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Airway Burns in an Infant following Aspiration of Microwave-heated Tea

1986; Elsevier BV; Volume: 90; Issue: 4 Linguagem: Inglês

10.1378/chest.90.4.621

1931-3543

Jeffery S. Garland, Thomas B. Rice, Kevin J. Kelly,

Tracheal and airway disorders

Airway obstruction developed in an infant who sustained thermal burns to the oropharynx and trachea after he aspirated microwave-heated tea. Bronchoscopic examination revealed upper and lower airway hyperemia, edema and blister formation. Physicians should be aware of this potential hazard of microwave-heated fluid. Early assessment and stabilization of the airway is important following scald injuries to the face and oropharynx. Airway obstruction developed in an infant who sustained thermal burns to the oropharynx and trachea after he aspirated microwave-heated tea. Bronchoscopic examination revealed upper and lower airway hyperemia, edema and blister formation. Physicians should be aware of this potential hazard of microwave-heated fluid. Early assessment and stabilization of the airway is important following scald injuries to the face and oropharynx. Oropharyngeal and esophageal scald injuries from ingesting food or liquid preheated in a microwave oven have been briefly reported in both the adult and pediatric literature.1Sando WC Gallaher KJ Rodgers BM Risk factors for microwave scald injuries in infants.J Pediatr. 1984; 105: 864-867Abstract Full Text PDF PubMed Scopus (42) Google Scholar, 2Lieberman DA Keeffe EB Esophageal burn and the microwave oven.Ann Intern Med. 1982; 97: 137Crossref PubMed Scopus (14) Google Scholar Scald injuries to the respiratory tract—unless associated with steam inhalation3Vivori E Cudmore RE Rickham PP Hecker CS Prevot J Inhalation injury to the respiratory tract of children in the management of the burned child. Urban and Schwarzenberg, Baltimore1981: 173-188Google Scholar—are rare, and respiratory burns induced by microwave-heated liquids have not been reported. To alert physicians to potentially serious burns following accidental ingestion of microwave-heated liquid, we report a microwave-related thermal injury to the airway of a 14-month-old infant.CASE REPORTA 14-month-old black male infant sustained first and second degree burns to his mouth, perioral region, chin, neck and upper chest after spilling a cup of microwave-heated tea. Physical examination revealed a crying, drooling child in minimal distress with first and second degree burns to his lips, lower mandible, anterior neck and chest Vital signs were: pulse 140 bpm, temperature 37.8°C, respiratory rate 24 breaths/min, and blood pressure 120/65 mm Hg. Examination of the mouth revealed erythema and bullae on the soft and hard palates, tongue and posterior pharynx. Chest auscultation revealed rhonchi and inspiratory stridor. No costal or subcostal retractions were noted.Airway control was obtained with a deflated 4.5 mm cuffed tube. A leak was present. Bullae were noted at the base of the tongue. The epiglottis was noted to be markedly swollen and erythematous. Chest radiographic examination demonstrated a right middle lobe infiltrate. Blood gas levels were normal. Except for an elevated white blood cell count of 24,600 cells/L, the complete blood cell count was normal. Tracheal aspirate taken at admission was unremarkable.Routine burn care was initiated, and the patient was easily weaned and extubated on the fourth day. No leak around the tube was present at extubation. Stridor, which was present immediately postextubation, increased over the next three days. Frequent racemic epinephrine treatments and mist-tent therapy were ineffective in controlling upper airway obstruction. Flexible bronchoscopic examination revealed an edematous epiglottis with erythematous borders. The arytenoids and vocal cords were markedly edematous. A hyperemic bleb was noted on the right arytenoid (Fig 1). The first 2 centimeters of the trachea were hemorrhagic with blisters and ulcerations on the lateral and anterior walls (Fig 2). Distal airways were normal.Figure 1BBronchoscopic view of the first 2 centimeters of the subglottic trachea. Hyperemia with ulceration and blister formation is noted on the lateral and anterior walls.View Large Image Figure ViewerDownload (PPT)Nafcillin, dexamethasone and racemic epinephrine therapy was given over the next several days. As stridor diminished, therapy was tapered. Repeat bronchoscopic examination five days later revealed mild epiglottic erythema and several small areas of inflammation in the first 2 centimeters of the subglottic region. As bronchoscopic findings improved, so did oral mucosal lesions and posterior pharynx lesions. A third bronchoscopic study done 17 days after admission showed complete resolution of all lesions. The patient was discharged without residual damage.DISCUSSIONDuring the first three years of life, cutaneous scald burns occurring in the bathroom or kitchen are one of the most common types of accidental burns.4Muir I. Burns and their treatment Chicago: Year Book Medical Publishers, Inc, 1974Google Scholar Airway burns, which are much less common, may be caused by several mechanisms. Inhalation of hot dry gases results in lesions to the nasopharynx and larynx. Distal airways are left undamaged because insufficient residual heat remains to burn lung tissue.3Vivori E Cudmore RE Rickham PP Hecker CS Prevot J Inhalation injury to the respiratory tract of children in the management of the burned child. Urban and Schwarzenberg, Baltimore1981: 173-188Google Scholar Direct injury to the airway and lungs from aspiration of hot liquids has also been reported.5Jung RC Gottlieb LS Respiratory tract burns after aspiration of hot coffee.Chest. 