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Sang L, Guo X, Zhao Y, Shi J, Niu Z, Wu Z, Hou S, Fan H, Lv Q. Protective Effect of Nebulized Heparin in the Animal Models of Smoke Inhalation Injury: A Meta-analysis and Systematic Review of Experimental Studies. J Burn Care Res 2023; 44:42-52. [PMID: 36269755 DOI: 10.1093/jbcr/irac156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Indexed: 01/14/2023]
Abstract
The pathophysiological mechanism of abnormal coagulation can result from smoke inhalation injury (SII). Heparin nebulization is a common treatment for lung disorders. This study aimed to use meta-analysis in animal models to examine the effectiveness of atomized heparin on SII. For our online searches, we used the Cochrane Central Register of Controlled Trials, PubMed, Web of Science, Chinese National Knowledge Infrastructure, Chinese BioMedical Literature Database, and Wanfang Database up to January 2022. Data for SII were retrieved and compared to control animals. The studies' findings were determined by combining standardized mean difference (SMD) analysis with 95% confidence intervals (CIs). The findings showed that as compared to the control group, the heparin-treated group had a lower death rate (relative risk 0.42; 95% CI 0.22, 0.80; p < .05). The meta-analysis demonstrated favorable changes in lung physiology, including PaO2/FiO2 (SMD 1.04; 95% CI 0.65, 1.44; p < .001), lung wet-to-dry weight ratio (SMD -1.83; 95% CI -2.47, -1.18; p < .001), and pulmonary shunt Qs/Qt (SMD -0.69; 95% CI -1.29, -0.08; p < .05) after heparin nebulization for lung injury. The present data indicated that pulmonary artery mean pressure in the heparin therapy group was significantly lowered after 24 and 48 hours of therapy, suggesting that the cardiovascular system could recover following heparin treatment. As a result, heparin nebulization appeared to be more effective against SII and improved cardiopulmonary function compared to the control group. Graphical Abstract.
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Affiliation(s)
- Lu Sang
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.,Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin, China
| | - Xiaoqin Guo
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.,Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin, China
| | - Yuchen Zhao
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.,Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin, China
| | - Jie Shi
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.,Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin, China
| | - Zhifang Niu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.,Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin, China
| | - Zhenlong Wu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.,Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin, China
| | - Shike Hou
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.,Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin, China
| | - Haojun Fan
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.,Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin, China
| | - Qi Lv
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.,Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin, China
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Nygaard RM, Endorf FW. Hyperbaric Oxygen and Mortality in Burns With Inhalation Injury: A Study of the National Burn Repository. J Burn Care Res 2021; 42:900-904. [PMID: 34105724 DOI: 10.1093/jbcr/irab105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Mortality in burn injury is primarily influenced by three factors: age, percent burn (%TBSA), and presence of inhalation injury. Numerous modalities have been tried in an attempt to treat those patients with burns and inhalation injury, including the use of hyperbaric oxygen (HBO). The aim of our study was to find the national prevalence of HBO for burns with inhalation injury, and whether HBO influenced mortality in these often severely injured patients. This retrospective study used the National Burn Repository (NBR) to identify hospital admissions of patients with both cutaneous burn and inhalation injuries. After applying exclusion criteria, a total of 13,044 patients were identified. Variables included in the multivariate regression analysis included age, sex, race, payer, mechanism of burn injury, TBSA group, total procedure number, mechanical ventilator days, and treatment with HBO. The main outcome variable was mortality. Of the 13,044 patients, 67 had HBO therapy. The HBO patients were older (mean age 51.7 vs 42.8 years, P < .001), but had smaller burns and thus a similar Baux score (66.6 vs 65.2, P = .661). The HBO patients had a higher mortality (29.9% vs 17.5%, P = .01). On multivariate regression analysis, HBO was an independent predictor of mortality (odds ratio = 2.484, P = .004). Other significant predictors of mortality included age, black race, Medicaid or uninsured patients, and %TBSA. The use of HBO for patients with burns and inhalation injury is uncommon in this database. It is unclear whether that reflects low prevalence or if individual centers do not all impute HBO into the NBR. For those patients in this database, HBO is an independent predictor of mortality. It can be difficult to determine the severity of inhalation injury in the NBR, so those patients receiving HBO could theoretically have more severe inhalation injury.
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3
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Livingstone SA, Wildi KS, Dalton HJ, Usman A, Ki KK, Passmore MR, Li Bassi G, Suen JY, Fraser JF. Coagulation Dysfunction in Acute Respiratory Distress Syndrome and Its Potential Impact in Inflammatory Subphenotypes. Front Med (Lausanne) 2021; 8:723217. [PMID: 34490308 PMCID: PMC8417599 DOI: 10.3389/fmed.2021.723217] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 07/29/2021] [Indexed: 12/12/2022] Open
Abstract
The Acute Respiratory Distress Syndrome (ARDS) has caused innumerable deaths worldwide since its initial description over five decades ago. Population-based estimates of ARDS vary from 1 to 86 cases per 100,000, with the highest rates reported in Australia and the United States. This syndrome is characterised by a breakdown of the pulmonary alveolo-epithelial barrier with subsequent severe hypoxaemia and disturbances in pulmonary mechanics. The underlying pathophysiology of this syndrome is a severe inflammatory reaction and associated local and systemic coagulation dysfunction that leads to pulmonary and systemic damage, ultimately causing death in up to 40% of patients. Since inflammation and coagulation are inextricably linked throughout evolution, it is biological folly to assess the two systems in isolation when investigating the underlying molecular mechanisms of coagulation dysfunction in ARDS. Although the body possesses potent endogenous systems to regulate coagulation, these become dysregulated and no longer optimally functional during the acute phase of ARDS, further perpetuating coagulation, inflammation and cell damage. The inflammatory ARDS subphenotypes address inflammatory differences but neglect the equally important coagulation pathway. A holistic understanding of this syndrome and its subphenotypes will improve our understanding of underlying mechanisms that then drive translation into diagnostic testing, treatments, and improve patient outcomes.
