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Velamuri SR, Ali Y, Lanfranco J, Gupta P, Hill DM. Inhalation Injury, Respiratory Failure, and Ventilator Support in Acute Burn Care. Clin Plast Surg 2024; 51:221-232. [PMID: 38429045 DOI: 10.1016/j.cps.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
Sustaining an inhalation injury increases the risk of severe complications and mortality. Current evidential support to guide treatment of the injury or subsequent complications is lacking, as studies either exclude inhalation injury or design limit inferences that can be made. Conventional ventilator modes are most commonly used, but there is no consensus on optimal strategies. Settings should be customized to patient tolerance and response. Data for pharmacotherapy adjunctive treatments are limited.
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Affiliation(s)
- Sai R Velamuri
- Department of Surgery, College of Medicine, University of Tennessee, Health Science Center, Memphis, TN 38103, USA.
| | - Yasmin Ali
- Department of Surgery, College of Medicine, University of Tennessee Health Science Center, 910 Madison Avenue, 2nd floor Suite 217, Memphis, TN 38103, USA
| | - Julio Lanfranco
- Division of Pulmonary and Critical Care, University of Tennessee Health Science Center, 965 Court Avenue Room H316B, Memphis, TN 38103, USA
| | - Pooja Gupta
- Pulmonary and Critical Care, University of Tennessee Health Science Center, 965 court avenue, Room H316B, Memphis, TN 38103, USA
| | - David M Hill
- Department of Pharmacy, Regional One Health, University of Tennessee, 80 madison avenue, Memphis TN 38103, USA
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2
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Megahed MA, Elhelbawy RH, Agha MA, Abdelatty NB, El-Koa AA, El-Kalashy MM. First-day computed tomography: does it has a role in the assessment of patients with inhalation lung injury? THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2023. [DOI: 10.1186/s43168-023-00191-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2023] Open
Abstract
Abstract
Background
Inhalation lung injury occurs in almost one-third of all serious burns and is responsible for a considerable proportion of burn patient fatalities each year. History of closed space fire or unconsciousness at the accident site, occurrence of pharyngeal or facial burns, hoarseness, and wheezing, and laboratory tests that include blood gas abnormalities or Carboxyhemoglobin levels in blood ˃ 10% are used to diagnose inhalation lung injury. It is also characterized by radiological findings of alveolar or interstitial edema, atelectasis, and/or consolidations, as well as the presence of erythema with laryngeal or tracheal edema in the bronchoscope.
Objectives
To study the diagnostic and prognostic efficacy of radiologist score and bronchial wall thickening as radiological CT findings in inhalation lung injury.
Methods
This prospective case–control study included 48 patients with inhalation lung injury (ILI) as a case group and 10 patients without ILI were selected as the control group, all recruited from the burn and plastic department. Within the first 12 h of suspected ILI, a fiberoptic bronchoscope was done to confirm the diagnosis. An initial chest X-ray was done followed by computed tomography through which the radiologist score (RADS) together with bronchial wall thickening (BWT) was done.
Results
Duration of ventilation was higher in cases than in controls (8.50 ± 3.94 vs 3.25 ± 0.50). The hospital duration was higher in cases than in controls (13.6 ± 4.68 vs9.50 ± 4.52). The BWT was 2.12 ± 0.66 (mean ± SD) in the ILI group while the control group was 1.32 ± 0.48 (mean ± SD). Correlating between baseline PaO2 and RADS score and BWT, it was found that there was a highly significant negative correlation between PaO2 and RADS score and BWT among inhalation lung injury patients (P value 0.001). The sensitivity of BWT in the detection of the need for mechanical ventilation was 83% at a cut-off point of 1.65. Its specificity was 78% and accuracy 75%.
Conclusion
CT done within 24 h of burn patients has a good role in the diagnosis and management of ILI from the burn.
