More Than One Third of Intubations in Patients Transferred to Burn Centers are Unnecessary: Proposed Guidelines for Appropriate Intubation of the Burn Patient

Advanced Burn Life Support emphasizes endotracheal intubation for patients with facial burns before transfer to a burn center to prevent airway obstruction. Many patients are intubated before transport and are often extubated shortly after burn center arrival. We hypothesize that many intubations performed before burn center transport are unnecessary. We conducted a retrospective review of all adults who were intubated before burn transfer and survived to discharge from August 2003 to June 2013. Intubations that had 2 or fewer ventilator days (i.e., potentially unnecessary intubations) were compared with those lasting longer than 2 days. Data collected included age, ventilator days, length of stay, % TBSA burn, % second degree, % third degree, % second degree face burn, % third degree face burn, and origin of burns. A total of 416 patient met inclusion criteria. Of these, 129 patients (31.0%) were intubated less than or equal to 1 day, and a total of 171 (40.1%) patients remained intubated for less than or equal to 2 days. Patients who were intubated less than or equal to 2 days differed from those intubated more than 2 days with respect to % TBSA burn (10.2 ± 8.1 vs 30.8 ± 19.7, P < .001), % third degree burn (2.84 ± 5.6 vs 22.5 ± 19.6, P < .001), % third degree face burn (0.14 ± 0.7 vs 0.94 ± 1.9, P < .001), and hospital days (11.7 ± 10.6 vs 50.7 ± 43.7, P < .001). Additionally, patients who were intubated less than or equal to 2 days were more likely to have been intubated in the pre–burn center setting (74.9% vs 51.8%, P < .001) and to have been burned outdoors (42.1% vs 24.9%; P < .001) than those who were intubated more than 2 days. Multivariate analysis revealed that intubation longer than 2 days was independently associated with older age and larger % TBSA burn. There were no reintubations in patients who were intubated 2 days or less. As a burn community, we have emphasized early intubation before transfer for those who have sustained significant burns, inhalational injury, or facial burns. Unfortunately, this has led to many potentially unnecessary intubations that expose patients to unnecessary complications. Although early intubation is a lifesaving intervention for many burn patients, criteria should be developed to determine when intubation is not needed.