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Affiliation(s)
- Samantha A Livingstone
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Karin S Wildi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland
| | | | - Asad Usman
- Department of Anesthesiology and Critical Care, The University of Pennsylvania, Philadelphia, PA, United States
| | - Katrina K Ki
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Margaret R Passmore
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Pulmonology and Critical Care, Hospital Clínic de Barcelona, Universitad de Barcelona and IDIBAPS, CIBERES, Barcelona, Spain
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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4
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van Haren FMP, Page C, Laffey JG, Artigas A, Camprubi-Rimblas M, Nunes Q, Smith R, Shute J, Carroll M, Tree J, Carroll M, Singh D, Wilkinson T, Dixon B. Nebulised heparin as a treatment for COVID-19: scientific rationale and a call for randomised evidence. Crit Care 2020; 24:454. [PMID: 32698853 PMCID: PMC7374660 DOI: 10.1186/s13054-020-03148-2] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/03/2020] [Indexed: 12/16/2022] Open
Abstract
Nebulised unfractionated heparin (UFH) has a strong scientific and biological rationale and warrants urgent investigation of its therapeutic potential, for COVID-19-induced acute respiratory distress syndrome (ARDS). COVID-19 ARDS displays the typical features of diffuse alveolar damage with extensive pulmonary coagulation activation resulting in fibrin deposition in the microvasculature and formation of hyaline membranes in the air sacs. Patients infected with SARS-CoV-2 who manifest severe disease have high levels of inflammatory cytokines in plasma and bronchoalveolar lavage fluid and significant coagulopathy. There is a strong association between the extent of the coagulopathy and poor clinical outcomes.The anti-coagulant actions of nebulised UFH limit fibrin deposition and microvascular thrombosis. Trials in patients with acute lung injury and related conditions found inhaled UFH reduced pulmonary dead space, coagulation activation, microvascular thrombosis and clinical deterioration, resulting in increased time free of ventilatory support. In addition, UFH has anti-inflammatory, mucolytic and anti-viral properties and, specifically, has been shown to inactivate the SARS-CoV-2 virus and prevent its entry into mammalian cells, thereby inhibiting pulmonary infection by SARS-CoV-2. Furthermore, clinical studies have shown that inhaled UFH safely improves outcomes in other inflammatory respiratory diseases and also acts as an effective mucolytic in sputum-producing respiratory patients. UFH is widely available and inexpensive, which may make this treatment also accessible for low- and middle-income countries.These potentially important therapeutic properties of nebulised UFH underline the need for expedited large-scale clinical trials to test its potential to reduce mortality in COVID-19 patients.
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Affiliation(s)
- Frank M P van Haren
- Australian National University, Medical School, Canberra, Australia.
- Intensive Care Unit, the Canberra Hospital, Canberra, Australia.
| | - Clive Page
- Sackler Institute of Pulmonary Pharmacology, King's College London, London, UK
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, and Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, National University of Ireland Galway, Galway, Ireland
- Department of Anaesthesia, University Hospital Galway, Saolta Hospital Group, Galway, Ireland
| | - Antonio Artigas
- Critical Center, Corporació Sanitaria Parc Tauli , CIBER Enfermedades Respiratorias, Autonomous University of Barcelona, Sabadell, Spain
| | - Marta Camprubi-Rimblas
- Institut d'Investigació I Innovació Parc Tauli (I3PT), CIBER de Enfermedades Respiratorias, Sabadell, Spain
| | - Quentin Nunes
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Roger Smith
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia
| | - Janis Shute
- School of Pharmacy and Biomedical Science, University of Portsmouth, Portsmouth, UK
| | - Mary Carroll
- Department of Respiratory Medicine, University of Southampton, Southampton, UK
| | - Julia Tree
- National Infection Service, Public Health England, Porton Down, UK
| | - Miles Carroll
- National Infection Service, Public Health England, Porton Down, UK
| | - Dave Singh
- Medicines Evaluation Unit, University of Manchester, Manchester, UK
| | - Tom Wilkinson
- Department of Respiratory Medicine, University of Southampton, Southampton, UK
| | - Barry Dixon
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia
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Abdelaal Ahmed Mahmoud A, Mahmoud HE, Mahran MA, Khaled M. Streptokinase Versus Unfractionated Heparin Nebulization in Patients With Severe Acute Respiratory Distress Syndrome (ARDS): A Randomized Controlled Trial With Observational Controls. J Cardiothorac Vasc Anesth 2020; 34:436-443. [DOI: 10.1053/j.jvca.2019.05.035] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 05/19/2019] [Accepted: 05/23/2019] [Indexed: 02/08/2023]
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6
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Guo B, Bai Y, Ma Y, Liu C, Wang S, Zhao R, Dong J, Ji HL. Preclinical and clinical studies of smoke-inhalation-induced acute lung injury: update on both pathogenesis and innovative therapy. Ther Adv Respir Dis 2019; 13:1753466619847901. [PMID: 31068086 PMCID: PMC6515845 DOI: 10.1177/1753466619847901] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Smoke-inhalation-induced acute lung injury (SI-ALI) is a leading cause of morbidity and mortality in victims of fire tragedies. SI-ALI contributes to an estimated 30% of burn-caused patient deaths, and recently, more attention has been paid to the specific interventions for this devastating respiratory illness. In the last decade, much progress has been made in the understanding of SI-ALI patho-mechanisms and in the development of new therapeutic strategies in both preclinical and clinical studies. This article reviews the recent progress in the treatment of SI-ALI, based on pathophysiology, thermal damage, airway obstruction, the nuclear-factor kappa-B signaling pathway, and oxidative stress. Preclinical therapeutic strategies include use of mesenchymal stem cells, hydrogen sulfide, peroxynitrite decomposition catalysts, and proton-pump inhibitors. Clinical interventions include high-frequency percussive ventilation, perfluorohexane, inhaled anticoagulants, and nebulized epinephrine. The animal model, dose, clinical application, and pharmacology of these medications are summarized. Future directions and further needs for developing innovative therapies are discussed.