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Sasaki J, Matsushima A, Ikeda H, Inoue Y, Katahira J, Kishibe M, Kimura C, Sato Y, Takuma K, Tanaka K, Hayashi M, Matsumura H, Yasuda H, Yoshimura Y, Aoki H, Ishizaki Y, Isono N, Ueda T, Umezawa K, Osuka A, Ogura T, Kaita Y, Kawai K, Kawamoto K, Kimura M, Kubo T, Kurihara T, Kurokawa M, Kobayashi S, Saitoh D, Shichinohe R, Shibusawa T, Suzuki Y, Soejima K, Hashimoto I, Fujiwara O, Matsuura H, Miida K, Miyazaki M, Murao N, Morikawa W, Yamada S. Japanese Society for Burn Injuries (JSBI) Clinical Practice Guidelines for Management of Burn Care (3rd Edition). Acute Med Surg 2022; 9:e739. [PMID: 35493773 PMCID: PMC9045063 DOI: 10.1002/ams2.739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/29/2022] [Accepted: 02/03/2022] [Indexed: 01/28/2023] Open
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Charles WN, Collins D, Mandalia S, Matwala K, Dutt A, Tatlock J, Singh S. Impact of inhalation injury on outcomes in critically ill burns patients: 12-year experience at a regional burns centre. Burns 2021; 48:1386-1395. [PMID: 34924231 DOI: 10.1016/j.burns.2021.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 11/15/2021] [Accepted: 11/22/2021] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Burns inhalation injury increases the attributable mortality of burns related trauma. However, diagnostic uncertainties around bronchoscopically graded severity, and its effect on outcomes, remain. This study evaluated the impact of different bronchoscopic burns inhalation injury grades on outcomes. METHODS A single-centre cohort study of all patients admitted to the London Burns centre intensive care unit (BICU) over 12 years. Demographic data, burn and burns inhalation injury characteristics, and ICU-related parameters were collected retrospectively. The primary outcome was mortality. Secondary outcomes were hospital and ICU lengths of stay. The impact of pneumonia was determined. Univariate and multivariable Cox's proportional hazards regression analyses informed factors predicting mortality. RESULTS Burns inhalation injury was diagnosed in 84 of 231 (36%) critically ill burns patients; 20 mild (grade 1), 41 severe (grades 2/3) and 23 unclassified bronchoscopically. Median (IQR) total body surface area burned (TBSA) was 20% (10-40). Mortality was significantly higher in patients with burns inhalation injury vs those without burns inhalation injury (38/84 [45%] vs 35/147 [24%], p < 0.001). Patients with pneumonia had a higher mortality than those without (34/125 [27%] vs 8/71 [11%], p = 0.009). In multivariable analysis, severe burns inhalation injury significantly increased mortality (adjusted HR=2.14, 95%CI: 1.12-4.09, p = 0.022), compared with mild injury (adjusted HR=0.58, 95% CI: 0.18-1.86, p = 0.363). Facial burns (adjusted HR=3.13, 95%CI: 1.69-5.79, p < 0.001), higher TBSA (adjusted HR=1.05, 95%CI: 1.04-1.06, p < 0.001) and older age (adjusted HR=1.04, 95%CI: 1.02-1.07, p < 0.001) also independently predicted mortality, though pneumonia did not. CONCLUSIONS Severe burns inhalation injury is a significant risk factor for mortality in critically ill burns patients. However, pneumonia did not increase mortality from burns inhalation injury. This work confirms prior implications of bronchoscopically graded burns inhalation injury. Further study is suggested, through registries, into the diagnostic accuracy and reliability of bronchoscopy in burns related lung injury.
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Affiliation(s)
- Walton N Charles
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Declan Collins
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; Department of Burns, Plastic and Reconstructive Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Sundhiya Mandalia
- Intensive Care Unit, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom; Department of Research and Development, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Kabir Matwala
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Atul Dutt
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Jason Tatlock
- Intensive Care Unit, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Suveer Singh
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; Intensive Care Unit, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom; Department of Research and Development, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom; Academic Department of Anaesthesia, Pain Management and Intensive Care (APMIC), Imperial College London, Chelsea and Westminster Hospital NHS Foundation Trust and Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom.
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Chotalia M, Pirrone C, Ali M, Mullhi R, Torlinska B, Mangham T, England K, Torlinski T. 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. Burns 2021; 47:1793-1801. [PMID: 33707087 DOI: 10.1016/j.burns.2021.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 02/16/2021] [Accepted: 02/22/2021] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Minesh Chotalia
- Department of Anaesthetics and Critical Care, West Midlands Burn Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK; Birmingham Acute Care Research Group, University of Birmingham, UK
| | - Christine Pirrone
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Muzzammil Ali
- Department of Anaesthetics and Critical Care, West Midlands Burn Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Randeep Mullhi
- Department of Anaesthetics and Critical Care, West Midlands Burn Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Barbara Torlinska
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, UK
| | - Thomas Mangham
- Department of Anaesthetics, Royal Preston Hospital, Lancashire Teaching Hospitals, UK
| | - Kaye England
- Department of Anaesthetics and Critical Care, West Midlands Burn Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Tomasz Torlinski
- Department of Anaesthetics and Critical Care, West Midlands Burn Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK.
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Tang JA, Amadio G, Nagappan L, Schmalbach CE, Dion GR. Laryngeal inhalational injuries: A systematic review. Burns 2021; 48:23-33. [PMID: 33814215 DOI: 10.1016/j.burns.2021.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 12/19/2020] [Accepted: 02/05/2021] [Indexed: 02/07/2023]
Abstract
Laryngeal inhalation injury carries a significant increase in mortality rate and often indicates immediate airway evaluation. This may be difficult in the setting of clinical deterioration necessitating immediate intubation, which itself can synergistically cause mucosal damage. Prior studies do not encompass predictive factors or long-term outcomes for the laryngotracheal complex. This systemic review of PubMed, Embase, and Cochrane identified studies investigating inhalational injuries of the upper airway. Demographic data as well as presentation, physical findings, and delayed sequelae were documented. Laryngotracheal burn patients were divided into two cohorts based on timing of laryngeal injury diagnosis (before- versus after-airway intervention). 1051 papers met initial search criteria and 43 studies were ultimately included. Airway stenosis was more common in patients that were intubated immediately (50.0%, n = 18 versus 5.2%, n = 13; p = 0.57). Posterior glottic involvement was only identified in patients intubated prior to airway evaluation (71.4%, n = 15). All studies reported a closed space setting for those patients in whom airway intervention preceded laryngeal evaluation. Laryngeal inhalational injuries are a distinct subset that can have a variety of minor to severe laryngotracheal delayed sequelae, particularly for thermal injuries occurring within enclosed spaces. Given these findings, early otolaryngology referral may mitigate or treat these effects.