1977; 72: 125-127Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Finally, steam inhalation may result in significant airway burns. The entire respiratory tract, including the lungs, can be involved because of the latent heat released during water condensation in the respiratory tract.3Vivori E Cudmore RE Rickham PP Hecker CS Prevot J Inhalation injury to the respiratory tract of children in the management of the burned child. Urban and Schwarzenberg, Baltimore1981: 173-188Google Scholar We suspect that burns sustained by our patient were secondary to the latter two mechanisms. He may have aspirated liquid as he dropped the cup from his hands and began crying, resulting in scald and steam injuries to his airway above and below the cords. Jung described an adult who aspirated hot coffee and suffered injuries similar to those sustained by our patient.5Jung RC Gottlieb LS Respiratory tract burns after aspiration of hot coffee.Chest. 1977; 72: 125-127Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Bronchoscopic examination four days after the initial injury revealed hemorrhagic, edematous mucosa with ulcerations to the level of segmental bronchial spurs.5Jung RC Gottlieb LS Respiratory tract burns after aspiration of hot coffee.Chest. 1977; 72: 125-127Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar As the lesions healed, granuloma-like lesions were noted on the bronchial walls 12 days after the initial burn.5Jung RC Gottlieb LS Respiratory tract burns after aspiration of hot coffee.Chest. 1977; 72: 125-127Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar These lesions were similar to the lesion we noted in the trachea of our patient seven days after the burn. Others have reported children with scald injuries to the face and neck with secondary steam inhalation.3Vivori E Cudmore RE Rickham PP Hecker CS Prevot J Inhalation injury to the respiratory tract of children in the management of the burned child. Urban and Schwarzenberg, Baltimore1981: 173-188Google Scholar In these cases, severe airway burns resulted in airway obstruction some hours later. Severe airway obstruction was prevented in our patient by prophylactic intubation. Localized infection or mechanical trauma from the endotracheal tube may have irritated the patient's already damaged supra-and subglottic regions. Such damage may have aggravated our patient's airway obstruction.Burns to the respiratory system from microwave-heated substances have not been reported. Microwave-heated bottles or cups of liquid can be particularly dangerous because of the discrepancy in temperature that may exist between the outside of the bottle or cup and the liquid inside. Sando et al1Sando WC Gallaher KJ Rodgers BM Risk factors for microwave scald injuries in infants.J Pediatr. 1984; 105: 864-867Abstract Full Text PDF PubMed Scopus (42) Google Scholar reported an infant who sustained oropharyngeal burns secondary to formula that had been heated in a microwave oven and ingested after the outside of the plastic bottle was judged to be cool. Similarly, our patient grabbed a cup of hot liquid from the microwave that felt cool to him.The injuries sustained by our patient, as well as his clinical course, serve to point out several important aspects of respiratory tract burn prevention and treatment in pediatric patients. Parents and caretakers of infants and small children should be warned about this potentially dangerous microwave hazard. Bottles or food heated in the microwave should be pre-tested directly rather than relying on the temperature of the container. Just as liquids heated on conventional stoves are kept well out of reach of children, so should microwave-heated fluids. Furthermore, any scald injury to the face or neck should lead to a careful investigation of the oral mucosa for evidence of burns. If present, early bronchoscopic examination to assess the injury or prophylactic intubation to protect the airway should be considered. If intubation is required, it should be done with an endotracheal tube that allows for a leak. Adequate sedation and restraints may be required to prevent further endotracheal tube damage to the already injured airway. Oropharyngeal and esophageal scald injuries from ingesting food or liquid preheated in a microwave oven have been briefly reported in both the adult and pediatric literature.1Sando WC Gallaher KJ Rodgers BM Risk factors for microwave scald injuries in infants.J Pediatr. 