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Affiliation(s)
- Bingxin Guo
- Institute of Lung and Molecular Therapy, Xinxiang Medical University, Xinxiang Henan, China
| | - Yichun Bai
- Institute of Lung and Molecular Therapy, Xinxiang Medical University, Xinxiang Henan, China
| | - Yana Ma
- Institute of Lung and Molecular Therapy, Xinxiang Medical University, Xinxiang Henan, China
| | - Cong Liu
- Institute of Lung and Molecular Therapy, Xinxiang Medical University, Xinxiang Henan, China
| | - Song Wang
- Institute of Lung and Molecular Therapy, Xinxiang Medical University, Xinxiang Henan, China
| | - Runzhen Zhao
- Department of Cellular and Molecular Biology, University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - Jiaxing Dong
- Institute of Lung and Molecular Therapy, Xinxiang Medical University, Xinxiang Henan, China
| | - Hong-Long Ji
- Texas Lung Injury Institute, University of Texas Health Science Center at Tyler, Tyler, TX, USA
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7
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Hamblin MR. Novel pharmacotherapy for burn wounds: what are the advancements. Expert Opin Pharmacother 2019; 20:305-321. [PMID: 30517046 PMCID: PMC6364296 DOI: 10.1080/14656566.2018.1551880] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 11/20/2018] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The prognosis for severe burns has improved significantly over the past 50 years. Meanwhile, burns have become an affliction mainly affecting the less well-developed regions of the world. Early excision and skin grafting has led to major improvements in therapeutic outcomes. AREAS COVERED The purpose of this article is to survey the use of pharmacotherapy to treat different pathophysiological complications of burn injury. The author, herein, discusses the use of drug treatments for a number of systemic metabolic disturbances including hyperglycemia, elevated catabolism, and gluconeogenesis. EXPERT OPINION Advancements in personalized and molecular medicine will make an impact on burn therapy. Similarities between severe burns and other critically ill patients will lead to cross-fertilization between different medical specialties. Furthermore, advances in stem cells and tissue regeneration will lead to improved healing and less lifelong disability. Indeed, research in new drug therapy for burns is actively progressing for many different complications.
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Affiliation(s)
- Michael R Hamblin
- a Wellman Center for Photomedicine , Massachusetts General Hospital , Boston , MA , USA
- b Department of Dermatology , Harvard Medical School , Boston , MA , USA
- c Harvard-MIT Division of Health Sciences and Technology , Cambridge , MA , USA
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8
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Abstract
Although the overall incidence of and mortality rate associated with burn injury have decreased in recent decades, burns remain a significant source of morbidity and mortality in children. Children with major burns require emergent resuscitation. Resuscitation is similar to that for adults, including pain control, airway management, and administration of intravenous fluid. However, in pediatrics, fluid resuscitation is needed for burns greater than or equal to 15% of total body surface area (TBSA) compared with burns greater than or equal to 20% TBSA for adults. Unique to pediatrics is the additional assessment for non-accidental injury and accurate calculation of the percentage of total burned surface area (TBSA) in children with changing body proportions are crucial to determine resuscitation parameters, prognosis, and disposition.
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Affiliation(s)
- Ashley M Strobel
- Department of Emergency Medicine, University of Minnesota School of Medicine, Hennepin County Medical Center, University of Minnesota Masonic Children's Hospital, 701 South Park Avenue R2.123, Minneapolis, MN 55414, USA.
