The diagnosis and management of inhalation injury: An evidence based approach

Incidence of Pneumonia Following Bronchoscopy and Bronchoalveolar Lavage in Burn Patients

The standard modality for diagnosis of smoke inhalational injury in burn patients is bronchoscopy with or without bronchoalveolar lavage (BAL). However, the risks associated with these procedures are poorly described in established literature. We sought to investigate the association between diagnostic BAL at admission and the development of pneumonia in burn patients. This retrospective analysis of intubated burn patients studied those who underwent bronchoscopy on admission, comparing patients who received BAL to those who did not. Demographics and baseline characteristics were analyzed using chi-squared or Student's t-test. Unadjusted and multivariable logistic regression studies assessed the effect of admission BAL on the development of pneumonia. Out of the 196 patients who underwent bronchoscopy, 98 met our criteria for analysis. The BAL group was more likely to be male and have a higher grade of abbreviated injury score. Patients who received BAL were more likely to develop pneumonia during the admission in both unadjusted and multivariable logistic regression models. These patients also had a longer hospital length of stay, greater number of ventilator days, and were more likely to undergo second bronchoscopy. These findings associate admission BAL with increased risk of pneumonia during the index hospitalization, suggesting a judicious use of BAL during admission bronchoscopy in burn patients.

Effect of Pilates exercises on pulmonary function, respiratory muscle strength, and functional capacity in patients with inhalation injury after flame thermal burn: A prospective randomized controlled trial

BACKGROUND

Inhalation injury is an acute respiratory tract injury that occurrs by inhalation of smoke, toxic gases, or steam. Early management is needed to reduce its mortality and morbidity. The purpose of this study was to ascertain whether Pilates training could help burn patients with inhalation injury after flame thermal burn in increasing pulmonary function, respiratory muscle strength, and functional ability.

METHODS

In this prospective, randomized, controlled trial, sixty participants (26 males and 34 females) with inhalation injury and deep partial-thickness flame burns of 30-40 % total body surface area (TBSA) were randomized in blocks of four, with a 1:1 allocation ratio into two groups: Group A (Pilates Group); received Pilates training plus conventional physical therapy program, and Group B (Control Group); received conventional physical therapy program only. This study was conducted at the Faculty of Physical Therapy's outpatient clinic, Cairo University, 3 sessions/week for 12 weeks. The primary outcome measure was the forced vital capacity (FVC) measured by a spirometer, while the secondary outcome measures were peak expiratory flow rate (PEFR), forced expiratory volume in 1 s (FEV1), FEV1/FVC% assessed by a spirometer, strength of respiratory muscles (maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP) assessed by the digital manovacuometer, and the functional capacity evaluated by 6-Minute Walk Test (6-MWT).

RESULTS

A two-way mixed-design MANOVA was used to analyze the results within and between groups. There were no significant differences in demographic data between groups (P > 0.05). There were significant differences in all variables after treatment in group A compared with group B; FVC (95 % CI: 0.38, 1.13) (P = 0.001), FEV1 (95 % CI: 0.39, 0.97) (P = 0.001), FEV1/FVC % (95 % CI: 1.90, 17.19) (P = 0.02), PEFR (95 % CI: 0.47, 0.99) (P = 0.001), MIP (95 % CI: 5.12, 11.44) (P = 0.001), MEP (95 % CI: 2.57, 8.24) (P = 0.001), 6-MWT (95 % CI: 27.22, 54.96) (P = 0.001), FVC (% predicted) (95 % CI: 3.58, 12.58) (P = 0.001), FEV1 (% predicted) (95 % CI: 1.21, 11.11) (P = 0.02), PEFR (% predicted) (95 % CI: 1.33, 10.83) (P = 0.01), MIP (% predicted) (95 % CI: 2.26, 11.72) (P = 0.001) and MEP (% predicted) (95 % CI: 1.33, 10.37) (P = 0.01).

CONCLUSION

The current study demonstrated that a Pilates exercise program in addition to a traditional physical therapy program for 12 weeks significantly improved the pulmonary function (FVC, FEV1, PEFR and FEV1/FEV), strength of respiratory muscles (MIP and MEP), and functional capacity (6-MWT) in patients with inhalation injury after flame burns. These results underscore the importance of including Pilates exercises in the rehabilitation plan for burn patients with inhalation injury. Future studies are needed to evaluate the effect of Pilates exercises on other degrees and TBSA of burn, long-term follow up, and to measure cardiopulmonary parameters.

