in the non-dysphagia group ^[59]. Severity is graded across a mild-to-severe spectrum, with one series reporting 52 percent mild, 20 percent moderate, and 28 percent severe oropharyngeal dysphagia after thermal burn ^[60].

Voice and the wider goals of airway recovery follow the same pathway. Dysphonia is a frequent late complication of inhalation injury, severe inhalation injury is associated with dysphonia and with poor dysphonia resolution at six months, and dysphonia severity tracks intubation duration ^[25]. The stated goals of laryngotracheal management after inhalation injury are to restore airway patency, preserve voice quality, and restore normal diet and swallow function ^[5].

Special Considerations

Pediatric patients

Children follow the adult pattern of over-intubation but reach the burn center intubated less often. Among 1520 admitted children, only 4 percent arrived intubated, intubation before admission was less frequent than in adults, and yet roughly a third of intubated children were extubated within 2 days, close to the adult potentially-unnecessary-intubation rate ^[17]. Pediatric airway management in facial and neck burn contracture rests on detailed planning and patient preparation, and awake airway management with airway anesthesia can be used safely in selected children ^[12]. Laryngotracheal stenosis in the pediatric burn patient is complex and multidisciplinary, with laryngotracheal reconstruction the mainstay; cricoid split has a role in carefully selected older children with acute subglottic injury, and a staged reconstruction with rescue-tracheostomy safety has been advocated given pro-inflammatory burn physiology [61, 62]. Tracheocutaneous fistula formation correlates with cannulation duration in children, and pediatric burn patients with tracheostomy showed worse morbidity and higher health burden than those without [54, 63].

Caustic and atypical airway injury

The burned airway also presents through non-thermal mechanisms. Caustic-agent injury can produce severe glottic edema requiring urgent control, and post-corrosive tracheal stenosis can cause delayed, life-threatening airway obstruction even with a tracheostomy in place [36, 51]. Pediatric subglottic stenosis after chemical or thermal injury has been managed with cricoid split and laryngotracheal reconstruction ^[62]. These mechanisms share the burned-airway principles of difficult instrumentation and delayed sequelae, while their diagnostic workup overlaps with caustic-ingestion pathways outside this topic's scope.

Pre-existing pulmonary disease

COPD does not independently worsen short-term outcomes after fire-related inhalation injury in one 184-patient analysis, with no difference in hospital days, ventilator days, complication rates, or mortality, although carbon-monoxide poisoning was the predominant mortality risk factor in that cohort ^[64].

Controversies and Evidence Gaps

Burn airway management carries several active controversies with direct bedside consequences.

The intubation threshold is the central unresolved question. The literature consistently documents over-intubation, with roughly a third of pre-burn-center and intubated-on-arrival patients extubated within 48 hours, and authors of multiple cohorts argue that objective criteria, gas-exchange data, and direct inspection should replace reflexive intubation on facial-burn pattern [4, 6, 11, 17]. Providers are urged to use objective tools such as the ABA and Denver criteria to avoid unnecessary tubes, yet the same criteria are sensitive at the cost of specificity, so the optimal operating point is not settled [6, 10].

Tracheostomy timing is unsettled. A multi-database analysis associated early tracheostomy with shorter length of stay and fewer ventilator days, and its authors support early tracheostomy in critically injured burn patients needing prolonged ventilation ^[16]; a separate burn-ICU cohort additionally linked early tracheostomy to earlier active exercise ^[42]. A nationwide observational study, by contrast, found no significant association between early tracheostomy and 28-day in-hospital mortality after adjustment, and concluded the appropriate timing and its effect on mortality remain unknown ^[7]. An evidence-based guideline review concluded that early tracheostomy seems to reduce ventilator duration but not pneumonia incidence, length of stay, or long-term mortality ^[44]. The pediatric data add caution, with one cohort showing worse morbidity and health burden in children who received tracheostomy and its authors urging the potential benefits be weighed against these outcomes ^[63].

The translaryngeal-versus-tracheostomy tradeoff is not fully reconciled across eras. The historical series found tracheostomy sequelae more frequent and severe than after translaryngeal intubation, while a contemporary matched analysis found tracheostomy safe and not linked to dysphagia or mortality, leaving the relative late-complication burden dependent on tube duration, stoma presence, and modern technique rather than a fixed rule [3, 43]. Across these questions, much of the supporting evidence is retrospective single-center or case-series work, and predictive tools such as tracheostomy nomograms and intubation-criteria formulas await external validation before they can standardize practice [41, 43].