| | - Ryan Fey
- Department of Surgery, University of Minnesota School of Medicine, Hennepin County Medical Center, 701 South Park Avenue, Minneapolis, MN 55414, USA
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Foncerrada G, Culnan DM, Capek KD, González-Trejo S, Cambiaso-Daniel J, Woodson LC, Herndon DN, Finnerty CC, Lee JO. Inhalation Injury in the Burned Patient. Ann Plast Surg 2018; 80:S98-S105. [PMID: 29461292 PMCID: PMC5825291 DOI: 10.1097/sap.0000000000001377] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Inhalation injury causes a heterogeneous cascade of insults that increase morbidity and mortality among the burn population. Despite major advancements in burn care for the past several decades, there remains a significant burden of disease attributable to inhalation injury. For this reason, effort has been devoted to finding new therapeutic approaches to improve outcomes for patients who sustain inhalation injuries.The three major injury classes are the following: supraglottic, subglottic, and systemic. Treatment options for these three subtypes differ based on the pathophysiologic changes that each one elicits.Currently, no consensus exists for diagnosis or grading of the injury, and there are large variations in treatment worldwide, ranging from observation and conservative management to advanced therapies with nebulization of different pharmacologic agents.The main pathophysiologic change after a subglottic inhalation injury is an increase in the bronchial blood flow. An induced mucosal hyperemia leads to edema, increases mucus secretion and plasma transudation into the airways, disables the mucociliary escalator, and inactivates hypoxic vasocontriction. Collectively, these insults potentiate airway obstruction with casts formed from epithelial debris, fibrin clots, and inspissated mucus, resulting in impaired ventilation. Prompt bronchoscopic diagnosis and multimodal treatment improve outcomes. Despite the lack of globally accepted standard treatments, data exist to support the use of bronchoscopy and suctioning to remove debris, nebulized heparin for fibrin casts, nebulized N-acetylcysteine for mucus casts, and bronchodilators.Systemic effects of inhalation injury occur both indirectly from hypoxia or hypercapnia resulting from loss of pulmonary function and systemic effects of proinflammatory cytokines, as well as directly from metabolic poisons such as carbon monoxide and cyanide. Both present with nonspecific clinical symptoms including cardiovascular collapse. Carbon monoxide intoxication should be treated with oxygen and cyanide with hydroxocobalamin.Inhalation injury remains a great challenge for clinicians and an area of opportunity for scientists. Management of this concomitant injury lags behind other aspects of burn care. More clinical research is required to improve the outcome of inhalation injury.The goal of this review is to comprehensively summarize the diagnoses, treatment options, and current research.
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Affiliation(s)
- Guillermo Foncerrada
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
- Shriners Hospitals for Children - Galveston, Galveston, Texas, USA
| | - Derek M. Culnan
- JMS Burn and Reconstructive Center at Merit Health Central, Jackson, MS, USA
| | - Karel D. Capek
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
- Shriners Hospitals for Children - Galveston, Galveston, Texas, USA
| | - Sagrario González-Trejo
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
- Shriners Hospitals for Children - Galveston, Galveston, Texas, USA
| | - Janos Cambiaso-Daniel
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
- Shriners Hospitals for Children - Galveston, Galveston, Texas, USA
| | - Lee C. Woodson
- Shriners Hospitals for Children - Galveston, Galveston, Texas, USA
- Department of Anesthesiology, University of Texas Medical Branch Galveston, Texas, USA
| | - David N. Herndon
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
- Shriners Hospitals for Children - Galveston, Galveston, Texas, USA
| | - Celeste C. Finnerty
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
- Shriners Hospitals for Children - Galveston, Galveston, Texas, USA
| | - Jong O. Lee
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
- Shriners Hospitals for Children - Galveston, Galveston, Texas, USA
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10
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McGinn KA, Weigartz K, Lintner A, Scalese MJ, Kahn SA. Nebulized Heparin With N-Acetylcysteine and Albuterol Reduces Duration of Mechanical Ventilation in Patients With Inhalation Injury. J Pharm Pract 2017; 32:163-166. [PMID: 29233052 DOI: 10.1177/0897190017747143] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Nebulized heparin has been proposed to improve pulmonary function in patients with inhalation injuries. The purpose of this study was to evaluate the impact of nebulized heparin with N-acetylcysteine (NAC) and albuterol on the duration of mechanical ventilation in burn patients. METHODS This is a retrospective study evaluating mechanically ventilated adult patients admitted to a regional burn center with inhalation injury. Outcomes were compared between patients who were prescribed a combination of nebulized heparin with NAC and albuterol versus similar patients who did not. RESULTS A total of 48 patients met inclusion criteria (heparin n = 22; nonheparin n = 26). Patients in the nonheparin group had higher percentage of total body surface area (TBSA) burned (29.00 [5.75-51.88] vs 5.25 [0.50-13.25] %TBSA; P = .009), longer duration of mechanical ventilation (6.50 [2.75-17.00] vs 3.00 [1.00-8.25] days; P = .022), and longer intensive care unit length of stay (LOS) (3.00 [3.00-28.75] vs 5.50 days [2.00-11.25]; P = .033). Upon regression, use of heparin was the only variable associated with reducing the duration of mechanical ventilation ( P = .039). CONCLUSION Nebulized heparin in combination with NAC and albuterol was associated with a significant reduction in the duration of mechanical ventilation.
