Airway involvement and mechanical ventilation in Steven Johnson Syndrome and Toxic Epidermal Necrolysis management

Steven-Johnson syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are severe drug allergic reactions characterized by skin and mucosal membrane detachments. Most of the literature focuses only on the skin and ocular mucosal damage, but more severe and life-threatening mucosal damage may actually occur in the respiratory tract. This airway involvement may cause an acute complication, e.g. acute respiratory failure, and chronic complications, e.g. bronchiolitis organizing pneumonia, bronchiectasis, and restrictive bronchiolitis. The presence of airway involvement in SJS/TEN requires a more detailed examination, ranging from examination of the ear, nose, and throat (ENT), to fiberoptic bronchoscopy done by a skilled clinician to determine the presence of bronchial epithelial detachment. A higher percentage of skin and mucosal detachment is associated with a greater need for mechanical ventilation. Male sex, age, low serum bicarbonate, high serum urea, and higher amount of infiltrate on chest X-rays are also associated with a higher risk for mechanical ventilation in patients with SJS/TEN. The general indications for intubation and mechanical ventilation in patients with SJS/TEN are respiratory failures, inability to clear the airway, shock, neurologic disorder, and uncontrollable pain. More specific indications for intubation and mechanical ventilation are oral involvement with an initial total body surface area (TBSA) during hospital admission was ≥70%, or progression of TBSA ≥15% in the first 3 days of hospitalization, or neurological disorders, or documented airway involvement based on direct laryngoscopy examination.