Das Rauchgasinhalationstrauma in der präklinischen Versorgung

[Inhalation injury--epidemiology, diagnosis and therapy]

OBJECTIVE

Inhalation injury is a vitally threatening medical syndrome, which might appear in patients with or without burn injuries. Thus, knowledge about development, diagnosis and treatment of inhalation injury should be available for each physician working in an intensive care unit.

METHODS

This review starts with the causal and formal pathogenesis of inhalation injuries. Furthermore, diagnosis and treatment in the critical care setting are presented, followed by the discussion of possible complications. Specific intoxications such as carbon monoxide are due to their importance separately discussed.

CONCLUSIONS

Inhalation injury present with an attributable excess mortality and thus worsen the prognosis of burned patients. New insights into the pathogenesis of inhalation injury, however, have led to improved therapeutic possibilities with improved outcome. Necessary prerequisites are a timely diagnosis and restrictive volume management, especially in patients with extensive burns. Prospective studies are needed to be able to answer the many emerging questions.

[Pathophysiology of acute lung injury in severe burn and smoke inhalation injury]

This review article describes the pathophysiological aspects of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), induced by combined burn and smoke inhalation and examines various therapeutic approaches. The injury results in a fall in arterial oxygenation as a result of airway obstruction, increased pulmonary transvascular fluid flux and loss of hypoxic pulmonary vasoconstriction. The changes in cardiopulmonary function are mediated by reactive oxygen and nitrogen species. Nitric oxide (NO) is generated by both inducible and constitutive isoforms of nitric oxide synthase (NOS). Recently, neuronal NOS emerged as a major component within the pathogenesis of ARDS. NO rapidly combines with the oxygen radical superoxide to form reactive and highly toxic nitrogen species such as peroxynitrite. The control of NO formation involves poly(ADP-ribose) polymerase and its ability to up-regulate the activity of nuclear transcription factors through ribosylation. In addition, present data support a major role of the bronchial circulation in the injury, as blockage of bronchial blood flow will also minimize the pulmonary injury. Current data suggest that cytotoxins and activated cells are formed in the airway and carried to the parenchyma.

Pathophysiology, management and treatment of smoke inhalation injury

Smoke inhalation injury continues to increase morbidity and mortality in burn patients in both the third world and industrialized countries. The lack of uniform criteria for the diagnosis and definition of smoke inhalation injury contributes to the fact that, despite extensive research, mortality rates have changed little in recent decades. The formation of reactive oxygen and nitrogen species, as well as the procoagulant and antifibrinolytic imbalance of alveolar homeostasis, all play a central role in the pathogenesis of smoke inhalation injury. Further hallmarks include massive airway obstruction owing to cast formation, bronchospasm, the increase in bronchial circulation and transvascular fluid flux. Therefore, anticoagulants, antioxidants and bronchodilators, especially when administered as an aerosol, represent the most promising treatment strategies. The purpose of this review article is to provide an overview of the pathophysiological changes, management and treatment options of smoke inhalation injury based on the current literature.