Airway management in a patient with Stevens-Johnson syndrome/toxic epidermal necrolysis: a case report

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) represent a spectrum of cutaneous hypersensitivity reactions, often drug-induced, with a mortality rate of up to 30%^1,2. Characterized by varying degrees of blistering, epidermal detachment, and mucosal ulceration, SJS/TEN can present with widespread skin and mucosal involvement affecting the lips, oral cavity, eyes, and the respiratory, gastrointestinal, and genital tracts². Multiorgan failure is possible and immunosuppressive therapies may be administered for treatment. Patients with more extensive disease are often admitted to an intensive care/burn unit for supportive treatment including wound care and circulatory and respiratory support, where a secure airway may be necessary.

Sedation and airway management in such situations can present unique challenges owing to difficulties with facemask placement on affected facial skin and the potential for airway instrumentation to cause further trauma to ulcerated and inflamed oral mucosa. Endoscopic techniques may be hampered by limited patient cooperation, difficult topical anesthesia of disrupted mucosa, and intra-oral blood and debris.

We present a case of endotracheal intubation utilizing apneic oxygenation with THRIVE in a patient with SJS/TEN complicated by facial skin and oral mucosal involvement affecting the lips and tongue. After review of the literature, this is the first case to report details of effective and safe airway management using THRIVE in a patient with this condition.

Case presentation

A previously healthy 16-year-old female was hospitalized after developing a widespread rash following initiation of several medications for anxiety and depression, including buspirone, olanzapine, lamotrigine, and escitalopram. After rapid progression of erythematous blistering and involvement of the eyes, oral mucosa, and genital tract, she was transferred to our center for intensive care admission with a clinical diagnosis of SJS/TEN, later confirmed by histologic analysis of a skin biopsy. In view of her deteriorating condition, endotracheal intubation was felt to be necessary, thus anesthesiology was consulted for assistance.

Physical examination demonstrated normal dentition and mouth opening limited by pain, with severe blistering and ulceration of her lips and tongue. Skin bullae were present over the face and neck. Intraoral examination was not possible. There was no evidence of altered voice or stridor and she was not dyspneic. Body mass index (BMI) was 17. Flexible nasopharyngoscopy was considered to examine the glottic inlet, to confirm absence of edema or obstruction, but was deferred as there were no clinical features suggestive of this.

Facemask ventilation was, in this setting, anticipated to be difficult, if not impossible given the presence of lesions. Awake endoscopic intubation was predicted to be challenging, with concerns for limited patient cooperation, difficult airway topicalization and the likelihood of endoscope advancement causing further tissue trauma and bleeding in an already inflamed and ulcerated airway.

An alternative approach was taken, utilizing THRIVE (Fisher and Paykel Optiflow THRIVE, New Zealand, Fig. 1) to preoxygenate and support apneic oxygenation while intubation was attempted following induction of anesthesia. In the absence of a history of obstructive sleep apnea (OSA) or elevated BMI and without clinical features of laryngeal edema or obstruction, it was further anticipated that THRIVE would be effective³, with the soft silicone nasal prongs of the THRIVE delivery tubing likely to be better tolerated than a facemask.

Video laryngoscopy was planned with a hyperangulated blade, to minimize force exerted against ulcerated and inflamed areas on the lips and tongue. On the basis of anatomic airway assessment, laryngoscopy was not predicted to be difficult though equipment for endoscopic intubation was present as was the otolaryngology service, to assist with any unanticipated challenges. The procedure was performed in the operating room.

Preoxygenation was achieved using THRIVE to deliver oxygen at 40 L/min for 3 minutes. Anesthesia was induced with propofol followed by rocuronium for neuromuscular blockade. Oxygen flow was increased to 70 L/min, while maintaining gentle jaw thrust, allowing for apneic oxygenation. On advancing the hyperangulated laryngoscope blade, there was limited mucosal involvement beyond the anterior part of the tongue and no glottic edema; intubation with a 7mm endotracheal tube was straightforward and atraumatic. Oxygen saturation was maintained at 100% throughout the apneic period.

Discussion

The Society of Dermatology Hospitalists provides supportive guidelines for airway management that include obtaining imaging, arterial blood gases, providing pulmonary toilet, and considering flexible laryngoscopy and bronchoscopy if there are signs of respiratory distress, however, indications for intubation are not well defined¹. A small retrospective case series of SJS/TEN cases found oral mucosal involvement and the need for procedural sedation to be the main causes for intubation⁴. Laryngeal edema was seen in 29% of patients intubated for SJS/TEN though this was not predictive of the need for intubation⁴. Others have recognized an absence of guidelines for intubation in SJS/TEN, though indications for intubation and early tracheostomy in these patients have been described, which includes oral involvement with either total body surface area affected from hospital day 1–3 of at least 15%, underlying neurological diagnosis preventing airway protection, or documented airway involvement on direct laryngoscopy⁵.

In the absence of existing guidance on methods of intubation, we suggest a use for THRIVE for selected cases of SJS/TEN, to preoxygenate and maintain apneic oxygenation, avoiding exacerbation of skin and airway involvement with placement of a facemask and airway adjuncts where there is face and oral mucosal involvement (Fig. 2).

THRIVE, also known as high-flow nasal oxygen therapy, was initially introduced in the critical care setting to facilitate oxygenation in patients with acute hypoxemic respiratory failure and following extubation, as an alternative to noninvasive ventilation. It has also found increasing use in recent years in the operating room as a method for preoxygenation and when used with total intravenous anesthesia, for apneic oxygenation, utilizing aventilatory mass flow of oxygen into the lungs.

THRIVE allows for effective extended apneic oxygenation in patients without obstructive pathologies or elevated BMI³, with our institution considering a BMI >35 as a threshold for caution. In considering alternatives to awake endoscopic intubation, the use of THRIVE in SJS/TEN, as reported here, should strongly be considered in the absence of obstructive symptoms, where BMI is favorable and laryngoscopy is anticipated to be straightforward.

References