Bone marrow mesenchymal stromal cells attenuate smoke inhalation injury by regulating the M1/M2-Th17/Treg immune homeostasis axis

Smoke inhalation injury (SII) is the leading cause of death in fire burn patients. The inflammatory response induced by smoke inhalation is a significant factor in the development of acute lung injury or acute respiratory distress syndrome (ALI/ARDS). Mesenchymal stem cells (MSCs) can alleviate various inflammatory diseases by regulating the polarization of macrophages from the M1 to the M2 phenotype. Moreover, MSCs can facilitate the inflammatory response by regulating Th17/Treg homeostasis. However, little is known about the associations among MSCs, M1/M2 macrophages and Th17/Treg homeostasis. Therefore, the purpose of this study was to evaluate whether MSCs affect subsequent Th17/Treg differentiation and immune homeostasis by regulating M1/M2 polarization in SII. Our results showed that bone marrow mesenchymal stem cells (BMSCs) ameliorated lung inflammatory injury and fibrosis after SII by affecting the polarization of alveolar macrophages (AMs) from the M1 to the M2 phenotype. Moreover, BMSCs maintain Th17/Treg immune homeostasis by increasing the proportion of Treg cells and decreasing the proportion of Th17 cells. In vitro, we further demonstrated that BMSCs promoted the polarization of AMs from the M1 to the M2 phenotype and decreased IL-23 levels. Reduced IL-23 decreased Th17 differentiation and promoted Th17/Treg balance. Therefore, BMSCs ameliorate the inflammatory response and lung damage after SII through regulating M1/M2 polarization and subsequent Th17/Treg immune homeostasis, which are linked to alveolar macrophage-derived IL-23. These findings provide novel insight into how BMSCs regulate the M1/M2-Th17/Treg immune homeostasis axis and provide new therapeutic targets for more effective control of the inflammatory response after SII.

Smoke Inhalation in Veterinary Patients: Pathophysiology, Diagnosis, and Management

Smoke contains a mixture of harmful gases, chemicals, and superheated particles. Inhalation of smoke causes generalized hypoxia and airway inflammation due to impaired oxygen transport and utilization, as well as thermal and chemical injury in the airways. Generally, treatment is supportive with oxygen therapy and airway management, including chest physiotherapy, bronchodilators, and nebulization. Immediate oxygen therapy is mandatory for all suspected smoke inhalation patients and should not be delayed pending diagnostic test results or due to "normal" oxygen saturation readings that can be falsely elevated in carbon monoxide intoxication. Smoke inhalation patients with mild clinical signs who respond well to initial stabilization generally have a favorable prognosis. However, patients with severe signs or progression despite initial stabilization may require more advanced or intensive care.

Rare multi-fungal sepsis: a case of triple-impact immunoparalysis

Patients with burn injury and inhalation injury are highly susceptible to infectious complications, including opportunistic pathogens, due to the loss of skin cover and mucosal damage of respiratory tract as well as the disruption of homeostasis. This case report, a 34-year-old man suffered critical burns, provides the first literature description of triple-impact immunoparalysis (critical burns, inhalation injury, and SARS-CoV-2 infection), leading to a lethal multifocal infection caused by several fungi including very rare environmental representatives Metschnikowia pulcherrima and Wickerhamomyces anomalus. The co-infection by these common environmental yeasts in a human is unique and has not yet been described in the literature. Importantly, our patient developed refractory septic shock and died despite targeted antifungal therapy including the most potent current antifungal agent-isavuconazole. It can be assumed that besides immunoparalysis, effectiveness of therapy by isavuconazole was impaired by the large distribution volume in this case. As this is a common situation in intensive care patients, routine monitoring of plasmatic concentration of isavuconazole can be helpful in personalization of the treatment and dose optimization. Whatmore, many fungal species often remain underdiagnosed during infectious complications, which could be prevented by implementation of new methods, such as next-generation sequencing, into clinical practice.

Prophylactic Systemic Antibiotic and Systemic Glucocorticoid Therapy After Burn Inhalation Injury: A Report of Two Cases and Review of Literature

Burn inhalation injury is a significant risk factor for mortality in burn patients. Despite the considerable progress made in the treatment of burn inhalation injury, there remains no consensus on the appropriate course of treatment, leading to ongoing controversy regarding the use of prophylactic systemic antibiotics and systemic glucocorticoids. This study presents two cases of burn inhalation injury diagnosed by fiberoptic bronchoscopy and treated with systemic glucocorticoids and prophylactic systemic antibiotics. By conducting a literature review, this study aimed to discuss the application of systemic glucocorticoids and prophylactic systemic antibiotics in patients with burn inhalation injuries. The suitability of prophylactic systemic antibiotics and systemic glucocorticoids for treating burn inhalation injury patients necessitates a comprehensive assessment of the patient's condition and an accurate judgment of the course of their disease.

Frequency, complications, and mortality of inhalation injury in burn patients: A systematic review and meta-analysis protocol

INTRODUCTION

Burns are tissue traumas caused by energy transfer and occur with a variable inflammatory response. The consequences of burns represent a public health problem worldwide. Inhalation injury (II) is a severity factor when associated with burn, leading to a worse prognosis. Its treatment is complex and often involves invasive mechanical ventilation (IMV). The primary purpose of this study will be to assess the evidence regarding the frequency and mortality of II in burn patients. The secondary purposes will be to assess the evidence regarding the association between IIs and respiratory complications (pneumonia, airway obstruction, acute respiratory failure, acute respiratory distress syndrome), need for IMV and complications in other organ systems, and highlight factors associated with IIs in burn patients and prognostic factors associated with acute respiratory failure, need for IMV and mortality of II in burn patients.