References

[1] Galicia KE, Mehta A, Kowalske KJ, Gibran NS, Stewart BT, McMullen K, et al. "Preliminary Exploration of Long-Term Patient Outcomes After Tracheostomy in Burns: A Burn Model System Study." The Journal of surgical research 2023. PMID: 37454428. https://pubmed.ncbi.nlm.nih.gov/37454428/ [2] Greathouse JS, Stuart JL, White WA. "Difficult airway management following severe gasoline burn injury: a case report." AANA journal 2012. PMID: 23251995. https://pubmed.ncbi.nlm.nih.gov/23251995/ [3] Lund T, Goodwin CW, McManus WF, Shirani KZ, Stallings RJ, Mason AD, et al. "Upper airway sequelae in burn patients requiring endotracheal intubation or tracheostomy." Annals of surgery 1985. PMID: 3883921. https://pubmed.ncbi.nlm.nih.gov/3883921/ [4] Chotalia M, Pirrone C, Mangham T, Torlinska B, Mullhi R, England K, et al. "The Predictive Applicability of Liberal vs Restrictive Intubation Criteria in Adult Patients With Suspected Inhalation Injury-A Retrospective Cohort Study." Journal of burn care & research : official publication of the American Burn Association 2020. PMID: 32504540. https://pubmed.ncbi.nlm.nih.gov/32504540/ [5] Zhen E, Misso D, Rea S, Vijayasekaran S, Fear M, Wood F. "Long-Term Laryngotracheal Complications After Inhalation Injury: A Scoping Review." Journal of burn care & research : official publication of the American Burn Association 2023. PMID: 35486925. https://pubmed.ncbi.nlm.nih.gov/35486925/ [6] Donnelly J. "The Effects of Pre-Burn Center Intubation on Rates of Pneumonia, Early Extubation, and Death: A Systematic Review." Journal of trauma nursing : the official journal of the Society of Trauma Nurses 2020. PMID: 32132491. https://pubmed.ncbi.nlm.nih.gov/32132491/ [7] Tsuchiya A, Yamana H, Kawahara T, Tsutsumi Y, Matsui H, Fushimi K, et al. "Tracheostomy and mortality in patients with severe burns: A nationwide observational study." Burns : journal of the International Society for Burn Injuries 2018. PMID: 29980328. https://pubmed.ncbi.nlm.nih.gov/29980328/ [8] Dyson K, Baker P, Garcia N, Braun A, Aung M, Pilcher D, et al. "To intubate or not to intubate? Predictors of inhalation injury in burn-injured patients before arrival at the burn centre." Emergency medicine Australasia : EMA 2021. PMID: 32856398. https://pubmed.ncbi.nlm.nih.gov/32856398/ [9] Huang RY, Chen SJ, Hsiao YC, Kuo LW, Liao CH, Hsieh CH, et al. "Positive signs on physical examination are not always indications for endotracheal tube intubation in patients with facial burn." BMC emergency medicine 2022. PMID: 35260094. https://pubmed.ncbi.nlm.nih.gov/35260094/ [10] Badulak JH, Schurr M, Sauaia A, Ivashchenko A, Peltz E. "Defining the criteria for intubation of the patient with thermal burns." Burns : journal of the International Society for Burn Injuries 2018. PMID: 29548862. https://pubmed.ncbi.nlm.nih.gov/29548862/ [11] Dingle LA, Wain RAJ, Bishop S, Soueid A, Sheikh Z. "Intubation in burns patients: a 5-year review of the Manchester regional burns centre experience." Burns : journal of the International Society for Burn Injuries 2021. PMID: 32861535. https://pubmed.ncbi.nlm.nih.gov/32861535/ [12] Unal D, Sumak Hazir M. "Airway Management in Pediatric Patients With Burn Contractures of the Face and Neck." Journal of burn care & research : official publication of the American Burn Association 2022. PMID: 35137105. https://pubmed.ncbi.nlm.nih.gov/35137105/ [13] Prakash S, Mullick P. "Airway management in patients with burn contractures of the neck." Burns : journal of the International Society for Burn Injuries 2015. PMID: 25868969. https://pubmed.ncbi.nlm.nih.gov/25868969/ [14] Clayton NA, Nicholls CM, Brownlow C, O'Hara J, Issler-Fisher AC, Fisher OM, et al. "Swallowing impairment