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

Severity of Inhalation Injury and Risk of Nosocomial Pneumonia: A Retrospective Cohort Study

BACKGROUND

The impact of inhalation injury on risk of nosocomial pneumonia (NP), an important complication in patients with burns, is not well established.

RESEARCH QUESTION

Is more severe inhalation injury associated with increased risk of NP?

STUDY DESIGN AND METHODS

We performed a retrospective cohort study of patients with suspected inhalation injury admitted to a regional burn center from 2011 to 2022 who underwent diagnostic bronchoscopy within 48 h of admission. We estimated the association of high-grade inhalation injury (Abbreviated Injury Scale score 3 and 4) vs low-grade inhalation injury (Abbreviated Injury Scale score 1 and 2) with NP adjusted for age, burn size, and comorbid obstructive lung disease. Death and hospital discharge were considered competing risks.

RESULTS

Of the 245 patients analyzed, 51 (21%) had high-grade injury, 180 (73%) had low-grade injury, and 14 (6%) had no inhalation injury. Among the 236 patients hospitalized for ≥ 48 h, NP occurred in 24 of 50 patients (48%) in the high-grade group, 54 of 172 patients (31%) in the low-grade group, and two of 14 patients (14%) in the no inhalation injury group. High-grade (vs low-grade) inhalation injury was associated with higher hazard of NP in both the proportional cause-specific hazard model (cause-specific hazard ratio, 2.04; 95% CI, 1.26-3.30; P = .004) and Fine-Gray subdistribution hazard model (subdistribution hazard ratio for NP, 2.24; 95% CI, 1.38-3.64; P = .001).

INTERPRETATION

Among patients with inhalation injury, more severe injury was associated with higher hazard of NP in competing risk analysis. Additional research is needed to investigate mechanisms that may explain the relationship between inhalation injury and NP and to identify more effective risk reduction strategies.

Do pre-burn center management algorithms work? Evaluation of pre-admission diagnosis and treatment adequacy of burn patients referred to a burn center

Interventions for burn management until the patient is transferred to a burn center affect mortality and morbidity. Therefore, adherence to the developed algorithms is an important issue. This study aimed to determine deficiencies in different aspects of the implementation of these algorithms during the pre-admission diagnosis and treatment processes of patients referred to our burn center. This study involved a 4-year review of patients referred to our burn center. One hundred and seventy burn cases admitted by referral were enrolled in the study. Adequacy of resuscitation within the first 24 hours, adherence to guidelines, and mortality were investigated. Resuscitation performed within the first 24 hours was found to be inadequate in 88 patients (51.8%). When the burned surface area percentages were evaluated all percentages were calculated higher before arrival. There were 78 major burn cases (45.9%), and the frequency of inhalation burns, intubation requirements and renal failure were more common in this group compared to the minor burn group (P < .001). The frequency of intubation without accurate indications was found to be 70.58%. Inadequate escharotomy was detected at a rate of 52.9%, and inadequate fasciotomy at a rate of 66.6%. The mortality rate was 22.4% among all patients. Interventions undertaken during the period until the patients' referral to these centers affect mortality and morbidity. In this study, it was found that the pre-hospital applications generated were insufficient, and it was proposed that burn patient care algorithms be developed with in-service training throughout the country.

An international RAND/UCLA expert panel to determine the optimal diagnosis and management of burn inhalation injury

BACKGROUND

Burn inhalation injury (BII) is a major cause of burn-related mortality and morbidity. Despite published practice guidelines, no consensus exists for the best strategies regarding diagnosis and management of BII. A modified DELPHI study using the RAND/UCLA (University of California, Los Angeles) Appropriateness Method (RAM) systematically analysed the opinions of an expert panel. Expert opinion was combined with available evidence to determine what constitutes appropriate and inappropriate judgement in the diagnosis and management of BII.

METHODS

A 15-person multidisciplinary panel comprised anaesthetists, intensivists and plastic surgeons involved in the clinical management of major burn patients adopted a modified Delphi approach using the RAM method. They rated the appropriateness of statements describing diagnostic and management options for BII on a Likert scale. A modified final survey comprising 140 statements was completed, subdivided into history and physical examination (20), investigations (39), airway management (5), systemic toxicity (23), invasive mechanical ventilation (29) and pharmacotherapy (24). Median appropriateness ratings and the disagreement index (DI) were calculated to classify statements as appropriate, uncertain, or inappropriate.

RESULTS

Of 140 statements, 74 were rated as appropriate, 40 as uncertain and 26 as inappropriate. Initial intubation with ≥ 8.0 mm endotracheal tubes, lung protective ventilatory strategies, initial bronchoscopic lavage, serial bronchoscopic lavage for severe BII, nebulised heparin and salbutamol administration for moderate-severe BII and N-acetylcysteine for moderate BII were rated appropriate. Non-protective ventilatory strategies, high-frequency oscillatory ventilation, high-frequency percussive ventilation, prophylactic systemic antibiotics and corticosteroids were rated inappropriate. Experts disagreed (DI ≥ 1) on six statements, classified uncertain: the use of flexible fiberoptic bronchoscopy to guide fluid requirements (DI = 1.52), intubation with endotracheal tubes of internal diameter < 8.0 mm (DI = 1.19), use of airway pressure release ventilation modality (DI = 1.19) and nebulised 5000IU heparin, N-acetylcysteine and salbutamol for mild BII (DI = 1.52, 1.70, 1.36, respectively).

CONCLUSIONS

Burns experts mostly agreed on appropriate and inappropriate diagnostic and management criteria of BII as in published guidance. Uncertainty exists as to the optimal diagnosis and management of differing grades of severity of BII. Future research should investigate the accuracy of bronchoscopic grading of BII, the value of bronchial lavage in differing severity groups and the effectiveness of nebulised therapies in different severities of BII.

The utility of arterial blood gas parameters and chest radiography in predicting appropriate intubations in burn patients with suspected inhalation injury-A retrospective cohort study

BACKGROUND

This study evaluates the utility of arterial blood gas (ABG) parameters and chest radiography in predicting intubation need in patients with burn injuries with suspected inhalation injury.

METHODS

Patients with suspected inhalation injury admitted to a single centre, Burn Intensive Care Unit, between April 4th 2016 and July 5th 2019, were included. Admission ABG parameters and chest radiograph opacification were compared with whether the patient received an appropriate intubation: defined as intubation for a duration of over 48 h. Area under the receiver operator characteristic curve was calculated (AUROC).

RESULTS

Eighty-nine patients were included. The majority (84%; n = 75) were intubated, of which 81% (n = 61) received appropriate intubations. pH had an AUROC of 0.88 and a pH of <7.30 had an 80% sensitivity and specificity for detecting appropriate intubation. P/F ratio had an AUROC of 0.81 and a P/F ratio of <40 had a 70% sensitivity and specificity for appropriate intubation. Chest radiograph opacification had poor utility in this regard (AUROC = 0.69). Adding pH and P/F ratio to the ABA criteria improved their sensitivity in detecting appropriate intubations (sensitivity: ABA + pH + P/F = 0.97 vs ABA = 0.86; p = 0.013), without altering their specificity.

CONCLUSIONS

In patients suspected inhalation injury, pH and P/F ratio were good predictors for appropriate intubations. Incorporating the parameters into the ABA criteria improved their clinical utility.