METHODS

This is a systematic literature review and meta-analysis, according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). PubMed/MEDLINE, Embase, LILACS/VHL, Scopus, Web of Science, and CINAHL databases will be consulted without language restrictions and publication date. Studies presenting incomplete data and patients under 19 years of age will be excluded. Data will be synthesized through continuous (mean and standard deviation) and dichotomous (relative risk) variables and the total number of participants. The means, sample sizes, standard deviations from the mean, and relative risks will be entered into the Review Manager web analysis software (The Cochrane Collaboration).

DISCUSSION

Despite the extensive experience managing IIs in burn patients, they still represent an important cause of morbidity and mortality. Diagnosis and accurate measurement of its damage are complex, and therapies are essentially based on supportive measures. Considering the challenge, their impact, and their potential severity, IIs represent a promising area for research, needing further studies to understand and contribute to its better evolution. The protocol of this review is registered on the International prospective register of systematic reviews platform of the Center for Revisions and Disclosure of the University of York, United Kingdom (https://www.crd.york.ac.uk/prospero), under number RD42022343944.

Characterization and prevention of flame burns caused by electric bicycle battery chargers: results from a 7-year experience

OBJECTIVE

With the recent exponential increase in express deliveries across China, the number of patients with flame burns caused by electric bicycle battery chargers (BEBBC) has markedly increased in burn units. In this study, we aimed to characterize BEBBC to systematically explore measures to prevent their occurrence.

METHODS

We performed a retrospective chart review of patients with flame burns who visited the Burn Department of Rui Jin Hospital between January 2015 and December 2021.

RESULTS

Sixty-three patients with BEBBC and 1412 with types of other flame burn were included in this study. Fifty-six of the 63 BEBBC cases occurred between 9 pm and 7 am. BEBBC incidents involved a higher incidence of group burn in which multiple individuals were affected. Non-local patients with BEBBC were significantly younger than their local counterparts. BEBBC had a higher mortality than types of other flame burn.

CONCLUSIONS

The rising incidence of BEBBC calls for greater attention because of the associated high mortality and heavy burden on society. Enacting related legislation, disseminating information to the public, and improving treatment to control infection can help prevent BEBBC, increase its cure rate, and reduce patient mortality.

Fluid balance in the resorption stage correlates with outcomes of severe burn patients

OBJECTIVE

The resorption stage is an important period involving early anti-shock treatment for severe burn patients. We aimed to investigate the quantitative variability in fluid balance during the resorption stage in severe burn patients, and to study its effect on patient outcomes.

METHODS

We conducted a single-centre retrospective study of 100 severe burn patients with involvement of > 50% total body surface area (TBSA). We extracted clinical data on demographics, clinical characteristics and outcomes; calculated the daily net fluid balance (difference between fluid intake and fluid output) and daily fluid intake/output within one week after injury; and analysed the association between fluid balance and functional outcomes and prognosis. The relative volume (ml/kg/TBSA) was used for the determination of daily fluid volume in this study.

RESULTS

The daily net fluid balance (ml/kg/TBSA) of the deceased patients on the 4th, 5th, 6th, and 7th days after injury was higher than that of the surviving patients, but the opposite trend was found for the daily fluid output (ml/kg/TBSA). The partial correlation test showed that in the resorption stage of severe burn patients, fluid output was negatively correlated with the index levels of renal function and liver function, CRP level, blood lactic acid (LA) level, frequency of ventilator treatment, and capillary leakage index (CLI), but net fluid balance showed a completely opposite correlation. Moreover, fluid intake was negatively correlated with the index level of renal function and LA level, but positively correlated with the frequency of ventilator treatment. Furthermore, the logistic regression analysis showed that the net fluid balance and fluid output on Day 6 post-injury were independent risk factors for prognosis.

CONCLUSION

This study suggested that greater fluid output in the resorption stage of severe burn patients was closely related to better outcomes, in addition, a gradually decreasing, lower positive net fluid balance may contribute to the improvement of functional outcomes, which will provide useful information for early fluid management and further prospective clinical study of severe burns.

Surviving Sepsis After Burn Campaign

INTRODUCTION

The Surviving Sepsis Campaign was developed to improve outcomes for all patients with sepsis. Despite sepsis being the primary cause of death after thermal injury, burns have always been excluded from the Surviving Sepsis efforts. To improve sepsis outcomes in burn patients, an international group of burn experts developed the Surviving Sepsis After Burn Campaign (SSABC) as a testable guideline to improve burn sepsis outcomes.

