Tracheostomy complicating massive burn injury. A plea for conservatism

The effective management of extensively burned patients is significantly compromised by the presence of an indwelling tracheostomy tube. In our series of twenty-five patients studied, all with burns exceeding 55 per cent of the body surface area, nine were managed with tracheostomy and sixteen without it. The incidence of pulmonary sepsis was 78 and 12.5 per cent, respectively, and cumulative mortality figures were 100 and 25 per cent, respectively. One hundred per cent correlation was noted between wound cultures and endotracheal aspirate cultures. The reduction in cross contamination afforded by the use of Bacteria-Controlled Nursing Units [14,15] strongly implicates wound-lung autoinfection as the common denominator, although certain more peripheral factors such as decreased lung bacterial clearance in the presence of sepsis, the use of continuous positive pressure ventilation to maintain tissue oxygenation, and hematogenously borne lung infection (septic emboli) clearly play an important role. Although tracheostomy in patients with true inhalation thermal injury may be life-saving, its injudicious application in this clinical setting may be fatal. Enthusiasm must be tempered with thorough clinical evaluation and sound judgment.