in older persons following burn injury: Validation of incidence and predictive factors for dysphagia." Burns : journal of the International Society for Burn Injuries 2024. PMID: 39181766. https://pubmed.ncbi.nlm.nih.gov/39181766/ [15] Clayton NA, Nicholls CM, Blazquez K, Brownlow C, Maitz PK, Fisher OM, et al. "Dysphagia in older persons following severe burns: Burn location is irrelevant to risk of dysphagia and its complications in patients over 75 years." Burns : journal of the International Society for Burn Injuries 2018. PMID: 30107942. https://pubmed.ncbi.nlm.nih.gov/30107942/ [16] Shah JK, Stanton EW, Najafali D, Nazerali R, Sheckter CC. "Early Versus Late Tracheostomy in Critically Injured Burn Survivors: A National, Multi-Database Analysis." Journal of burn care & research : official publication of the American Burn Association 2025. PMID: 40370328. https://pubmed.ncbi.nlm.nih.gov/40370328/ [17] Lebrun S, Louvet N, Sabourdin N, Constant I. "Early extubations in children intubated prior to arrival in Paediatric Burn ICU: A single center retrospective study over 1520 admissions." Anaesthesia, critical care & pain medicine 2025. PMID: 39988230. https://pubmed.ncbi.nlm.nih.gov/39988230/ [18] Dillon JK, Bhat A, Barnes C, Stewart B, Burke AB. "Oral Endotracheal Tube Stabilization for Facial Burns in Infants-Report of Two Techniques." Journal of burn care & research : official publication of the American Burn Association 2023. PMID: 37232409. https://pubmed.ncbi.nlm.nih.gov/37232409/ [19] Tang JA, Amadio G, Nagappan L, Schmalbach CE, Dion GR. "Laryngeal inhalational injuries: A systematic review." Burns : journal of the International Society for Burn Injuries 2022. PMID: 33814215. https://pubmed.ncbi.nlm.nih.gov/33814215/ [20] Perkins L, Horita H, Adams L, Marshall W, Lee J, Doucet J, et al. "Inhalation Injury: Which Providers Can Assess the Need for Intubation?." Journal of burn care & research : official publication of the American Burn Association 2023. PMID: 37208913. https://pubmed.ncbi.nlm.nih.gov/37208913/ [21] Moshrefi S, Sheckter CC, Shepard K, Pereira C, Davis DJ, Karanas Y, et al. "Preventing Unnecessary Intubations: A 5-Year Regional Burn Center Experience Using Flexible Fiberoptic Laryngoscopy for Airway Evaluation in Patients With Suspected Inhalation or Airway Injury." Journal of burn care & research : official publication of the American Burn Association 2019. PMID: 31222272. https://pubmed.ncbi.nlm.nih.gov/31222272/ [22] Guo GH, Sun W. "[Goal-targeted therapy of inhalation injury with intratracheal delivery of drugs]." Zhonghua shao shang za zhi = Zhonghua shaoshang zazhi = Chinese journal of burns 2018. PMID: 30060345. https://pubmed.ncbi.nlm.nih.gov/30060345/ [23] Chotalia M, Pirrone C, Ali M, Mullhi R, Torlinska B, Mangham T, et al. "The utility of arterial blood gas parameters and chest radiography in predicting appropriate intubations in burn patients with suspected inhalation injury-A retrospective cohort study." Burns : journal of the International Society for Burn Injuries 2021. PMID: 33707087. https://pubmed.ncbi.nlm.nih.gov/33707087/ [24] Kohn S, Stolovas A, Urrestarazu F, Robatto E, Silva J, Aramendi I. "Factors associated with prolonged mechanical ventilation in the burn patient." Burns : journal of the International Society for Burn Injuries 2026. PMID: 41380217. https://pubmed.ncbi.nlm.nih.gov/41380217/ [25] Clayton NA, Hall J, Ward EC, Kol MR, Maitz PK. "Clinical profile and recovery pattern of dysphonia following inhalation injury: A 10-year review." Burns : journal of the International Society for Burn Injuries 2025. PMID: 39721235. https://pubmed.ncbi.nlm.nih.gov/39721235/ [26] Foncerrada G, Culnan DM, Capek KD, González-Trejo