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Affiliation(s)
- Jessica A Tang
- Department of Otolaryngology, Head and Neck Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Grace Amadio
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Lavanya Nagappan
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Cecelia E Schmalbach
- Department of Otolaryngology, Head and Neck Surgery, Temple University Hospital, Philadelphia, PA, USA; Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA; Temple Head and Neck Institute, Philadelphia, PA, USA
| | - Gregory R Dion
- US Army Institute of Surgical Research, Joint Base San Antonio, Fort Sam Houston, TX, USA.
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Tripathi K, Kanchwala N, Mohan RR, Baranwal S, Jha M, Bhattacharya S. Role of fibreoptic bronchoscopy in early diagnosis of inhalational burns in patients with facial burns. INDIAN JOURNAL OF BURNS 2021. [DOI: 10.4103/ijb.ijb_6_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Dyamenahalli K, Garg G, Shupp JW, Kuprys PV, Choudhry MA, Kovacs EJ. Inhalation Injury: Unmet Clinical Needs and Future Research. J Burn Care Res 2020; 40:570-584. [PMID: 31214710 DOI: 10.1093/jbcr/irz055] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pulmonary and systemic insults from inhalation injury can complicate the care of burn patients and contribute to significant morbidity and mortality. However, recent progress in diagnosis and treatment of inhalation injury has not kept pace with the care of cutaneous thermal injury. There are many challenges unique to inhalation injury that have slowed advancement, including deficiencies in our understanding of its pathophysiology, the relative difficulty and subjectivity of bronchoscopic diagnosis, the lack of diagnostic biomarkers, the necessarily urgent manner in which decisions are made about intubation, and the lack of universal recommendations for the application of mucolytics, anticoagulants, bronchodilators, modified ventilator strategies, and other measures. This review represents a summary of critical shortcomings in our understanding and management of inhalation injury identified by the American Burn Association's working group on Cutaneous Thermal Injury and Inhalation Injury in 2018. It addresses our current understanding of the diagnosis, pathophysiology, and treatment of inhalation injury and highlights topics in need of additional research, including 1) airway repair mechanisms; 2) the airway microbiome in health and after injury; and 3) candidate biomarkers of inhalation injury.
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Affiliation(s)
- Kiran Dyamenahalli
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, University of Colorado School of Medicine, Aurora
| | - Gaurav Garg
- Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Jeffrey W Shupp
- Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Paulius V Kuprys
- Department of Surgery, Burn & Shock Trauma Research Institute, Health Sciences Division, Loyola University, Maywood, Illinois
| | - Mashkoor A Choudhry
- Department of Surgery, Burn & Shock Trauma Research Institute, Health Sciences Division, Loyola University, Maywood, Illinois
| | - Elizabeth J Kovacs
- Department of Surgery, Division of GI, Trauma and Endocrine Surgery, University of Colorado School of Medicine, Aurora
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9
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Miyagawa N, Kobayashi M, Kawazoe Y, Nomura R, Kushimoto S. Extensive inhalation injury treated with veno-venous extracorporeal membrane oxygenation followed by systemic corticosteroid administration: A case report. BURNS OPEN 2020. [DOI: 10.1016/j.burnso.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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10
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Chotalia M, Pirrone C, Mangham T, Torlinska B, Mullhi R, England K, Torlinski T. The Predictive Applicability of Liberal vs Restrictive Intubation Criteria in Adult Patients With Suspected Inhalation Injury-A Retrospective Cohort Study. J Burn Care Res 2020; 41:1290-1296. [PMID: 32504540 DOI: 10.1093/jbcr/iraa092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This study compares the ability of liberal vs restrictive intubation criteria to detect prolonged intubation and inhalation injury in burn patients with suspected inhalation injury. Emerging evidence suggests that using liberal criteria may lead to unnecessary intubation in some patients. A single-center retrospective cohort study was conducted in adult patients with suspected inhalation injury admitted to intensive care at Queen Elizabeth Hospital, Birmingham between April 2016 and July 2019. Liberal intubation criteria, as reflected in local guidelines, were compared to restrictive intubation criteria, as outlined in the American Burn Association guidelines. The number of patients displaying positive characteristics from either guideline was compared to the number of patients who had prolonged intubation (more than 48 hours) and inhalation injury. In detecting a need for prolonged intubation (n = 85), the liberal criteria had greater sensitivity (liberal = 0.98 [0.94-1.00] vs restrictive = 0.84 [0.75-0.93]; P = .013). However, the restrictive criteria had greater specificity (restrictive = 0.96 [0.89-1.00] vs liberal = 0.48 [0.29-0.67]; P < .001). In detecting inhalation injury (n = 72), the restrictive criteria were equally sensitive (restrictive = 0.94 [0.87-1.00] vs liberal = 0.98 [0.84-1.00]; P = .48) and had greater specificity (restrictive = 0.86 [0.72-1.00] vs liberal = 0.04 [0.00-0.13]; P < .001). In patients who met liberal but not restrictive criteria, 65% were extubated within 48 hours and 90% did not have inhalation injury. Liberal intubation criteria were more sensitive at detecting a need for prolonged intubation, while restrictive criteria were more specific. Most patients intubated based on liberal criteria alone were extubated within 48 hours. Restrictive criteria were highly sensitive and specific at detecting inhalation injury.