METHODS

The International Society for Burn Injuries (ISBI) reached out to regional or national burn organizations to recommend members to participate in the program. Two members of the ISBI developed specific "patient/population, intervention, comparison and outcome" (PICO) questions that paralleled the 2021 Surviving Sepsis Campaign [1]. SSABC participants were asked to search the current literature and rate its quality for each topic. At the Congress of the ISBI, in Guadalajara, Mexico, August 28, 2022, a majority of the participants met to create "statements" based on the literature. The "summary statements" were then sent to all members for comment with the hope of developing an 80% consensus. After four reviews, a consensus statement for each topic was created or "no consensus" was reported.

RESULTS

The committee developed sixty statements within fourteen topics that provide guidance for the early treatment of sepsis in burn patients. These statements should be used to improve the care of sepsis in burn patients. The statements should not be considered as "static" comments but should rather be used as guidelines for future testing of the best treatments for sepsis in burn patients. They should be updated on a regular basis.

CONCLUSION

Members of the burn community from the around the world have developed the Surviving Sepsis After Burn Campaign guidelines with the goal of improving the outcome of sepsis in burn patients.

Machine learning approach for predicting inhalation injury in patients with burns

BACKGROUND

The coronavirus disease pandemic has had a tangible impact on bronchoscopy for burn inpatients due to isolation and triage measures. We utilised the machine-learning approach to identify risk factors for predicting mild and severe inhalation injury and whether patients with burns experienced inhalation injury. We also examined the ability of two dichotomous models to predict clinical outcomes including mortality, pneumonia, and duration of hospitalisation.

METHODS

A retrospective 14-year single-centre dataset of 341 intubated patients with burns with suspected inhalation injury was established. The medical data on day one of admission and bronchoscopy-diagnosed inhalation injury grade were compiled using a gradient boosting-based machine-learning algorithm to create two prediction models: model 1, mild vs. severe inhalation injury; and model 2, no inhalation injury vs. inhalation injury.

RESULTS

The area under the curve (AUC) for model 1 was 0·883, indicating excellent discrimination. The AUC for model 2 was 0·862, indicating acceptable discrimination. In model 1, the incidence of pneumonia (P < 0·001) and mortality rate (P < 0·001), but not duration of hospitalisation (P = 0·1052), were significantly higher in patients with severe inhalation injury. In model 2, the incidence of pneumonia (P < 0·001), mortality (P < 0·001), and duration of hospitalisation (P = 0·021) were significantly higher in patients with inhalation injury.

CONCLUSIONS

We developed the first machine-learning tool for differentiating between mild and severe inhalation injury, and the absence/presence of inhalation injury in patients with burns, which is helpful when bronchoscopy is not available immediately. The dichotomous classification predicted by both models was associated with the clinical outcomes.

Effects of Inspiratory Muscle Training on Clinical Predictors of Respiratory Muscle Strength and Lung Function in Burned Patients with Inhalation Injury

Chronic airway illness is a well-documented inhalation injury side effect. Many pulmonary function impairments persisted for several months after lung parenchymal injury. Thus, the purpose of this study was to investigate the effects of inspiratory muscle training on respiratory muscle strength and pulmonary function (PFT) in patients who had suffered an inhalation injury. This study included male patients with inhalation injuries aged 20-35 years. Patients were chosen at random and assigned to an exercise group, which received inspiratory muscle training and routine chest physiotherapy, including early ambulation, coughing, and deep breathing, three times weekly for 4 weeks, and the control group, which only received routine chest physiotherapy. All participants were assessed for PFT and respiratory muscle strength at enrollment and the end of the study. The statistical analysis for outcome variables between both groups revealed no significant differences before treatment (P > .05) of forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), maximal inspiratory pressure, and maximal expiratory pressure. According to the findings of this study, including IMT as part of a physical therapy program led to significant gains (P ˂ .05) in FVC and FEV1. However, after treatment, there was not a substantial difference found in either the MIP or the MEP between the groups. The exercise group performed better in terms of FVC, FEV1, MIP, and MEP after receiving treatment, according to these significant and non-significant differences.

Outcomes of COPD Patients with Flame Burn and Inhalation Injuries at a Single Institution

The presence of any comorbid condition may lead to worse outcomes after burn injury. Chronic obstructive pulmonary disease (COPD) is a condition with significant morbidity and mortality. In 2018, about 16 million adults in the United States reported a diagnosis of COPD based on data from the American Lung Association. The objective of this study was to explore the outcomes of patients with COPD admitted to our Burn Center with flame burns and/or inhalation injury. Patients were identified using our Institutional Burn Center registry and linked to the clinical and administrative data. All adult flame-injured and/or inhalation injury-only patients admitted to our burn center between July 1, 2011 and June 30, 2020 were included. Demographics, length of stay, burn, and patient characteristics and outcomes, including mortality, were evaluated. Four thousand three hundred ninety-seven patients were included in the study. Patients were divided into two populations, those with COPD (n = 515) and those without a diagnosis of COPD (n = 3882). Patients with COPD were older, more likely to be white and male, and had smaller sized burns, p < .001. Patients with COPD were more likely to be smokers and have comorbid conditions. There was no statistically significant difference between the incidence of inhalation injury, lengths of stay, or number of ventilator days. Burn size and inhalation injury increased mortality risk regardless of COPD severity, as did age among those not on home oxygen. More studies are needed to determine the genomic or proteomic changes in patients with COPD that lead to worse outcomes after flame injury, and/or inhalation injury alone.