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Affiliation(s)
- Kaitlin A McGinn
- 1 Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy, Auburn, AL, USA.,2 Department of Surgery, University of South Alabama Medical Center, Mobile, AL, USA
| | - Katie Weigartz
- 1 Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy, Auburn, AL, USA
| | - Alicia Lintner
- 2 Department of Surgery, University of South Alabama Medical Center, Mobile, AL, USA
| | - Michael J Scalese
- 1 Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy, Auburn, AL, USA.,2 Department of Surgery, University of South Alabama Medical Center, Mobile, AL, USA
| | - Steven A Kahn
- 2 Department of Surgery, University of South Alabama Medical Center, Mobile, AL, USA
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11
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Enkhbaatar P, Pruitt BA, Suman O, Mlcak R, Wolf SE, Sakurai H, Herndon DN. Pathophysiology, research challenges, and clinical management of smoke inhalation injury. Lancet 2016; 388:1437-1446. [PMID: 27707500 PMCID: PMC5241273 DOI: 10.1016/s0140-6736(16)31458-1] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 08/11/2016] [Accepted: 08/16/2016] [Indexed: 01/02/2023]
Abstract
Smoke inhalation injury is a serious medical problem that increases morbidity and mortality after severe burns. However, relatively little attention has been paid to this devastating condition, and the bulk of research is limited to preclinical basic science studies. Moreover, no worldwide consensus criteria exist for its diagnosis, severity grading, and prognosis. Therapeutic approaches are highly variable depending on the country and burn centre or hospital. In this Series paper, we discuss understanding of the pathophysiology of smoke inhalation injury, the best evidence-based treatments, and challenges and future directions in diagnostics and management.
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Affiliation(s)
- Perenlei Enkhbaatar
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX, USA.
| | - Basil A Pruitt
- Department of Surgery, Division of Trauma, University of Texas Health Science Center, San Antonio, TX, USA
| | - Oscar Suman
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA; Shriners Hospitals for Children, Galveston, TX, USA
| | - Ronald Mlcak
- Shriners Hospitals for Children, Galveston, TX, USA; Department of Respiratory Care, School of Health Professions, University of Texas Medical Branch, Galveston, TX, USA
| | - Steven E Wolf
- Department of Surgery, University of Texas, Southwestern Medical Center, Dallas, TX, USA
| | - Hiroyuki Sakurai
- Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - David N Herndon
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA; Shriners Hospitals for Children, Galveston, TX, USA
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12
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Is inhaled prophylactic heparin useful for prevention and management of pneumonia in ventilated ICU patients? J Crit Care 2016; 35:231-239. [PMID: 27591357 DOI: 10.1016/j.jcrc.2016.06.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE The purpose was to determine the efficacy of prophylactic inhaled heparin for the prevention and treatment of pneumonia in patients receiving mechanical ventilation (MV). METHODS A phase 2, double-blind, randomized controlled trial stratified for study center and patient type (nonoperative, postoperative) was conducted in 3 university-affiliated intensive care units. Patients aged at least 18 years and requiring invasive MV for more than 48 hours were randomized to usual care, nebulization of unfractionated sodium heparin (5000 U in 2 mL), or nebulization with 0.9% sodium chloride (2 mL) 4 times daily with the main outcome measures, the development of ventilator-associated pneumonia (VAP), ventilator-associated complication, and Sequential Organ Failure Assessment scores in patients with admission pneumonia or developing VAP. TRIAL REGISTRATION ACTRN12612000038897. RESULTS A total of 214 patients were enrolled (72 usual care, 71 inhaled sodium heparin, 71 inhaled sodium chloride). There were no differences between treatment groups in terms of the development of VAP using either Klompas criteria (6%-7%, P=1.00) or clinical diagnosis (24%-26%, P=.85). CONCLUSION Low-dose nebulized heparin cannot be recommended for prophylaxis against VAP or to hasten recovery from pneumonia in patients receiving MV.
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13
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Walker PF, Buehner MF, Wood LA, Boyer NL, Driscoll IR, Lundy JB, Cancio LC, Chung KK. Diagnosis and management of inhalation injury: an updated review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:351. [PMID: 26507130 PMCID: PMC4624587 DOI: 10.1186/s13054-015-1077-4] [Citation(s) in RCA: 127] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In this article we review recent advances made in the pathophysiology, diagnosis, and treatment of inhalation injury. Historically, the diagnosis of inhalation injury has relied on nonspecific clinical exam findings and bronchoscopic evidence. The development of a grading system and the use of modalities such as chest computed tomography may allow for a more nuanced evaluation of inhalation injury and enhanced ability to prognosticate. Supportive respiratory care remains essential in managing inhalation injury. Adjuncts still lacking definitive evidence of efficacy include bronchodilators, mucolytic agents, inhaled anticoagulants, nonconventional ventilator modes, prone positioning, and extracorporeal membrane oxygenation. Recent research focusing on molecular mechanisms involved in inhalation injury has increased the number of potential therapies.
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Affiliation(s)
- Patrick F Walker
- Department of Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD, 20889, USA
| | - Michelle F Buehner
- Department of General Surgery, San Antonio Military Medical Center, 3551 Roger Brooke Dr., Fort Sam Houston, TX, 78234, USA.