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Affiliation(s)
- Minesh Chotalia
- Department of Anaesthetics and Critical Care, West Midlands Burns Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Christine Pirrone
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Australia
| | - Thomas Mangham
- Department of Anaesthetics and Critical Care, West Midlands Burns Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Barbara Torlinska
- Centre for Patient Reported Outcome Research, Institute of Applied Health Research, University of Birmingham,, UK
| | - Randeep Mullhi
- Department of Anaesthetics and Critical Care, West Midlands Burns Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Kaye England
- Department of Anaesthetics and Critical Care, West Midlands Burns Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Tomasz Torlinski
- Department of Anaesthetics and Critical Care, West Midlands Burns Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
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Holley AD, Reade MC, Lipman J, Cohen J. There is no fire without smoke! Pathophysiology and treatment of inhalational injury in burns: A narrative review. Anaesth Intensive Care 2020; 48:114-122. [PMID: 32316738 DOI: 10.1177/0310057x20913282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Smoke inhalation resulting in acute lung injury is a common challenge facing critical care practitioners caring for patients with severe burns, contributing significantly to morbidity and mortality. The intention of this review is to critically evaluate the published literature and trends in the diagnosis, management, implications and novel therapies in caring for patients with inhalation injury.
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Affiliation(s)
- Anthony D Holley
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia.,Jamieson Trauma Institute, Brisbane, Australia.,Australian Defence Force, Australia
| | - Michael C Reade
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia.,Jamieson Trauma Institute, Brisbane, Australia.,Australian Defence Force, Australia
| | - Jeffrey Lipman
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia.,Jamieson Trauma Institute, Brisbane, Australia
| | - Jeremy Cohen
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia.,Jamieson Trauma Institute, Brisbane, Australia
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12
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Choi JH, Chou LD, Roberts TR, Beely BM, Wendorff DS, Espinoza MD, Sieck K, Dixon AT, Burmeister D, Jordan BS, Brenner M, Chen Z, Necsoiu C, Cancio LC, Batchinsky AI. Point-of-care endoscopic optical coherence tomography detects changes in mucosal thickness in ARDS due to smoke inhalation and burns. Burns 2018; 45:589-597. [PMID: 30482414 DOI: 10.1016/j.burns.2018.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 10/09/2018] [Accepted: 10/15/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND The prevalence of acute respiratory distress syndrome (ARDS) in mechanically ventilated burn patients is 33%, with mortality varying from 11-46% depending on ARDS severity. Despite the new Berlin definition for ARDS, prompt bedside diagnosis is lacking. We developed and tested a bedside technique of fiberoptic-bronchoscopy-based optical coherence tomography (OCT) measurement of airway mucosal thickness (MT) for diagnosis of ARDS following smoke inhalation injury (SII) and burns. METHODS 16 female Yorkshire pigs received SII and 40% thermal burns. OCT MT and PaO2-to-FiO2 ratio (PFR) measurements were taken at baseline, after injury, and at 24, 48, and 72h after injury. RESULTS Injury led to thickening of MT which was sustained in animals that developed ARDS. Significant correlations were found between MT, PFR, peak inspiratory pressure (PIP), and total infused fluid volume. CONCLUSIONS OCT is a useful tool to quantify MT changes in the airway following SII and burns. OCT may be effective as a diagnostic tool in the early stages of SII-induced ARDS and should be tested in humans.
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Affiliation(s)
- Jae Hyek Choi
- The Geneva Foundation, Tacoma WA, United States; United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX, United States.
| | - Li-Dek Chou
- Beckman Laser Institute, University of California Irvine, Irvine, CA, United States
| | - Teryn R Roberts
- The Geneva Foundation, Tacoma WA, United States; United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX, United States
| | - Brendan M Beely
- The Geneva Foundation, Tacoma WA, United States; United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX, United States
| | - Daniel S Wendorff
- The Geneva Foundation, Tacoma WA, United States; United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX, United States
| | - Mark D Espinoza
- United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX, United States
| | - Kyle Sieck
- The Geneva Foundation, Tacoma WA, United States; United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX, United States
| | - Alexander T Dixon
- The Geneva Foundation, Tacoma WA, United States; United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX, United States
| | - David Burmeister
- United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX, United States
| | - Bryan S Jordan
- United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX, United States
| | - Matthew Brenner
- Beckman Laser Institute, University of California Irvine, Irvine, CA, United States
| | - Zhongping Chen
- Beckman Laser Institute, University of California Irvine, Irvine, CA, United States
| | - Corina Necsoiu
- United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX, United States
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX, United States
| | - Andriy I Batchinsky
- The Geneva Foundation, Tacoma WA, United States; United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, TX, United States
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13
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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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Abstract
This article summarizes research conducted over the last decade in the field of inhalation injury in thermally injured patients. This includes brief summaries of the findings of the 2006 State of the Science meeting with regard to inhalation injury, and of the subsequent 2007 Inhalation Injury Consensus Conference. The reviewed studies are categorized in to five general areas: diagnosis and grading; mechanical ventilation; systemic and inhalation therapy; mechanistic alterations; and outcomes.