S, Cambiaso-Daniel J, Woodson LC, et al. "Inhalation Injury in the Burned Patient." Annals of plastic surgery 2018. PMID: 29461292. https://pubmed.ncbi.nlm.nih.gov/29461292/ [27] Dion GR, Pingree CS, Rico PJ, Christensen CL. "Laryngeal Thermal Injury Model." Journal of burn care & research : official publication of the American Burn Association 2020. PMID: 32087018. https://pubmed.ncbi.nlm.nih.gov/32087018/ [28] Jayawardena A, Lowery AS, Wootten C, Dion GR, Summitt JB, McGrane S, et al. "Early Surgical Management of Thermal Airway Injury: A Case Series." Journal of burn care & research : official publication of the American Burn Association 2019. PMID: 30445620. https://pubmed.ncbi.nlm.nih.gov/30445620/ [29] Hunt JL, Agee RN, Pruitt BA. "Fiberoptic bronchoscopy in acute inhalation injury." The Journal of trauma 1975. PMID: 1152086. https://pubmed.ncbi.nlm.nih.gov/1152086/ [30] Freno D, Sahawneh J, Harrison S, Sahawneh T, Patterson S, Kahn SA. "Determining the role of nasolaryngoscopy in the initial evaluation for upper airway injury in patients with facial burns." Burns : journal of the International Society for Burn Injuries 2018. PMID: 29122412. https://pubmed.ncbi.nlm.nih.gov/29122412/ [31] Cahan LOS, Kotovich D, Hamo MB, Gross M, Cahan SS, Hashavya S. "Fiberoptic laryngoscopy findings in pediatric burn patients referred to the pediatric emergency department." The American journal of emergency medicine 2025. PMID: 39736249. https://pubmed.ncbi.nlm.nih.gov/39736249/ [32] Gigengack RK, Cleffken BI, Loer SA. "Advances in airway management and mechanical ventilation in inhalation injury." Current opinion in anaesthesiology 2020. PMID: 33060384. https://pubmed.ncbi.nlm.nih.gov/33060384/ [33] Lu Y, Zhang W, Zhang Y, Hu X, Xu R, Shi H, et al. "Airway management for patients with tracheal stenosis and severe scar contracture of the face and neck via bronchoscopy: a case report." Journal of cardiothoracic surgery 2024. PMID: 39304900. https://pubmed.ncbi.nlm.nih.gov/39304900/ [34] Fayolle-Pivot L, Magnin C, Tissot S, Bertin-Maghit M, Allaouchiche B. "[Awake intubation using Pentax Airway Scope as an alternative to awake fiberoptic intubation in management of anticipated difficult tracheal intubation in major burn patients]." Annales francaises d'anesthesie et de reanimation 2013. PMID: 23453928. https://pubmed.ncbi.nlm.nih.gov/23453928/ [35] Ali QE, Siddiqui OA, Amir SH, Ahmad S, Jamil S. "[King Vision video laryngoscope for severe post burn contracture neck: an encouraging experience]." Revista brasileira de anestesiologia 2017. PMID: 27662773. https://pubmed.ncbi.nlm.nih.gov/27662773/ [36] Rinaldi P, Canciello S, Sinagoga A, Schettino F, Lauro G, Porcelli ME, et al. "Oxygenation Through the Working Channel of Fiberscope During Awake Tracheal Intubation in Severe Glottic Edema Following Caustic Agents Injury." The Journal of emergency medicine 2026. PMID: 41950691. https://pubmed.ncbi.nlm.nih.gov/41950691/ [37] Hernández-Flores P, Pampin F, Santibañez C, Valenzuela B, Escobar E, Echeverry-Aponte V, et al. "[Advanced Orotracheal Tube Fixation Techniques in Severe Burn Patients: Innovations from a Chilean Hospital]." Revista medica de Chile 2024. PMID: 39450844. https://pubmed.ncbi.nlm.nih.gov/39450844/ [38] Rizzo JA, Haq M, McMahon RA, Aden JK, Brillhart DB, Cancio LC. "Extubation Failure in a Burn Intensive Care Unit: Examination of Contributing Factors." Journal of burn care & research : official publication of the American Burn Association 2021. PMID: 32918478. https://pubmed.ncbi.nlm.nih.gov/32918478/ [39] Nelson C, Weigel I, Galet C, Wibbenmeyer L, Kurjatko A. "Unplanned Extubation in the Burn Unit: A Retrospective Review." Journal of burn care & research : official publication