1984; 105: 864-867Abstract Full Text PDF PubMed Scopus (42) Google Scholar, 2Lieberman DA Keeffe EB Esophageal burn and the microwave oven.Ann Intern Med. 1982; 97: 137Crossref PubMed Scopus (14) Google Scholar Scald injuries to the respiratory tract—unless associated with steam inhalation3Vivori E Cudmore RE Rickham PP Hecker CS Prevot J Inhalation injury to the respiratory tract of children in the management of the burned child. Urban and Schwarzenberg, Baltimore1981: 173-188Google Scholar—are rare, and respiratory burns induced by microwave-heated liquids have not been reported. To alert physicians to potentially serious burns following accidental ingestion of microwave-heated liquid, we report a microwave-related thermal injury to the airway of a 14-month-old infant. CASE REPORTA 14-month-old black male infant sustained first and second degree burns to his mouth, perioral region, chin, neck and upper chest after spilling a cup of microwave-heated tea. Physical examination revealed a crying, drooling child in minimal distress with first and second degree burns to his lips, lower mandible, anterior neck and chest Vital signs were: pulse 140 bpm, temperature 37.8°C, respiratory rate 24 breaths/min, and blood pressure 120/65 mm Hg. Examination of the mouth revealed erythema and bullae on the soft and hard palates, tongue and posterior pharynx. Chest auscultation revealed rhonchi and inspiratory stridor. No costal or subcostal retractions were noted.Airway control was obtained with a deflated 4.5 mm cuffed tube. A leak was present. Bullae were noted at the base of the tongue. The epiglottis was noted to be markedly swollen and erythematous. Chest radiographic examination demonstrated a right middle lobe infiltrate. Blood gas levels were normal. Except for an elevated white blood cell count of 24,600 cells/L, the complete blood cell count was normal. Tracheal aspirate taken at admission was unremarkable.Routine burn care was initiated, and the patient was easily weaned and extubated on the fourth day. No leak around the tube was present at extubation. Stridor, which was present immediately postextubation, increased over the next three days. Frequent racemic epinephrine treatments and mist-tent therapy were ineffective in controlling upper airway obstruction. Flexible bronchoscopic examination revealed an edematous epiglottis with erythematous borders. The arytenoids and vocal cords were markedly edematous. A hyperemic bleb was noted on the right arytenoid (Fig 1). The first 2 centimeters of the trachea were hemorrhagic with blisters and ulcerations on the lateral and anterior walls (Fig 2). Distal airways were normal.Nafcillin, dexamethasone and racemic epinephrine therapy was given over the next several days. As stridor diminished, therapy was tapered. Repeat bronchoscopic examination five days later revealed mild epiglottic erythema and several small areas of inflammation in the first 2 centimeters of the subglottic region. As bronchoscopic findings improved, so did oral mucosal lesions and posterior pharynx lesions. A third bronchoscopic study done 17 days after admission showed complete resolution of all lesions. The patient was discharged without residual damage. A 14-month-old black male infant sustained first and second degree burns to his mouth, perioral region, chin, neck and upper chest after spilling a cup of microwave-heated tea. Physical examination revealed a crying, drooling child in minimal distress with first and second degree burns to his lips, lower mandible, anterior neck and chest Vital signs were: pulse 140 bpm, temperature 37.8°C, respiratory rate 24 breaths/min, and blood pressure 120/65 mm Hg. Examination of the mouth revealed erythema and bullae on the soft and hard palates, tongue and posterior pharynx. Chest auscultation revealed rhonchi and inspiratory stridor. No costal or subcostal retractions were noted. Airway control was obtained with a deflated 4.5 mm cuffed tube. A leak was present. Bullae were noted at the base of the tongue. The epiglottis was noted to be markedly swollen and erythematous. Chest radiographic examination demonstrated a right middle lobe infiltrate. Blood gas levels were normal. Except for an elevated white blood cell count of 24,600 cells/L, the complete blood cell count was normal. Tracheal aspirate taken at admission was unremarkable. Routine burn care was initiated, and the patient was easily weaned and extubated on the fourth day. No leak around the tube was present at extubation. Stridor, which was present immediately postextubation, increased over the next three days. Frequent racemic epinephrine treatments and mist-tent therapy were ineffective in controlling upper airway obstruction. Flexible bronchoscopic examination revealed an edematous epiglottis with erythematous borders. The arytenoids and vocal cords were markedly edematous. A hyperemic bleb was noted on the right arytenoid (Fig 1). The first 2 centimeters of the trachea were hemorrhagic with blisters and ulcerations on the lateral and anterior walls (Fig 2). Distal airways were normal. Nafcillin, dexamethasone and racemic epinephrine therapy was given over the next several days. As stridor diminished, therapy was tapered. Repeat bronchoscopic examination five days later revealed mild epiglottic erythema and several small areas of inflammation in the first 2 centimeters of the subglottic region. As bronchoscopic findings improved, so did oral mucosal