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Gupta K, Mehrotra M, Kumar P, Gogia AR, Prasad A, Fisher JA. Smoke Inhalation Injury: Etiopathogenesis, Diagnosis, and Management. Indian J Crit Care Med 2018; 22:180-188. [PMID: 29657376 PMCID: PMC5879861 DOI: 10.4103/ijccm.ijccm_460_17] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Smoke inhalation injury is a major determinant of morbidity and mortality in fire victims. It is a complex multifaceted injury affecting initially the airway; however, in short time, it can become a complex life-threatening systemic disease affecting every organ in the body. In this review, we provide a summary of the underlying pathophysiology of organ dysfunction and provide an up-to-date survey of the various critical care modalities that have been found beneficial in caring for these patients. Major pathophysiological change is development of edema in the respiratory tract. The tracheobronchial tree is injured by steam and toxic chemicals, leading to bronchoconstriction. Lung parenchyma is damaged by the release of proteolytic elastases, leading to release of inflammatory mediators, increase in transvascular flux of fluids, and development of pulmonary edema and atelectasis. Decreased levels of surfactant and immunomodulators such as interleukins and tumor-necrosis-factor-α accentuate the injury. A primary survey is conducted at the site of fire, to ensure adequate airway, breathing, and circulation. A good intravenous access is obtained for the administration of resuscitation fluids. Early intubation, preferably with fiberoptic bronchoscope, is prudent before development of airway edema. Bronchial hygiene is maintained, which involves therapeutic coughing, chest physiotherapy, deep breathing exercises, and early ambulation. Pharmacological agents such as beta-2 agonists, racemic epinephrine, N-acetyl cysteine, and aerosolized heparin are used for improving oxygenation of lungs. Newer agents being tested are perfluorohexane, porcine pulmonary surfactant, and ClearMate. Early diagnosis and treatment of smoke inhalation injury are the keys for better outcome.
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Affiliation(s)
- Kapil Gupta
- Department of Anaesthesia, Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Mayank Mehrotra
- Department of Anesthesia, Integral Institute of Medical Sciences, Lucknow, India
| | - Parul Kumar
- Department of Emergency Medicine, Sinai Health Systems, Chicago, USA
| | - Anoop Raj Gogia
- Department of Anaesthesia, Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Arun Prasad
- Department of Anaesthesia, University Health Network, and University of Toronto, Toronto, Canada
| | - Joseph Arnold Fisher
- Department of Anaesthesia, University Health Network, and University of Toronto, Toronto, Canada
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16
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Onishi S, Osuka A, Kuroki Y, Ueyama M. Indications of early intubation for patients with inhalation injury. Acute Med Surg 2017; 4:278-285. [PMID: 29123875 PMCID: PMC5674455 DOI: 10.1002/ams2.269] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 01/13/2017] [Indexed: 12/05/2022] Open
Abstract
Aim For patients with inhalation injury, the indications for early intubation are diverse. The purpose of this study was to identify the most reliable symptoms, physical findings, and medical examinations with which to determine the indications for early intubation in patients with inhalation injury. Methods We retrospectively collected patient data from medical records. Collected data included age, sex, burn size, symptoms, physical findings, carboxyhemoglobin levels (COHb), and bronchial wall thickness (BWT) determined from chest computed tomography images. We analyzed the relationships between these findings and the early intubation. We performed fiberoptic bronchoscopy in all patients, and analyzed the relationships between bronchoscopic severity and other findings. Results Of the 205 patients, 80 patients were diagnosed as having inhalation injury, and 34 patients were intubated. Burn size, facial burns, neck burns, use of accessory respiratory muscles, and COHb seemed to be related with intubation, whereas singed nasal hair was not. If the patients suffered ≥27% total body surface area burn and BWT ≥3.5 mm, the positive predictive value for early intubation was 1.00. If the patients suffered smaller cutaneous burn without neck burn, and their COHb <4.0%, the negative predictive value for early intubation was 0.97. Fiberoptic bronchoscopy findings from above the glottis were mainly related with patients’ symptoms. Findings from below the glottis were mainly related with BWT and COHb. Conclusions Patients’ symptoms, especially use of accessory respiratory muscles, are reliable, and BWT and COHb are also useful tools, for determining the indication for early intubation.