of the American Burn Association 2025. PMID: 39903685. https://pubmed.ncbi.nlm.nih.gov/39903685/ [40] Jones HM, Galet C, Kurjatko A. "How Long Do We Have? A Retrospective Review of Palliative Extubation in the Burn Unit." Journal of burn care & research : official publication of the American Burn Association 2025. PMID: 40709767. https://pubmed.ncbi.nlm.nih.gov/40709767/ [41] Zhu W, Liu W, Zhang Y, Luo W, Li N, Li Y, et al. "A predictive formula for the indication of airway management in burn patients." European journal of medical research 2025. PMID: 41291963. https://pubmed.ncbi.nlm.nih.gov/41291963/ [42] Smailes S, Spoors C, da Costa FM, Martin N, Barnes D. "Early tracheostomy and active exercise programmes in adult intensive care patients with severe burns." Burns : journal of the International Society for Burn Injuries 2022. PMID: 34955297. https://pubmed.ncbi.nlm.nih.gov/34955297/ [43] Janik S, Grasl S, Yildiz E, Besser G, Kliman J, Hacker P, et al. "A new nomogram to predict the need for tracheostomy in burned patients." European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2021. PMID: 33346855. https://pubmed.ncbi.nlm.nih.gov/33346855/ [44] Raimondi N, Vial MR, Calleja J, Quintero A, Cortés Alban A, Celis E, et al. "Evidence-based guides in tracheostomy use in critical patients." Medicina intensiva 2017. PMID: 28188061. https://pubmed.ncbi.nlm.nih.gov/28188061/ [45] Gravvanis AI, Tsoutsos DA, Iconomou TG, Papadopoulos SG. "Percutaneous versus Conventional Tracheostomy in Burned Patients with Inhalation Injury." World journal of surgery 2005. PMID: 16311847. https://pubmed.ncbi.nlm.nih.gov/16311847/ [46] Smailes ST, Ives M, Richardson P, Martin RV, Dziewulski P. "Percutaneous dilational and surgical tracheostomy in burn patients: incidence of complications and dysphagia." Burns : journal of the International Society for Burn Injuries 2014. PMID: 24041514. https://pubmed.ncbi.nlm.nih.gov/24041514/ [47] Feldman MJ, Milner SM, Dhanjani KM, Stjepanovic Z, Gerold K. "Semi-open percutaneous tracheostomy in burn patients." Burns : journal of the International Society for Burn Injuries 2011. PMID: 21474249. https://pubmed.ncbi.nlm.nih.gov/21474249/ [48] Guo M, Li JD. "[Application value of color Doppler ultrasound-guided percutaneous dilational tracheostomy with dilatation forceps in patients with head and neck burns complicated with upper respiratory tract obstruction]." Zhonghua shao shang za zhi = Zhonghua shaoshang zazhi = Chinese journal of burns 2019. PMID: 31154739. https://pubmed.ncbi.nlm.nih.gov/31154739/ [49] Schlossmacher P, Martinet O, Testud R, Agesilas F, Benhamou L, Gauzëre BA. "Emergency percutaneous tracheostomy in a severely burned patient with upper airway obstruction and circulatory arrest." Resuscitation 2006. PMID: 16325326. https://pubmed.ncbi.nlm.nih.gov/16325326/ [50] Qing Y, Cen Y, Liu XX, Xu XW, Wang HS. "[Analysis of extubation time and late complications after early tracheotomy in patients with inhalation injury]." Zhonghua shao shang za zhi = Zhonghua shaoshang zazhi = Chinese journal of burns 2011. PMID: 21651848. https://pubmed.ncbi.nlm.nih.gov/21651848/ [51] Trivedi S, Thaware P, Kushwaha J, Lakra AP, Ankita, R M, et al. "Emergency bedside fibreoptic bronchoscopy for mucus plug-related dynamic airway obstruction causing extreme hypercapnia in post-corrosive tracheal stenosis." BMJ case reports 2026. PMID: 41535062. https://pubmed.ncbi.nlm.nih.gov/41535062/ [52] Jiang J, Bai Y, Tang J, Shen X, Zhou J, Li Y. "The multidisciplinary strategy to severe neck contracture and complex post-tracheostomy tracheal stenosis: A case report." Medicine 2026. PMID: 41560059. https://pubmed.ncbi.nlm.nih.gov/41560059/ [53] Furák J, Szakács L, Nagy A, Rovó