Clinical characteristics and predictors of burn complicated with smoke inhalation injury: A retrospective analysis

Fire smoke enters the human lungs through the respiratory tract. The damage to the respiratory tract and lung tissue is known as smoke inhalation injury (SII). Fire smoke can irritate airway epithelium cells, weaken endothelial cell adhesion and lyse alveolar type II epithelia cells, leading to emphysema, decreased lung function, pneumonia and risk of acute lung injury/acute respiratory distress syndrome (ARDS). The purpose of the present study was to analyze the clinical characteristics of patients with SII and the risk factors affecting their prognosis. A total of 103 patients with SII admitted between January 2016 to December 2021 to the Burns Unit of the Characteristic Medical Center of Chinese People's Armed Police Force and 983 Hospital of the Joint Logistics Support Force of the Chinese People's Liberation Army were selected for the present study. The demographics and clinical features between different severities of SII were analyzed. Univariate/multivariate logistic regression was used to analyze the potential predictors for severity, ARDS and mortality of patients with SII. Receiver operating characteristic (ROC) curves were used to screen independent risk factors and identify their prediction accuracy. It was concluded that total body surface area (TBSA), III burn area (of total %TBSA), cases of respiratory infections, ARDS morbidity, mortality, acute physiology and chronic health evaluation II, lung injury prediction score, lactic acid, white blood cells (WBC), alanine transaminase, blood urea nitrogen, serum creatinine and uric acid were indicators that were raised with increasing severity of SII. However red blood cells, hemoglobin, platelet count, total protein, albumin, and albumin/globulin were decreased with the increasing severity of SII (P<0.05). WBC >20.91 (10⁹/l) was a reliable indicator for severe SII. Lactic acid >9.60 (mmol/l) demonstrated a high degree of accuracy in predicting ARDS development in patients with SII. Hemoglobin <83.00 (g/l) showed a high degree of accuracy in predicting mortality. In summary, the highlighted assessment parameters could be used to contribute to devising improved treatment plans to preempt worsening conditions (such as shock, ARDS, multiple organ dysfunction syndrome and death).

A Rationale for Safe Ventilation with Inhalation Injury: An Editorial Review

Lung injury from smoke inhalation manifests as airway and parenchymal damage, at times leading to the acute respiratory distress syndrome. From the beginning of this millennium, the approach to mechanical ventilation in the patient with ARDS was based on reduction of tidal volume to 6 milliliters/kilogram of ideal body weight, maintaining a ceiling of plateau pressure, and titration of driving pressure (plateau pressure minus PEEP). Beyond these broad constraints, there is little specification for the mechanics of ventilator settings, consideration of the metabolic impact of the disease process on the patient, or interaction of patient disease and ventilator settings. Various studies suggest that inhomogeneity of lung injury, which increases the risk of regional lung trauma from mechanical ventilation, may be found in the patient with smoke inhalation. We now appreciate that energy transfer principles may affect optimal ventilator management and come into play in damaged heterogenous lungs. Mechanical ventilation in the patient with inhalation injury should consider various factors. Self-injurious respiratory demand by the patient can be reduced using analgesia and sedation. Dynamic factors beginning with rate management can reduce the incidence of potentially damaging ventilation. Moreover, preclinical study is underway to examine the flow of gas based on the ventilator mode selected, which may also be a factor triggering regional lung injury.

Use of the Braden Scale to Predict Injury Severity in Mass Burn Casualties

Background

Mass burn casualties impose an enormous burden on triage systems. The triage capacity of the Braden Scale for detecting injury severity has not been evaluated in mass burn casualties.

Material/Methods

The New Injury Severity Score (NISS) was used to dichotomize the injury severity of patients. The Braden Scale and other potentially indicative measurement tools were evaluated using univariate analysis and multivariate logistic regression. The relationships between the Braden Scale and other continuous variables with injury severity were further explored by correlation analysis and fitted with regression models. Receiver operating characteristic (ROC) curve analysis was used to validate triage capacity and compare prognostic accuracy.

Results

A total of 160 hospitalized patients were included in our study; 37 were severely injured, and 123 were not. Injury severity was independently associated with the Numerical Rating Scale (adjusted OR, 1.816; 95% CI, 1.035–3.187) and Braden Scale (adjusted OR, 0.693; 95% CI, 0.564–0.851). The ROC curve of the fitted quadratic model of the Braden Scale was 0.896 (0.840–0.953), and the cut-off value was 17. The sensitivity was 81.08% (64.29–91.44%) and the specificity was 82.93% (74.85–88.89%). Comparison of ROC curves demonstrated an infinitesimal difference between the Braden Scale and NISS for predicting 30-day hospital discharge (Z=0.291, P=0.771) and Intensive Care Unit admission (Z=2.016, P=0.044).