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Affiliation(s)
- Shinya Onishi
- Department of Trauma, Critical Care Medicine and Burn Center Japan Community Health Care Organization Chukyo Hospital Nagoya AICHI Japan
| | - Akinori Osuka
- Department of Trauma, Critical Care Medicine and Burn Center Japan Community Health Care Organization Chukyo Hospital Nagoya AICHI Japan
| | - Yuichi Kuroki
- Department of Trauma, Critical Care Medicine and Burn Center Japan Community Health Care Organization Chukyo Hospital Nagoya AICHI Japan
| | - Masashi Ueyama
- Department of Trauma, Critical Care Medicine and Burn Center Japan Community Health Care Organization Chukyo Hospital Nagoya AICHI Japan
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17
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Nebulized Epinephrine Limits Pulmonary Vascular Hyperpermeability to Water and Protein in Ovine With Burn and Smoke Inhalation Injury. Crit Care Med 2016; 44:e89-96. [PMID: 26465218 DOI: 10.1097/ccm.0000000000001349] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To test the hypothesis that nebulized epinephrine ameliorates pulmonary dysfunction by dual action-bronchodilation (β2-adrenergic receptor agonism) and attenuation of airway hyperemia (α1-adrenergic receptor agonism) with minimal systemic effects. DESIGN Randomized, controlled, prospective, and large animal translational studies. SETTING University large animal ICU. SUBJECTS Twelve chronically instrumented sheep. INTERVENTIONS The animals were exposed to 40% total body surface area third degree skin flame burn and 48 breaths of cooled cotton smoke inhalation under deep anesthesia and analgesia. The animals were then placed on a mechanical ventilator, fluid resuscitated, and monitored for 48 hours in a conscious state. After the injury, sheep were randomized into two groups: 1) epinephrine, nebulized with 4 mg of epinephrine every 4 hours starting 1 hour post injury, n = 6; or 2) saline, nebulized with saline in the same manner, n = 6. MEASUREMENTS AND MAIN RESULTS Treatment with epinephrine had a significant reduction of the pulmonary transvascular fluid flux to water (p < 0.001) and protein (p < 0.05) when compared with saline treatment from 12 to 48 hours and 36 to 48 hours, respectively. Treatment with epinephrine also reduced the systemic accumulation of body fluids (p < 0.001) with a mean of 1,410 ± 560 mL at 48 hours compared with 3,284 ± 422 mL of the saline group. Hemoglobin levels were comparable between the groups. Changes in respiratory system dynamic compliance, mean airway pressure, PaO2/FiO2 ratio, and oxygenation index were also attenuated with epinephrine treatment. No considerable systemic effects were observed with epinephrine treatment. CONCLUSIONS Nebulized epinephrine should be considered for use in future clinical studies of patients with burns and smoke inhalation injury.
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18
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Scaglione M, Linsenmaier U, Schueller G, Berger F, Wirth S. Airway Disease. EMERGENCY RADIOLOGY OF THE CHEST AND CARDIOVASCULAR SYSTEM 2016. [PMCID: PMC7119984 DOI: 10.1007/174_2016_39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Mariano Scaglione
- Dept of Radiology, Pineta Grande Medical Center, Castel Volturno, Caserta, Italy
| | | | | | - Ferco Berger
- VU University Medical Center, Amsterdam, The Netherlands
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19
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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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20
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Aliannejad R. Comment on "Comparison of virtual bronchoscopy to fiber-optic bronchoscopy for assessment of inhalation injury severity". Burns 2015; 41:1613-5. [PMID: 26387428 DOI: 10.1016/j.burns.2015.05.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Accepted: 05/14/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Rasoul Aliannejad
- Department of Pulmonary, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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21
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Yamamura H, Morioka T, Hagawa N, Yamamoto T, Mizobata Y. Computed tomographic assessment of airflow obstruction in smoke inhalation injury: Relationship with the development of pneumonia and injury severity. Burns 2015; 41:1428-34. [PMID: 26187056 DOI: 10.1016/j.burns.2015.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Revised: 06/13/2015] [Accepted: 06/17/2015] [Indexed: 01/07/2023]
Abstract
PURPOSE The prediction of pulmonary deterioration in patients with smoke inhalation injury is important because this influences the strategy for patient management. We hypothesized that narrowing of the luminal bronchus due to bronchial wall thickening correlates to respiratory deterioration in smoke inhalation injury patients. METHODS In a prospective observational study, all patients were enrolled at a single tertiary trauma and critical care center. In 40 patients, chest computed tomographic images were obtained within a few hours after smoke inhalation injury. We assessed bronchial wall thickness and luminal area % on chest computed tomographic images. Airway wall thickness to total bronchial diameter (T/D) ratio, percentage of luminal area, and clinical indices were compared between patients with smoke inhalation injury and control patients. RESULTS The T/D ratio of patients with smoke inhalation was significantly higher than that of control patients (p<0.001), and the luminal area of these patients was significantly smaller than that of control patients (p<0.001). The number of mechanical ventilation days correlated with the initial infusion volume, T/D ratio, and luminal area %. ROC analysis showed a cut-off value of 0.26 for the T/D ratio, with a sensitivity of 79.0% and specificity of 73.7%, and a value of 23.4% for luminal area %, with a sensitivity of 68.4% and specificity of 84.2%. CONCLUSIONS These data revealed the utility of computed tomography scanning on admission to show that the patients with smoke inhalation injury had airway wall thickening compared to control patients without smoke inhalation injury. Airflow narrowing due to airway wall thickening was related to the development of pneumonia and the number of mechanical ventilation days in patients with smoke inhalation injury. Airflow narrowing is one important factor of respiratory deterioration in smoke inhalation injury.