lesions and posterior pharynx lesions. A third bronchoscopic study done 17 days after admission showed complete resolution of all lesions. The patient was discharged without residual damage. DISCUSSIONDuring the first three years of life, cutaneous scald burns occurring in the bathroom or kitchen are one of the most common types of accidental burns.4Muir I. Burns and their treatment Chicago: Year Book Medical Publishers, Inc, 1974Google Scholar Airway burns, which are much less common, may be caused by several mechanisms. Inhalation of hot dry gases results in lesions to the nasopharynx and larynx. Distal airways are left undamaged because insufficient residual heat remains to burn lung tissue.3Vivori E Cudmore RE Rickham PP Hecker CS Prevot J Inhalation injury to the respiratory tract of children in the management of the burned child. Urban and Schwarzenberg, Baltimore1981: 173-188Google Scholar Direct injury to the airway and lungs from aspiration of hot liquids has also been reported.5Jung RC Gottlieb LS Respiratory tract burns after aspiration of hot coffee.Chest. 1977; 72: 125-127Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Finally, steam inhalation may result in significant airway burns. The entire respiratory tract, including the lungs, can be involved because of the latent heat released during water condensation in the respiratory tract.3Vivori E Cudmore RE Rickham PP Hecker CS Prevot J Inhalation injury to the respiratory tract of children in the management of the burned child. Urban and Schwarzenberg, Baltimore1981: 173-188Google Scholar We suspect that burns sustained by our patient were secondary to the latter two mechanisms. He may have aspirated liquid as he dropped the cup from his hands and began crying, resulting in scald and steam injuries to his airway above and below the cords. Jung described an adult who aspirated hot coffee and suffered injuries similar to those sustained by our patient.5Jung RC Gottlieb LS Respiratory tract burns after aspiration of hot coffee.Chest. 1977; 72: 125-127Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Bronchoscopic examination four days after the initial injury revealed hemorrhagic, edematous mucosa with ulcerations to the level of segmental bronchial spurs.5Jung RC Gottlieb LS Respiratory tract burns after aspiration of hot coffee.Chest. 1977; 72: 125-127Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar As the lesions healed, granuloma-like lesions were noted on the bronchial walls 12 days after the initial burn.5Jung RC Gottlieb LS Respiratory tract burns after aspiration of hot coffee.Chest. 1977; 72: 125-127Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar These lesions were similar to the lesion we noted in the trachea of our patient seven days after the burn. Others have reported children with scald injuries to the face and neck with secondary steam inhalation.3Vivori E Cudmore RE Rickham PP Hecker CS Prevot J Inhalation injury to the respiratory tract of children in the management of the burned child. Urban and Schwarzenberg, Baltimore1981: 173-188Google Scholar In these cases, severe airway burns resulted in airway obstruction some hours later. Severe airway obstruction was prevented in our patient by prophylactic intubation. Localized infection or mechanical trauma from the endotracheal tube may have irritated the patient's already damaged supra-and subglottic regions. Such damage may have aggravated our patient's airway obstruction.Burns to the respiratory system from microwave-heated substances have not been reported. Microwave-heated bottles or cups of liquid can be particularly dangerous because of the discrepancy in temperature that may exist between the outside of the bottle or cup and the liquid inside. Sando et al1Sando WC Gallaher KJ Rodgers BM Risk factors for microwave scald injuries in infants.J Pediatr. 1984; 105: 864-867Abstract Full Text PDF PubMed Scopus (42) Google Scholar reported an infant who sustained oropharyngeal burns secondary to formula that had been heated in a microwave oven and ingested after the outside of the plastic bottle was judged to be cool. Similarly, our patient grabbed a cup of hot liquid from the microwave that felt cool to him.The injuries sustained by our patient, as well as his clinical course, serve to point out several important aspects of respiratory tract burn prevention and treatment in pediatric patients. Parents and caretakers of infants and small children should be warned about this potentially dangerous microwave hazard. Bottles or food heated in the microwave should be pre-tested directly rather than relying on the temperature of the container. Just as liquids heated on conventional stoves are kept well out of reach of children, so should microwave-heated fluids. Furthermore, any scald injury to the face or neck should lead to a careful investigation of the oral mucosa for evidence of burns. If present, early bronchoscopic examination to assess the injury or prophylactic intubation to protect the airway should be considered. If intubation is required, it should be done with an endotracheal tube that allows for a leak. Adequate sedation and restraints may be required to prevent further endotracheal tube