Conclusions

The Braden Scale is a suitable triage tool for predicting injury severity and forecasting disability-related outcomes in patients affected by mass burn casualty incidents.

Outcomes following traumatic inhalational airway injury - Predictors of mortality and effect of procedural intervention

OBJECTIVE

Study outcomes, predictors of mortality, and effects of procedural interventions on patients following traumatic inhalational airway injury.

STUDY

Design: Retrospective study.

SETTING

National Trauma Data Bank METHODS: Patients over the age of eighteen admitted between 2008 and 2016 to NTDB-participating sites were included. In-hospital mortality and length of stay were the primary outcomes.

RESULTS

The final study cohort included 13,351 patients. History of active smoking was negatively associated with in-house mortality with an OR of 0.33 (0.25-0.44). History of alcohol use, and presence of significant medical co-morbidities were positively associated with in-house mortality with OR of 5.28 (4.32-6.46) 2.74 (19.4-3.86) respectively. There was little to no association between procedural interventions and in-house mortality. Intubation, laryngobronchoscopy, and tracheostomy had OR of 0.90 (0.67-1.20), 1.02 (0.79-1.30), and 0.94 (0.58-1.51), respectively. However, procedural intervention did affect both the median hospital and ICU lengths of stay of patients. Median hospital and ICU length of stay were shorter for patients receiving endotracheal intubation. Median hospital length of stay was longer for patients undergoing bronchoscopy and laryngoscopy, but median ICU length of stay was shorter for patients undergoing bronchoscopy and laryngoscopy. Patients receiving a tracheostomy have both significantly increased median hospital and ICU lengths of stay.

CONCLUSIONS

Active smoking was associated with decreased odds of in-hospital mortality, while presence of pre-existing medical comorbidities and history of alcohol use disorder was associated with increased odds of in-hospital mortality. Procedural intervention had little to no association with in-hospital mortality but did affect overall hospital and ICU LOS.

Acute respiratory distress syndrome caused by carbon monoxide poisoning and inhalation injury recovered after extracorporeal membrane oxygenation along with direct hemoperfusion with polymyxin B-immobilized fiber column: a case report

BACKGROUND

Inhalation injury from smoke or chemical products and carbon monoxide poisoning are major causes of death in burn patients from fire accidents. Respiratory tract injuries from inhalation injury and carbon monoxide poisoning can lead to acute respiratory distress syndrome and cytokine storm syndrome. In the case of acute respiratory failure needing mechanical ventilation accompanied by cytokine storm, mortality is high and immediate adequate treatment at the emergency department is very important.

CASE PRESENTATION

This report describes a case of acute respiratory distress syndrome and cytokine storm followed by carbon monoxide poisoning in a 34-year-old Korean male patient who was in a house fire, and was successfully treated by extracorporeal membrane oxygenation and direct hemoperfusion with polymyxin B-immobilized fiber column at emergency department.

CONCLUSIONS

To prevent mortality in acute respiratory distress syndrome with cytokine storm from inhalation injury and to promote a better prognosis, we suggest that early implication of extracorporeal membranous oxygenation along with direct hemoperfusion with polymyxin B-immobilized fiber column even at the emergency department should be considered.

Acute respiratory failure and burn patient outcomes

PURPOSE OF REVIEW

Advances in the care of inhalational injuries have not kept pace with advances that have been seen in the treatment of cutaneous burns. There is not yet a standard of care for best outcomes for airway management of patients with known or suspected inhalational injuries. Clinicians must decide if to intubate the patient, and if so, whether to intubate early or late in their presentation. Unnecessary intubation affects morbidity and mortality. This review will summarize literature that highlights present practices in the treatment of patients with inhalation injuries.

RECENT FINDINGS

There have been promising investigations into biomarkers that can be used to quantify a patient's risk and better target therapies. Grading systems serve to better stratify the burn victim's prognosis and then direct their care. Special ventilator modes can assist in ventilating burn patients with inhalation injuries that experience difficulties in oxygenating.

SUMMARY

Inhalational injuries are a significant source of morbidity and mortality in thermally injured patients. Treatment modalities, such as modified ventilator settings, alteration in fluid resuscitation, and a standardized grading system may improve morbidity and mortality.

Advances in airway management and mechanical ventilation in inhalation injury

PURPOSE OF REVIEW

Airway management, mechanical ventilation, and treatment of systemic poisoning in burn patients with inhalation injury remains challenging. This review summarizes new concepts as well as open questions.

