Early and late complications among 15 victims exposed to indoor fire and smoke inhalation

Inhalation Injury, Respiratory Failure, and Ventilator Support in Acute Burn Care

Sustaining an inhalation injury increases the risk of severe complications and mortality. Current evidential support to guide treatment of the injury or subsequent complications is lacking, as studies either exclude inhalation injury or design limit inferences that can be made. Conventional ventilator modes are most commonly used, but there is no consensus on optimal strategies. Settings should be customized to patient tolerance and response. Data for pharmacotherapy adjunctive treatments are limited.

Laryngeal inhalational injuries: A systematic review

Laryngeal inhalation injury carries a significant increase in mortality rate and often indicates immediate airway evaluation. This may be difficult in the setting of clinical deterioration necessitating immediate intubation, which itself can synergistically cause mucosal damage. Prior studies do not encompass predictive factors or long-term outcomes for the laryngotracheal complex. This systemic review of PubMed, Embase, and Cochrane identified studies investigating inhalational injuries of the upper airway. Demographic data as well as presentation, physical findings, and delayed sequelae were documented. Laryngotracheal burn patients were divided into two cohorts based on timing of laryngeal injury diagnosis (before- versus after-airway intervention). 1051 papers met initial search criteria and 43 studies were ultimately included. Airway stenosis was more common in patients that were intubated immediately (50.0%, n = 18 versus 5.2%, n = 13; p = 0.57). Posterior glottic involvement was only identified in patients intubated prior to airway evaluation (71.4%, n = 15). All studies reported a closed space setting for those patients in whom airway intervention preceded laryngeal evaluation. Laryngeal inhalational injuries are a distinct subset that can have a variety of minor to severe laryngotracheal delayed sequelae, particularly for thermal injuries occurring within enclosed spaces. Given these findings, early otolaryngology referral may mitigate or treat these effects.

Inhalation injury after exposure to indoor fire and smoke: The Brazilian disaster experience

OBJECTIVE

To describe the pre-hospital, emergency department, and intensive care unit (ICU) care and prognosis of patients with inhalation injury after exposure to indoor fire and smoke.

MATERIALS AND METHODS

This is a prospective observational cohort study that includes patients admitted to seven ICUs after a fire disaster. The following data were collected: demographic characteristics; use of fiberoptic bronchoscopy; degree of inhalation injury; percentage of burned body surface area; mechanical ventilation parameters; and subsequent events during ICU stay. Patients were followed to determine the ICU and hospital mortality rates.

RESULTS

Within 24h of the incident, 68 patients were admitted to seven ICUs. The patients were young and had no comorbidities. Most patients (n=35; 51.5%) only had an inhalation injury. The mean ventilator-free days for patients with an inhalation injury degree of 0 or I was 12.5±8.1 days. For patients with an inhalation injury degree of II or III, the mean ventilator-free days was 9.4±5.8 days (p=0.12). In terms of the length of ICU stay for patients with degrees 0 or I, and patients with degrees II or III, the median was 7.0 days (5.0-8.0 days) and 12.0 days (8.0-23.0 days) (p<0.001), respectively. In addition, patients with a larger percentage of burned surface areas also had a longer ICU stay; however, no association with ventilator-free days was found. The patients with <10% of burned body surface area showed a mean of 9.2±5.4 ventilator-free days. The mean ventilator-free days for patients who had >10% burned body surface area was 11.9±9.5 (p=0.26). The length of ICU stay for the <10% and >10% burned body surface area patients was 7.0 days (5.0-10.0 days) and 23.0 days (11.5-25.5 days) (p<0.001), respectively.

CONCLUSIONS

We conclude that burn patients with inhalation injuries have different courses of disease, which are mainly determined by the percentage of burned body surface area.

Application of flexible bronchoscopy in inhalation lung injury

Background

As acute inhalational injury is an uncommon presentation to most institutions, a standard approach to its assessment and management, especially using flexible bronchoscopy, has not received significant attention.

Methods

The objective of this study is to evaluate the value of using flexible bronchoscopy as part of the evaluation and management of patients with inhalational lung injury. Twenty-three cases of inhalational lung injury were treated in our three hospitals after a fire in a residential building. The twenty cases that underwent bronchoscopy as part of their management are included in this analysis. After admission, the first bronchoscopy was conducted within 18-72 hours post inhalational injury. G2-level patients were reexamined 24 hours after the first bronchoscopy, while G1-level patients were reexamined 72 hours later. Subsequently, all patients were re-examined every 2-3 days until recovered or until only tunica mucosa bronchi congestion was identified by bronchoscopy.

Results

Twenty patients had airway injury diagnosed by bronchoscopy including burns to the larynx and glottis or large airways. Bronchoscopic classification of the inhalation injury was performed, identifying 12 cases of grade G1 changes and 8 cases of grade G2. The airway injury in the 12 cases of grade G1 patients demonstrated recovery in 2-8 days, in the airway injury of the 8 cases of grade G2 patients had a prolonged recovery with airway injury improving in 6-21 days averaged. The difference in recovery time between the two groups was significant (P <0.05).

Conclusions

The use of flexible bronchoscopy has great value in the diagnosis of inhalational injury without any complications. Its use should be incorporated into clinical practice.

Virtual slides

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1476676925108926

Early single-shot intravenous steroids do not affect pulmonary complications and mortality in burned or scalded patients

BACKGROUND AND OBJECTIVES

Inhalation injury, especially in combination with cutaneous burns, is the major cause of morbidity and mortality in patients admitted to burn care centers. Either with or without the presence of a cutaneous burn, inhalation injury contributes to high risk for developing severe pulmonary complications. Steroids may reduce a prolonged and destructive inflammatory response to toxic or allergic substances. The objective of this study was to evaluate the effect of early single-shot intravenous steroids on pulmonary complications and mortality in burned or scalded patients with or without inhalation injury.