L. "Multiple costal cartilage graft reconstruction for the treatment of a full-length laryngotracheal stenosis after an inhalation burn." Interactive cardiovascular and thoracic surgery 2011. PMID: 21798888. https://pubmed.ncbi.nlm.nih.gov/21798888/ [54] Camargo L, Heiman AJ, Ricci JA. "Closure of Persistent Tracheocutaneous Fistulas in Pediatric Burn Patients." Journal of burn care & research : official publication of the American Burn Association 2020. PMID: 32112079. https://pubmed.ncbi.nlm.nih.gov/32112079/ [55] Dhanani J, Pincus J, Townsend S, Pang G, Vujcich E, Windsor M, et al. "Delayed Tracheoesophageal Fistula and Refractory Respiratory Failure Caused by Inhalation Burns and Emergency Venovenous ECMO to Facilitate Its Management: A Case Report." Journal of burn care & research : official publication of the American Burn Association 2023. PMID: 36941770. https://pubmed.ncbi.nlm.nih.gov/36941770/ [56] Liu B, Wan JB, Zhang GA. "[Morphological and pathological changes of larynx after severe laryngeal burn in dogs and their relationship with laryngostenosis]." Zhonghua shao shang za zhi = Zhonghua shaoshang zazhi = Chinese journal of burns 2018. PMID: 30157560. https://pubmed.ncbi.nlm.nih.gov/30157560/ [57] Hebert S, Erdogan M, Green RS, Rasmussen J. "The Use of Extracorporeal Membrane Oxygenation in Severely Burned Patients: A Survey of North American Burn Centers." Journal of burn care & research : official publication of the American Burn Association 2022. PMID: 34091669. https://pubmed.ncbi.nlm.nih.gov/34091669/ [58] Suzuki Y, Williams TP, Patino J, Zhu M, Colvill KM, Brooks K, et al. "Extracorporeal Membrane Oxygenation for Pediatric Burn Patients: Is Management Improving Over Time?." ASAIO journal (American Society for Artificial Internal Organs : 1992) 2022. PMID: 35213886. https://pubmed.ncbi.nlm.nih.gov/35213886/ [59] Pavez R A, Martínez MP. "Dysphagia in the burn patient: Experience in a National Burn Reference Centre." Burns : journal of the International Society for Burn Injuries 2019. PMID: 30691929. https://pubmed.ncbi.nlm.nih.gov/30691929/ [60] Nourmohammadi F, Rahimzadegan-Marefat S, Ghoreishi ZS, Bakhtiyari J, Ghanbari S. "Oropharyngeal Dysphagia and Odynophagia in Patients with Thermal Burn Injuries." Dysphagia 2026. PMID: 41085790. https://pubmed.ncbi.nlm.nih.gov/41085790/ [61] Jayawardena ADL, Bouhabel S, Sheridan RL, Hartnick CJ. "Laryngotracheal Reconstruction in the Pediatric Burn Patient: Surgical Techniques and Decision Making." Journal of burn care & research : official publication of the American Burn Association 2020. PMID: 32112103. https://pubmed.ncbi.nlm.nih.gov/32112103/ [62] Yaneza MM, Kubba H, Wynne DM, Clement WA. "Cricoid split for acute subglottic injury in the older child." International journal of pediatric otorhinolaryngology 2012. PMID: 22537842. https://pubmed.ncbi.nlm.nih.gov/22537842/ [63] Iglesias NJ, Prasai A, Golovko G, Ozhathil DK, Wolf SE. "Retrospective outcomes analysis of tracheostomy in a paediatric burn population." Burns : journal of the International Society for Burn Injuries 2023. PMID: 35523658. https://pubmed.ncbi.nlm.nih.gov/35523658/ [64] Fedor CJ, Arellano JA, Liu HY, Kaulakis MG, Corcos AC, Siedsma MP, et al. "Clearing the Air: Impact of COPD on Inhalation Injury Outcomes." Journal of burn care & research : official publication of the American Burn Association 2025. PMID: 40483684. https://pubmed.ncbi.nlm.nih.gov/40483684/ [65] Wu Y, Jiao X, Jiang Z. "[Application and efficacy of inverted U-shaped flap combined with prepositioned guidewire technique in airway management for patients with severe burns]." Zhonghua wei zhong bing ji jiu yi xue 2026. PMID: 41958135. https://pubmed.ncbi.nlm.nih.gov/41958135/