RECENT FINDINGS

Several life-threatening complications, such as airway patency impairment and respiratory insufficiency, can arise in burn patients and require adequate and timely airway management. However, unnecessary endotracheal intubation should be avoided. Direct visual inspection via nasolaryngoscopy can guide appropriate airway management decisions. In cases of lower airway injury, bronchoscopy is recommended to remove casts and estimate the extent of the injury in intubated patients. Several mechanical ventilation strategies have been studied. An interesting modality might be high-frequency percussive ventilation. However, to date, there is no sound evidence that patients with inhalation injury should be ventilated with modes other than those applied to non-burn patients. In all burn patients exposed to enclosed fire, carbon monoxide as well as cyanide poisoning should be suspected. Carbon monoxide poisoning should be treated with an inspiratory oxygen fraction of 100%, whereas cyanide poisoning should be treated with hydroxocobalamin.

SUMMARY

Burn patients need specialized care that requires specific knowledge about airway management, mechanical ventilation, and carbon monoxide and cyanide poisoning.

Intubation in burns patients: a 5-year review of the Manchester regional burns centre experience

Despite criteria to guide intubation from the American Burn Association (ABA), concerns remain regarding over-intubation of burns patients. The purpose of this study was to review appropriateness of intubation at a UK regional burns centre over a 5-year period. A 5-year retrospective review of adult patients admitted to the Manchester Burns Centre who underwent intubation at or prior to admission was performed. Intubations for non-burn indications or burns >40%TBSA were excluded. Patient demographic and burn characteristics data were extracted from medical records. Indications for intubation were compared to ABA and Denver criteria. 47 patients were identified, of which 40 met inclusion criteria for analysis. 72.5% and 95% of these patients met ABA or Denver criteria respectively. 30.8% of patients were extubated within 48 h. 50% patients extubated within 48 h had ≤1 indication for intubation or negative laryngoscopy. Complications related to intubation and ventilation were noted in 37.5% of patients, with ventilation associated pneumonia (VAP) being the most common occurring in 27.5%. 95% of patients fulfilled recognised criteria for intubation. However, 30% were extubated within 48 h, suggesting potentially avoidable intubation. This study suggests current intubation criteria may over-estimate risk of airway compromise and supports results from non-UK studies that a proportion of patients may be suitable for close observation rather than early intubation.

Nebulized Heparin for Adult Patients With Smoke Inhalation Injury: A Review of the Literature

Objective: To review the clinical effects of nebulized heparin and N-acetylcysteine (NAC) in patients with smoke inhalation injury (IHI) and provide recommendations for use. Data Sources: A search of PubMed, MEDLINE, and Scopus databases was completed from database inception through April 15, 2020, using terms: heparin, acetylcysteine, smoke inhalation injury, and burn injury. Study Selection and Data Extraction: All studies pertaining to efficacy and safety of nebulized heparin and/or NAC for IHI in adult patients were evaluated. Reference lists were reviewed for additional publications. Nonhuman studies, non-English, and case report publications were excluded. Data Synthesis: Eight studies were included. Four demonstrated positive outcomes, 3 demonstrated no benefit or possible harm, and 1 assessed safety. Supporting trials treated patients within 48 hours of injury with 10 000 units of nebulized heparin with NAC for 7 days or until extubation. Two trials with negative findings treated patients within 72 hours, or unspecified, with 5000 units of nebulized heparin with NAC for 7 days, while the third used 25 000 units within 36 hours but was grossly underpowered for analysis. Clinical findings include reduced duration of mechanical ventilation and improved lung function with possible increase risk of pneumonia and no evidence of increased bleeding risk. Conclusions: Nebulized heparin may improve oxygenation and reduce duration of mechanical ventilation in IHI. If nebulized heparin is used, 10 000 units every 4 hours alternating with NAC and albuterol at 4-hour intervals is recommended. Sterile technique should be emphasized. Monitoring for bronchospasm or new-onset pneumonia should be considered.

Variation in documented inhalation injury rates following burn injury in Australia and New Zealand

INTRODUCTION

The negative impact of inhalation injuries on in-hospital outcomes for burn patients is well known, but the burns community is yet to form a consensus on diagnostic criteria and clinical definitions. The diagnosis of inhalation injuries is consequently highly subjective. This study aimed to assess the variation in the rate of documented inhalation injury for adult patients in Australian and New Zealand burn units.

METHODS

Data for sequential admissions collected from eight adult burn centres across Australia and New Zealand between July 2009 and June 2016 were extracted from the Burns Registry of Australia and New Zealand (BRANZ). Inhalation injury was classified in two ways: (i) a field in the BRANZ data dictionary, and (ii) through a series of International Classification of Disease 10th Revision Australian Modification (ICD-10-AM) codes. Variation in inhalation injury prevalence was assessed using descriptive statistics, funnel plots, logistic regression, and predicted probabilities.

RESULTS

There were 11,206 admissions to BRANZ sites over the study period. Inhalation injury prevalence was the highest at Site D (13.1% for the BRANZ field and 11.8% for the ICD-10-AM codes), but there was significant variation between the contributing sites and the inhalation injury classification methods.