damage to the already injured airway. During the first three years of life, cutaneous scald burns occurring in the bathroom or kitchen are one of the most common types of accidental burns.4Muir I. Burns and their treatment Chicago: Year Book Medical Publishers, Inc, 1974Google Scholar Airway burns, which are much less common, may be caused by several mechanisms. Inhalation of hot dry gases results in lesions to the nasopharynx and larynx. Distal airways are left undamaged because insufficient residual heat remains to burn lung tissue.3Vivori E Cudmore RE Rickham PP Hecker CS Prevot J Inhalation injury to the respiratory tract of children in the management of the burned child. Urban and Schwarzenberg, Baltimore1981: 173-188Google Scholar Direct injury to the airway and lungs from aspiration of hot liquids has also been reported.5Jung RC Gottlieb LS Respiratory tract burns after aspiration of hot coffee.Chest. 1977; 72: 125-127Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Finally, steam inhalation may result in significant airway burns. The entire respiratory tract, including the lungs, can be involved because of the latent heat released during water condensation in the respiratory tract.3Vivori E Cudmore RE Rickham PP Hecker CS Prevot J Inhalation injury to the respiratory tract of children in the management of the burned child. Urban and Schwarzenberg, Baltimore1981: 173-188Google Scholar We suspect that burns sustained by our patient were secondary to the latter two mechanisms. He may have aspirated liquid as he dropped the cup from his hands and began crying, resulting in scald and steam injuries to his airway above and below the cords. Jung described an adult who aspirated hot coffee and suffered injuries similar to those sustained by our patient.5Jung RC Gottlieb LS Respiratory tract burns after aspiration of hot coffee.Chest. 1977; 72: 125-127Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Bronchoscopic examination four days after the initial injury revealed hemorrhagic, edematous mucosa with ulcerations to the level of segmental bronchial spurs.5Jung RC Gottlieb LS Respiratory tract burns after aspiration of hot coffee.Chest. 1977; 72: 125-127Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar As the lesions healed, granuloma-like lesions were noted on the bronchial walls 12 days after the initial burn.5Jung RC Gottlieb LS Respiratory tract burns after aspiration of hot coffee.Chest. 1977; 72: 125-127Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar These lesions were similar to the lesion we noted in the trachea of our patient seven days after the burn. Others have reported children with scald injuries to the face and neck with secondary steam inhalation.3Vivori E Cudmore RE Rickham PP Hecker CS Prevot J Inhalation injury to the respiratory tract of children in the management of the burned child. Urban and Schwarzenberg, Baltimore1981: 173-188Google Scholar In these cases, severe airway burns resulted in airway obstruction some hours later. Severe airway obstruction was prevented in our patient by prophylactic intubation. Localized infection or mechanical trauma from the endotracheal tube may have irritated the patient's already damaged supra-and subglottic regions. Such damage may have aggravated our patient's airway obstruction. Burns to the respiratory system from microwave-heated substances have not been reported. Microwave-heated bottles or cups of liquid can be particularly dangerous because of the discrepancy in temperature that may exist between the outside of the bottle or cup and the liquid inside. Sando et al1Sando WC Gallaher KJ Rodgers BM Risk factors for microwave scald injuries in infants.J Pediatr. 1984; 105: 864-867Abstract Full Text PDF PubMed Scopus (42) Google Scholar reported an infant who sustained oropharyngeal burns secondary to formula that had been heated in a microwave oven and ingested after the outside of the plastic bottle was judged to be cool. Similarly, our patient grabbed a cup of hot liquid from the microwave that felt cool to him. The injuries sustained by our patient, as well as his clinical course, serve to point out several important aspects of respiratory tract burn prevention and treatment in pediatric patients. Parents and caretakers of infants and small children should be warned about this potentially dangerous microwave hazard. Bottles or food heated in the microwave should be pre-tested directly rather than relying on the temperature of the container. Just as liquids heated on conventional stoves are kept well out of reach of children, so should microwave-heated fluids. Furthermore, any scald injury to the face or neck should lead to a careful investigation of the oral mucosa for evidence of burns. If present, early bronchoscopic examination to assess the injury or prophylactic intubation to protect the airway should be considered. If intubation is required, it should be done with an endotracheal tube that allows for a leak. Adequate sedation and restraints may be required to prevent further endotracheal tube damage to the already injured airway. We would like to thank Mrs. Frances Sommer for secretarial assistance and Mrs. Cynthia Garland for editing this manuscript.