| | - Leslie A Wood
- Department of Medicine, San Antonio Military Medical Center, 3551 Roger Brooke Dr., Fort Sam Houston, TX, 78234, USA
| | - Nathan L Boyer
- Department of Medicine, San Antonio Military Medical Center, 3551 Roger Brooke Dr., Fort Sam Houston, TX, 78234, USA
| | - Ian R Driscoll
- United States Army Institute of Surgical Research, Fort Sam Houston, TX, 78234, USA
| | - Jonathan B Lundy
- United States Army Institute of Surgical Research, Fort Sam Houston, TX, 78234, USA
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, Fort Sam Houston, TX, 78234, USA
| | - Kevin K Chung
- United States Army Institute of Surgical Research, Fort Sam Houston, TX, 78234, USA.,Department of Surgery, Uniformed Services University of the Health Sciences, Building A, 4301 Jones Bridge Rd, Bethesda, MD, 20814, USA
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Advantages and pitfalls of combining intravenous antithrombin with nebulized heparin and tissue plasminogen activator in acute respiratory distress syndrome. J Trauma Acute Care Surg 2014; 76:126-33. [PMID: 24368367 DOI: 10.1097/ta.0b013e3182ab0785] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pulmonary coagulopathy has become an important therapeutic target in adult respiratory distress syndrome (ARDS). We hypothesized that combining intravenous recombinant human antithrombin (rhAT), nebulized heparin, and nebulized tissue plasminogen activator (TPA) more effectively improves pulmonary gas exchange compared with a single rhAT infusion, while maintaining the anti-inflammatory properties of rhAT in ARDS. Therefore, the present prospective, randomized experiment was conducted using an established ovine model. METHODS Following burn and smoke inhalation injury (40% of total body surface area, third-degree flame burn, and 4 × 12 breaths of cold cotton smoke), 18 chronically instrumented sheep were randomly assigned to receive intravenous saline plus saline nebulization (control), intravenous rhAT (6 IU/kg/h) started 1 hour after injury plus saline nebulization (AT i.v.) or intravenous rhAT combined with nebulized heparin (10,000 IU every 4 hours, started 2 hours after injury), and nebulized TPA (2 mg every 4 hours, started 4 hours after injury) (triple therapy, n = 6 each). All animals were mechanically ventilated and fluid resuscitated according to standard protocols during the 48-hour study period. RESULTS Both treatment approaches attenuated ARDS compared with control animals. Notably, triple therapy was associated with an improved PaO2/FiO2 ratio (p = 0.007), attenuated pulmonary obstruction (p = 0.02) and shunting (p = 0.025), as well as reduced ventilatory pressures (p < 0.05 each) versus AT i.v. at 48 hours. However, the anti-inflammatory effects of sole AT i.v., namely, the inhibition of neutrophil activation (neutrophil count in the lymph and pulmonary polymorphonuclear cells, p < 0.05 vs. control each), pulmonary transvascular fluid flux (lymph flow, p = 0.004 vs. control), and systemic vascular leakage (cumulative net fluid balance, p < 0.001 vs. control), were abolished in the triple therapy group. CONCLUSION Combining intravenous rhAT with nebulized heparin and nebulized TPA more effectively restores pulmonary gas exchange, but the anti-inflammatory effects of sole rhAT are abolished with the triple therapy. Interferences between the different anticoagulants may represent a potential explanation for these findings.
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Glas GJ, Van Der Sluijs KF, Schultz MJ, Hofstra JJH, Van Der Poll T, Levi M. Bronchoalveolar hemostasis in lung injury and acute respiratory distress syndrome. J Thromb Haemost 2013; 11:17-25. [PMID: 23114008 DOI: 10.1111/jth.12047] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Enhanced intrapulmonary fibrin deposition as a result of abnormal broncho-alveolar fibrin turnover is a hallmark of acute respiratory distress syndrome (ARDS), pneumonia and ventilator-induced lung injury (VILI), and is important to the pathogenesis of these conditions. The mechanisms that contribute to alveolar coagulopathy are localized tissue factor-mediated thrombin generation, impaired activity of natural coagulation inhibitors and depression of bronchoalveolar urokinase plasminogen activator-mediated fibrinolysis, caused by the increase of plasminogen activator inhibitors. There is an intense and bidirectional interaction between coagulation and inflammatory pathways in the bronchoalveolar compartment. Systemic or local administration of anticoagulant agents (including activated protein C, antithrombin and heparin) and profibrinolytic agents (such as plasminogen activators) attenuate pulmonary coagulopathy. Several preclinical studies show additional anti-inflammatory effects of these therapies in ARDS and pneumonia.
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Affiliation(s)
- G J Glas
- Laboratory for Experimental Intensive Care and Anesthesiology, University of Amsterdam, Amsterdam, the Netherlands
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Yamamoto Y, Enkhbaatar P, Sousse LE, Sakurai H, Rehberg SW, Asmussen S, Kraft ER, Wright CL, Bartha E, Cox RA, Hawkins HK, Traber LD, Traber MG, Szabo C, Herndon DN, Traber DL. Nebulization with γ-tocopherol ameliorates acute lung injury after burn and smoke inhalation in the ovine model. Shock 2012; 37:408-14. [PMID: 22266978 PMCID: PMC3306540 DOI: 10.1097/shk.0b013e3182459482] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We hypothesize that the nebulization of γ-tocopherol (g-T) in the airway of our ovine model of acute respiratory distress syndrome will effectively improve pulmonary function following burn and smoke inhalation after 96 h. Adult ewes (n = 14) were subjected to 40% total body surface area burn and were insufflated with 48 breaths of cotton smoke under deep anesthesia, in a double-blind comparative study. A customized aerosolization device continuously delivered g-T in ethanol with each breath from 3 to 48 h after the injury (g-T group, n = 6), whereas the control group (n = 5) was nebulized with only ethanol. Animals were weaned from the ventilator when possible. All animals were killed after 96 h, with the exception of one untreated animal that was killed after 64 h. Lung g-T concentration significantly increased after g-T nebulization compared with the control group (38.5 ± 16.8 vs. 0.39 ± 0.46 nmol/g, P < 0.01). The PaO(2)/FIO(2) ratio was significantly higher after treatment with g-T compared with the control group (310 ± 152 vs. 150 ± 27.0, P < 0.05). The following clinical parameters were improved with g-T treatment: pulmonary shunt fraction, peak and pause pressures, lung bloodless wet-to-dry weight ratios (2.9 ± 0.87 vs. 4.6 ± 1.4, P < 0.05), and bronchiolar obstruction (2.0% ± 1.1% vs. 4.6% ± 1.7%, P < 0.05). Nebulization of g-T, carried by ethanol, improved pulmonary oxygenation and markedly reduced the time necessary for assisted ventilation in burn- and smoke-injured sheep. Delivery of g-T into the lungs may be a safe, novel, and efficient approach for management of acute lung injury patients who have sustained oxidative damage to the airway.