CONCLUSION

There is significant variation in the prevalence of documented inhalation injury among Australian and New Zealand burns units. The variation in the prevalence of documented inhalation injury across Australian and New Zealand sites reinforces the need for a consensus definition in the diagnosis of these injuries. Further work is required to improve data quality and reconcile the differences between clinical and ICD-10-AM coding prevalence before changes in clinical practice can be recommended from these data.

Management of severe thermal burns in the acute phase in adults and children

OBJECTIVES

To provide recommendations to facilitate the management of severe thermal burns during the acute phase in adults and children.

DESIGN

A committee of 20 experts was asked to produce recommendations in six fields of burn management, namely, (1) assessment, admission to specialised burns centres, and telemedicine; (2) haemodynamic management; (3) airway management and smoke inhalation; (4) anaesthesia and analgesia; (5) burn wound treatments; and (6) other treatments. At the start of the recommendation-formulation process, a formal conflict-of-interest policy was developed and enforced throughout the process. The entire process was conducted independently of any industry funding. The experts drew up a list of questions that were formulated according to the PICO model (Population, Intervention, Comparison, and Outcomes). Two bibliography experts per field analysed the literature published from January 2000 onwards using predefined keywords according to PRISMA recommendations. The quality of data from the selected literature was assessed using GRADE® methodology. Due to the current paucity of sufficiently powered studies regarding hard outcomes (i.e. mortality), the recommendations are based on expert opinion.

RESULTS

The SFAR guidelines panel generated 24 statements regarding the management of acute burn injuries in adults and children. After two scoring rounds and one amendment, strong agreement was reached for all recommendations.

CONCLUSION

Substantial agreement was reached among a large cohort of experts regarding numerous strong recommendations to optimise the management of acute burn injuries in adults and children.

The value of a bariatric specific chart to initiate resuscitation of adult bariatric burns

INTRODUCTION

The prevalence of obese adults is rising across the world with a tripling of rates since 1975. The resuscitation of large burns in obese patients brings unique challenges leading some to advocate the use of a bariatric specific burn chart.

AIMS

We sought to determine whether bariatric burn specific charts can better estimate burn percentage to prevent under resuscitation. We also reviewed the impact of obesity upon the length of hospital stay, morbidity and mortality at our institution.

METHODS

A retrospective case note review, of patients identified from the prospective International Burns Injury Database (iBID), was undertaken of patients' ≥18 years of age with burns ≥15% of their total body surface area.

RESULTS

There were 79 overweight and 53 bariatric patients from a total of 232 patients identified. There was no statistical difference in burn percentage or fluid input estimation between the Lund & Browder and Neaman charts. Complications were seen in 51% of the normal weight patients. Obese patients had a similar incidence of death (24%) compared to the normal weight group (26%). The class I obese had the lowest complication rate at 28% and lowest mortality rate at 11%.

CONCLUSIONS

Bariatric specific charts did not demonstrate any benefits in optimising bariatric resuscitation. There appears to be a 'physiological benefit' in the class I obese who sustained burns undergoing resuscitation.

Impact of diagnostic bronchoscopy in burned adults with suspected inhalation injury

INTRODUCTION

Inhalation injury is a common complication of thermal trauma. Fiberoptic bronchoscopy (FOB) is regarded as current standard practice in diagnosing and grading inhalation injury. Nonetheless, its predictive value in terms of therapeutic decision-making and clinical outcome is controversial.

METHODS

Adult burn patients with inhalation injury (InI) were selected from the National Burn Repository of the American Burn Association. Subjects were propensity score pair-matched based on injury severity and grouped based on whether or not FOB had been performed (FOB, CTR, respectively). Mortality, incidence of pneumonia, length of hospitalization, length of ICU stay and dependency on mechanical ventilation were compared between the two groups.

RESULTS

3014 patients were matched in two groups with a mean TBSA of 22.4%. There was no significant difference in carboxyhemoglobin fraction at admission. Patients, who underwent FOB on admission had a significantly increased incidence of pneumonia (p < 0.001), mortality (p < 0.05), length of hospitalization (p = 0.002), ICU stay (p < 0.001) and duration of mechanical ventilation (p = 0.006). In a subgroup analysis of patients with TBSA of at least 20%, incidence of pneumonia was significantly higher in the FOB group (p < 0.001) and longer mechanical ventilation was required (p = 0.036).

DISCUSSION

Diagnosis and grading of InI through FOB is the current standard, although its predictive value regarding key outcome parameters and therapeutic decision-making, remains unclear. The potential procedural risk of FOB itself should be considered. This study demonstrates correlations of FOB with major clinical outcomes in both a general collective of burned adults as well as severely burned adults. Although these findings must be interpreted with caution, they may induce further research into potential harm of FOB and critical review of routine diagnostic FOB in suspected inhalation injury in thermally injured patients.