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Affiliation(s)
- Hitoshi Yamamura
- Department of Critical Care Medicine, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka City 545-8585, Osaka, Japan.
| | - Takasei Morioka
- Department of Critical Care Medicine, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka City 545-8585, Osaka, Japan
| | - Naohiro Hagawa
- Department of Critical Care Medicine, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka City 545-8585, Osaka, Japan
| | - Tomonori Yamamoto
- Department of Critical Care Medicine, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka City 545-8585, Osaka, Japan
| | - Yasumitsu Mizobata
- Department of Critical Care Medicine, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka City 545-8585, Osaka, Japan
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22
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Role of fiberoptic bronchoscopy in management of smoke inhalation lung injury. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2015. [DOI: 10.1016/j.ejcdt.2015.03.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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23
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Abstract
The diverse medical disciplines that are involved in the care of burn patients is reflected in the robust and varied scientific and clinical research of burn injury. In the calendar year of 2013, over 1000 articles were published in peer-reviewed journals in the area of burn injury. This review summarizes select, interesting, and potentially influential articles in areas of critical care, epidemiology, infection, inhalation injury, nutrition and metabolism, pain and pruritus, psychology, reconstruction and rehabilitation, and wounds.
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24
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Goldberg SA, Kharbanda B, Pepe PE. Year in review 2013: Critical Care--out-of-hospital cardiac arrest, traumatic injury, and other emergency care conditions. Crit Care 2014; 18:593. [PMID: 25672494 PMCID: PMC4330928 DOI: 10.1186/s13054-014-0593-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
In this review, we discuss articles published in 2013 contributing to the existing literature on the management of out-of-hospital cardiac arrest and the evaluation and management of several other emergency conditions, including traumatic injury. The utility of intravenous medications, including epinephrine and amiodarone, in the management of cardiac arrest is questioned, as are cardiac arrest termination-of-resuscitation rules. Articles discussing mode of transportation in trauma are evaluated, and novel strategies for outcome prediction in traumatic injury are proposed. Diagnostic strategies, including computerized tomography scan for the diagnosis of smoke inhalation injury and serum biomarkers for the diagnosis of post-cardiac arrest syndrome and acute aortic dissection, are also explored. Although many of the articles discussed raise more questions than they answer, they nevertheless provide ample opportunity for further investigation.
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Affiliation(s)
- Scott A Goldberg
- Department of Emergency Medicine, Brigham and Women’s Hospital, 75 Francis Street, Neville House, Boston, MA 02115 USA
| | - Bryan Kharbanda
- Department of Emergency Medicine, Brigham and Women’s Hospital, 75 Francis Street, Neville House, Boston, MA 02115 USA
| | - Paul E Pepe
- Department of Emergency Medicine, Brigham and Women’s Hospital, 75 Francis Street, Neville House, Boston, MA 02115 USA
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25
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Kwon HP, Zanders TB, Regn DD, Burkett SE, Ward JA, Nguyen R, Necsoiu C, Jordan BS, York GE, Jimenez S, Chung KK, Cancio LC, Morris MJ, Batchinsky AI. Comparison of virtual bronchoscopy to fiber-optic bronchoscopy for assessment of inhalation injury severity. Burns 2014; 40:1308-15. [PMID: 25112807 DOI: 10.1016/j.burns.2014.06.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 06/16/2014] [Accepted: 06/17/2014] [Indexed: 11/20/2022]
Abstract
PURPOSE Compare virtual bronchoscopy (VB) to fiberoptic bronchoscopy (FOB) for scoring smoke inhalation injury (SII). METHODS Swine underwent computerized tomography (CT) with VB and FOB before (0) and 24 and 48 h after SII. VB and FOB images were scored by 5 providers off line. RESULTS FOB and VB scores increased over time (p<0.001) with FOB scoring higher than VB at 0 (0.30±0.79 vs. 0.03±0.17), 24 h (4.21±1.68 vs. 2.47±1.50), and 48h (4.55±1.83 vs. 1.94±1.29). FOB and VB showed association with PaO2-to-FiO2 ratios (PFR) with areas under receiver operating characteristic curves (ROC): for PFR≤300, VB 0.830, FOB 0.863; for PFR≤200, VB 0.794, FOB 0.825; for PFR≤100, VB 0.747, FOB 0.777 (all p<0.001). FOB showed 80.3% specificity, 77% sensitivity, 88.8% negative-predictive value (NPV), and 62.3% positive-predictive value (PPV) for PFR≤300 and VB showed 67.2% specificity, 85.5% sensitivity, 91.3% NPV, and 53.4% PPV. CONCLUSIONS VB provided similar injury severity scores to FOB, correlated with PFR, and reliably detected airway narrowing. VB performed during admission CT may be a useful screening tool specifically to demonstrate airway narrowing induced by SII.
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Affiliation(s)
- Herbert P Kwon
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, United States
| | - Thomas B Zanders
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, United States
| | - Dara D Regn
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, United States
| | - Samuel E Burkett
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, United States
| | - John A Ward
- Department of Clinical Investigation, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, United States
| | - Ruth Nguyen
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, United States
| | - Corina Necsoiu
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, United States
| | - Bryan S Jordan
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234-6315, United States
| | - Gerald E York
- Department of Radiology, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, United States
| | - Santiago Jimenez
- Department of Radiology, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, United States
| | - Kevin K Chung
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234-6315, United States
| | - Leopoldo C Cancio
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234-6315, United States
| | - Michael J Morris
- Pulmonary/Critical Care Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, United States
| | - Andriy I Batchinsky
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234-6315, United States.