METHODS

Retrospective analysis of a prospective single center database of patients registered between 1989 and 2011 who were admitted to the intensive care unit of our burn care center after burn or scald injury. Uni-variate statistical analysis was performed comparing two groups (steroid treated vs. non steroid treated patients) with regard to clinical outcome. Main parameters were sepsis, mortality and pulmonary complications such as pneumonia, ALI and ARDS. Multi-variate analysis was used by logistic regression with mortality and pulmonary complications as the dependent variables to identify independent risk factors after burn or scald injuries.

RESULTS

A total of 1637 patients with complete data were included in the present analysis. 199 (12.2%) received single-shot intravenous steroids during the prehospital phase of care. In 133 (66.8%) of these patients, inhalation injury was diagnosed via bronchoscopy. Steroid treated patients had sustained a significantly higher severity of burn than non-steroid treated patients (Abbreviated Burn Severity Index 7.1±3 vs. 6.0±2.9; p<0.001). In a multivariate analysis using a logistic regression model early intravenous steroid treatment had no significant effect on pulmonary complications and mortality.

CONCLUSIONS

In our single center cohort of burned and scalded patients single-shot intravenous steroids during the pre-hospital phase of care was not associated with pulmonary complications or mortality.

Isolated inhalational injury: Clinical course and outcomes in a multidisciplinary intensive care unit

Background and Aims:

Although smoke inhalation is well known to cause acute lung injury, there are few reports in literature that study the evolution, clinical course and outcomes of isolated inhalational lung injury in a modern intensive care setting. A major fire disaster provided us the opportunity to study victims of isolated inhalational injury admitted to our Multidisciplinary Intensive Care Unit (MICU).

Materials and Methods:

We studied the clinical course, ICU and hospital outcomes of 13 victims of a fire disaster who required mechanical ventilation for isolated inhalational lung injury. All patients were followed up at regular intervals, and their functional status was assessed at 8 months after hospital discharge.

Results:

The Lung Injury Scores (LIS) worsened to reach a nadir on Day 3 of injury. There was a significant correlation between the LIS on Day 3 and duration of mechanical ventilation (r = 0.8; P = 0.003), ICU (r = 0.8; P = 0.002) and hospital (r = 0.6; P = 0.02) days. Late-onset airway complications were encountered in four patients. Three of them required long-term artificial airways – two with a tracheostomy while the third patient required surgical insertion of a “T” tube. Persistent problems with phonation occurred in two patients. At 8 months postdischarge, all patients were independent with activities of daily living; all were back to work, except for two who continued to need artificial airways.

Conclusions:

Inhalational lung injury progresses over the first few days and is worst after 72 h. Late-onset airway complications may manifest after several weeks and require repeated intervention.

Comparing ambient, air-convection, and fluid-convection heating techniques in treating hypothermic burn patients, a clinical RCT

Background

Hypothermia in burns is common and increases morbidity and mortality. Several methods are available to reach and maintain normal core body temperature, but have not yet been evaluated in critical care for burned patients. Our unit's ordinary technique for controlling body temperature (Bair Hugger^®+ radiator ceiling + bed warmer + Hotline^®) has many drawbacks e.g.; slow and the working environment is hampered.

The aim of this study was to compare our ordinary heating technique with newly-developed methods: the Allon™2001 Thermowrap (a temperature regulating water-mattress), and Warmcloud (a temperature regulating air-mattress).

Methods

Ten consecutive burned patients (> 20% total burned surface area and a core temperature < 36.0°C) were included in this prospective, randomised, comparative study. Patients were randomly exposed to 3 heating methods. Each treatment/measuring-cycle lasted for 6 hours. Each heating method was assessed for 2 hours according to a randomised timetable. Core temperature was measured using an indwelling (bladder) thermistor. Paired t-tests were used to assess the significance of differences between the treatments within the patients. ANOVA was used to assess the differences in temperature from the first to the last measurement among all treatments. Three-way ANOVA with the Tukey HSD post hoc test and a repeated measures ANOVA was used in the same manner, but included information about patients and treatment/measuring-cycles to control for potential confounding. Data are presented as mean (SD) and (range). Probabilities of less than 0.05 were accepted as significant.

Results

The mean increase, 1.4 (SD 0.6°C; range 0.6-2.6°C) in core temperature/treatment/measuring-cycle highly significantly favoured the Allon™2001 Thermowrap in contrast to the conventional method 0.2 (0.6)°C (range -1.2 to 1.5°C) and the Warmcloud 0.3 (0.4)°C (range -0.4 to 0.9°C). The procedures for using the Allon™2001 Thermowrap were experienced to be more comfortable and straightforward than the conventional method or the Warmcloud.

Conclusions

The Allon™2001 Thermowrap was more effective than the Warmcloud or the conventional method in controlling patients' temperatures.

Inhalation burn injury in children

With advances in burn care, many children are surviving severe burn injuries. Inhalation injury remains a predictor of morbidity and mortality in burn injury. Inhalation of smoke and toxic gases leads to pulmonary complications, including airway obstruction from bronchial casts, pulmonary edema, decreased pulmonary compliance, and ventilation-perfusion mismatch, as well as systemic toxicity from carbon monoxide poisoning and cyanide toxicity. The diagnosis of inhalation injury is suggested by the history and physical exam and can be confirmed by bronchoscopy. Management consists of supportive measures, pulmonary toilet, treatment of pulmonary infection and ventilatory support as needed. This review details the pathophysiology, diagnosis, and management options for inhalation injury.