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Affiliation(s)
- Yusuke Yamamoto
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas 77555-0833, USA
- Department of Plastic and Reconstructive Surgery, Tokyo Women’s Medical University, 8-1 Kawata-cho, Shinjuku-ku, Tokyo 162-8666, Japan
| | - Perenlei Enkhbaatar
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas 77555-0833, USA
| | - Linda E. Sousse
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas 77555-0833, USA
| | - Hiroyuki Sakurai
- Department of Plastic and Reconstructive Surgery, Tokyo Women’s Medical University, 8-1 Kawata-cho, Shinjuku-ku, Tokyo 162-8666, Japan
| | - Sebastian W. Rehberg
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas 77555-0833, USA
| | - Sven Asmussen
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas 77555-0833, USA
| | - Edward R. Kraft
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas 77555-0833, USA
| | - Charlotte L. Wright
- Linus Pauling Institute, Oregon State University, Corvallis, Oregon 97331-6512, USA
| | - Eva Bartha
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas 77555-0833, USA
| | - Robert A. Cox
- Department of Pathology, University of Texas Medical Branch, Galveston, Texas 77555-0833, USA
| | - Hal K. Hawkins
- Department of Pathology, University of Texas Medical Branch, Galveston, Texas 77555-0833, USA
| | - Lillian D. Traber
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas 77555-0833, USA
| | - Maret G. Traber
- Linus Pauling Institute, Oregon State University, Corvallis, Oregon 97331-6512, USA
| | - Csaba Szabo
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas 77555-0833, USA
| | - David N. Herndon
- Shriners Hospitals for Children, Burn Unit, Galveston, Texas 77555-0833
| | - Daniel L. Traber
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas 77555-0833, USA
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Yamamoto Y, Enkhbaatar P, Sakurai H, Rehberg S, Asmussen S, Ito H, Sousse LE, Cox RA, Deyo DJ, Traber LD, Traber MG, Herndon DN, Traber DL. Development of a long-term ovine model of cutaneous burn and smoke inhalation injury and the effects of early excision and skin autografting. Burns 2012; 38:908-16. [PMID: 22459154 DOI: 10.1016/j.burns.2012.01.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Revised: 01/04/2012] [Accepted: 01/06/2012] [Indexed: 10/28/2022]
Abstract
UNLABELLED Smoke inhalation injury frequently increases the risk of pneumonia and mortality in burn patients. The pathophysiology of acute lung injury secondary to burn and smoke inhalation is well studied, but long-term pulmonary function, especially the process of lung tissue healing following burn and smoke inhalation, has not been fully investigated. By contrast, early burn excision has become the standard of care in the management of major burn injury. While many clinical studies and small-animal experiments support the concept of early burn wound excision, and show improved survival and infectious outcomes, we have developed a new chronic ovine model of burn and smoke inhalation injury with early excision and skin grafting that can be used to investigate lung pathophysiology over a period of 3 weeks. MATERIALS AND METHODS Eighteen female sheep were surgically prepared for this study under isoflurane anesthesia. The animals were divided into three groups: an Early Excision group (20% TBSA, third-degree cutaneous burn and 36 breaths of cotton smoke followed by early excision and skin autografting at 24h after injury, n=6), a Control group (20% TBSA, third-degree cutaneous burn and 36 breaths of cotton smoke without early excision, n=6) and a Sham group (no injury, no early excision, n=6). After induced injury, all sheep were placed on a ventilator and fluid-resuscitated with Lactated Ringers solution (4 mL/% TBS/kg). At 24h post-injury, early excision was carried out to fascia, and skin grafting with meshed autografts (20/1000 in., 1:4 ratio) was performed under isoflurane anesthesia. At 48 h post-injury, weaning from ventilator was begun if PaO(2)/FiO(2) was above 250 and sheep were monitored for 3 weeks. RESULTS At 96 h post-injury, all animals were weaned from ventilator. There are no significant differences in PaO(2)/FiO(2) between Early Excision and Control groups at any points. All animals were survived for 3 weeks without infectious complication in Early Excision and Sham groups, whereas two out of six animals in the Control group had abscess in lung. The percentage of the wound healed surviving area (mean ± SD) was 74.7 ± 7.8% on 17 days post-surgery in the Early Excision group. Lung wet-to-dry weight ratio (mean ± SD) was significantly increased in the Early Excision group vs. Sham group (p<0.05). The calculated net fluid balance significantly increased in the early excision compared to those seen in the Sham and Control groups. Plasma protein, oncotic pressure, hematocrit of % baseline, hemoglobin of % baseline, white blood cell and neutrophil were significantly decreased in the Early Excision group vs. Control group. CONCLUSIONS The early excision model closely resembles practice in a clinical setting and allows long-term observations of pulmonary function following burn and smoke inhalation injury. Further studies are warranted to assess lung tissue scarring and measuring collagen deposition, lung compliance and diffusion capacity.