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26
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Kameda T, Fujita M. Point-of-care ultrasound detection of tracheal wall thickening caused by smoke inhalation. Crit Ultrasound J 2014; 6:11. [PMID: 25097745 PMCID: PMC4105106 DOI: 10.1186/2036-7902-6-11] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Accepted: 07/01/2014] [Indexed: 11/21/2022] Open
Abstract
Smoke inhalation is the leading cause of death due to fires. When a patient presents with smoke inhalation, prompt assessment of the airway and breathing is necessary. Point-of-care ultrasonography (US) is used for the rapid assessment of critically ill or injured patients. We herein present a case report of a 54-year-old male who was transferred to the emergency department with shortness of breath, coughing, carbonaceous sputa, and rhinorrhea after inhaling smoke caused by a fire in his locked bedroom. He had no surface burns on the face and no edema or erosion in the oral cavity. He had hoarseness without stridor. His breath sounds were positive for expiratory wheezes. Laryngoscopy showed light edema and erosive findings on the supraglottic region. Bedside point-of-care US revealed hypoechoic thickening of the tracheal wall. The thickening was confirmed by a computed tomographic scan. The patient was carefully monitored with preparation for emergency airway management and was treated with supplemental oxygen and an aerosolized beta-2 adrenergic agonist in the intensive care unit. The symptoms were subsequently relieved, and reexamination by US after 2 days showed remission of the wall thickening. Point-of-care US may therefore be a useful modality for the rapid diagnosis and effective follow-up of tracheal wall thickening caused by smoke inhalation.
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Affiliation(s)
- Toru Kameda
- Department of Emergency Medicine, Red Cross Society Azumino Hospital, 5685 Toyoshina, Azumino, Nagano 399-8292, Japan
| | - Masato Fujita
- Department of Emergency and Intensive Care Medicine, Red Cross Society Azumino Hospital, 5685 Toyoshina, Azumino, Nagano 399-8292, Japan
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27
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Kim CH, Woo H, Hyun IG, Song WJ, Kim C, Choi JH, Kim DG, Lee MG, Jung KS. Pulmonary function assessment in the early phase of patients with smoke inhalation injury from fire. J Thorac Dis 2014; 6:617-24. [PMID: 24976982 DOI: 10.3978/j.issn.2072-1439.2014.04.11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 04/02/2014] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Fire smoke contains toxic gases and numerous chemical compounds produced by incomplete combustion, and may cause injury to the airways. Increased airway reactivity, as well as a decrease in lung function, has been reported as a sequela of smoke inhalation injury. This study was undertaken to assess lung functions in the early phase of patients with smoke inhalation damage from fires. METHODS A total of 15 patients with fire smoke inhalation (fire smoke group) and 15 subjects with chronic cough but no previous history of lung disease (chronic cough group) were enrolled. For diagnosis of inhalation injury, we performed bronchoscopy, high-resolution computed tomography (HRCT), as well as arterial carboxyhemoglobin (COHb) at admission. Clinical characteristics, pulmonary function tests (PFTs) and mannitol bronchial provocation tests (BPTs) were analyzed and compared between the two groups. RESULTS In fire smoke group, initial COHb levels and the PaO2/FiO2 ratio were (14.8±18.49)% and 425.7±123.68, respectively. Of seven patients performing HRCT, 4 (57.1%) showed the CT findings compatible with lung involvement of inhalation injury. Post bronchodilator value of the percent of forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) were (76.0±24.27)% and (79.8±27.82)%, respectively. Pre-and post- bronchodilator forced expiratory flow between 25% and 75% of the FVC (FEF25-75) and the percent predicted FEF25-75 were 2.41±1.47 vs. 2.65±1.45 L (P=0.045), and (68.7±37.29)% vs. (76.4±36.70)% (P=0.031), respectively. Two patients (13.3%) had positive bronchodilator response (BDR). In fire smoke and chronic cough group, all the subjects showed mannitol BPTs within normal limits. CONCLUSIONS Fire smoke inhalation leads to mild obstructive small airway disease pattern of pulmonary function in the early phase of patients with fire smoke damage. Further studies, however, need to be followed to identify the relationship between airway narrowing to inhaled mannitol and smoke inhalation injury.
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Affiliation(s)
- Cheol-Hong Kim
- 1 Department of Internal Medicine, 2 Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - Heungjeong Woo
- 1 Department of Internal Medicine, 2 Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - In Gyu Hyun
- 1 Department of Internal Medicine, 2 Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - Won Jun Song
- 1 Department of Internal Medicine, 2 Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - Changhwan Kim
- 1 Department of Internal Medicine, 2 Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - Jeong-Hee Choi
- 1 Department of Internal Medicine, 2 Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - Dong-Gyu Kim
- 1 Department of Internal Medicine, 2 Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - Myung Goo Lee
- 1 Department of Internal Medicine, 2 Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - Ki-Suck Jung
- 1 Department of Internal Medicine, 2 Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
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