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Affiliation(s)
- Yusuke Yamamoto
- Department of Anesthesiology, Investigational Intensive Care Unit, The University of Texas Medical Branch, Shriners Burns Hospital for Children, 601 Harborside Drive, Galveston, TX 77555-1102, USA
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Wood bark smoke induces lung and pleural plasminogen activator inhibitor 1 and stabilizes its mRNA in porcine lung cells. Shock 2012; 36:128-37. [PMID: 21478814 DOI: 10.1097/shk.0b013e31821d60a4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although aberrant fibrinolysis and plasminogen activator inhibitor 1 (PAI-1) are implicated in acute lung injury, the role of this serpin in the pathogenesis of wood bark smoke (WBS)-induced acute lung injury (SIALI) and its regulation in resident lung cells after exposure to smoke are unclear. A total of 22 mechanically ventilated pigs were included in this study. Immunohistochemical analyses were used to assess fibrin and PAI-1 in the lungs of pigs with SIALI in situ. Plasminogen activator inhibitor 1 was measured in bronchoalveolar lavage fluids by Western blotting. Induction of PAI-1 was determined at the protein and mRNA levels by Western and polymerase chain reaction analyses in primary porcine alveolar type II cells, fibroblasts, and pleural mesothelial cells. Plasminogen activator inhibitor 1 mRNA stability was determined by transcription chase studies. Gel shift analyses were used to characterize the mechanism regulating PAI-1 mRNA stability. Smoke-induced ALI induced PAI-1, with prominent extravascular fibrin deposition in large and small airways as well as alveolar and subpleural compartments. In pleural mesothelial cells, lung fibroblasts, and alveolar type II cells, PAI-1 mRNA was stabilized by WBS extract and contributed to induction of PAI-1. The mechanism involves dissociation of a novel 6-phospho-d-gluconate-NADP oxidoreductase-like PAI-1 mRNA binding protein from PAI-1 mRNA. Exposure to WBS induces prominent airway and mesothelial expression of PAI-1, associated with florid distribution of fibrin in SIALI in vivo Wood bark smoke components induce PAI-1 in vitro in part by stabilization of PAI-1 mRNA, a newly recognized pathway that may promote extravascular fibrin deposition and lung dysfunction in SIALI.
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Pulmonary activation of coagulation and inhibition of fibrinolysis after burn injuries and inhalation trauma. ACTA ACUST UNITED AC 2011; 70:1389-97. [PMID: 21460745 DOI: 10.1097/ta.0b013e31820f85a7] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pulmonary coagulopathy is intrinsic to pneumonia and other forms of acute lung injury. We hypothesized patients with burn injuries and inhalation trauma to have similar alterations in pulmonary coagulation and fibrinolysis. METHODS We performed a prospective study on changes in pulmonary and systemic thrombin generation and fibrinolytic activity in patients with burn injuries and inhalation trauma requiring mechanical ventilation. Nondirected bronchial lavage was performed on alternate days. Patients requiring mechanical ventilation for nonpulmonary reasons who did not meet the North American European Consensus Conference criteria for acute lung injury functioned as control patients. RESULTS We studied 13 patients with burn injuries and inhalation trauma and 15 control patients. On admission, patients with burn injuries and inhalation trauma showed a significant increase in thrombin generation in the airways compared with control patients, as reflected by increased lavage fluid levels of thrombin-antithrombin complexes and fibrin degradation products, and decreased lavage fluid levels of activated protein C and antithrombin. Simultaneously, burn patients showed a significant decrease in fibrinolytic activity, as reflected by decreased lavage fluid levels of plasminogen activator activity. Pulmonary coagulopathy persisted throughout the period of mechanical ventilation and was accompanied by similar changes in systemic coagulation and fibrinolysis. There was no significant correlation between changes in coagulation and fibrinolysis and the extent of burn injury. CONCLUSIONS Patients with burn injuries and inhalation trauma requiring mechanical ventilation show a distinct and sustained procoagulant and antifibrinolytic shift in the pulmonary compartment. Pulmonary coagulopathy could be an important therapeutic target in these patients.
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Abstract
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.
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Abstract
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.
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Affiliation(s)
- Christina W Fidkowski
- Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston MA 02155, USA
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Nieuwenhuizen L, de Groot PG, Grutters JC, Biesma DH. A review of pulmonary coagulopathy in acute lung injury, acute respiratory distress syndrome and pneumonia. Eur J Haematol 2009; 82:413-25. [PMID: 19220414 DOI: 10.1111/j.1600-0609.2009.01238.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Enhanced bronchoalveolar coagulation is a hallmark of many acute inflammatory lung diseases such as acute lung injury, acute respiratory distress syndrome and pneumonia. Intervention with natural anticoagulants in these diseases has therefore become a topic of interest. Recently, new data on the role of pulmonary coagulation and inflammation has become available. The aim of this review is to summarize these findings. Furthermore, the results of anticoagulant therapeutic interventions in these disorders are discussed.
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