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

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

BACKGROUND

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

RESEARCH QUESTION

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

STUDY DESIGN AND METHODS

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

RESULTS

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

INTERPRETATION

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

Inpatient and post-discharge outcomes following inhalation injury among critically injured burn patients

Inhalation injury is associated with high inpatient mortality, but the impact of inhalation injury after discharge and on non-mortality outcomes are poorly characterized. To address this gap, we evaluated the effect of inhalation injury on post-discharge morbidity, mortality and hospital readmissions among patients who sustained burn injury, as well as on in-hospital outcomes for context.This was a retrospective cohort study of patients with cutaneous fire/flame burns admitted to a burn center intensive care unit from 1/1/2009-12/31/2015, with or without inhalation injury. Records were linked to statewide hospital admission and vital statistics databases to assess post-discharge outcomes. Mixed-effects Poisson regression was used to assess mortality, complications, and readmissions. The overall cohort included 830 patients with cutaneous burns; of these, 201 patients had inhalation injury. In-hospital mortality was 31% among inhalation injury patients versus 6% in patients without inhalation injury (adjusted OR 2.35; 95% CI 1.66-3.31). Inhalation injury was also associated with an increased risk of in-hospital pneumonia and tracheostomy (p<0.05 for all). Inhalation injury was not associated with greater post-discharge mortality, all-cause readmission, readmission for pulmonary diagnosis, or readmission requiring intubation. Among the subset of patients with bronchoscopy-confirmed inhalation injury (n=124; 62% of inhalation injuries), higher injury grade was not associated with greater inpatient or post-discharge mortality. Inhalation injury was associated with increased early morbidity and mortality, but did not contribute to post-discharge mortality or readmission. These findings have implications for shared decision-making with patients and families, and for estimating healthcare utilization after initial hospitalization.

Inhalation injury is associated with long-term employment outcomes in the burn population: Findings from a cross-sectional examination of the Burn Model System National Database

Introduction

Inhalation injuries carry significant acute care burden including prolonged ventilator days and length of stay. However, few studies have examined post-acute outcomes of inhalation injury survivors. This study compares the long-term outcomes of burn survivors with and without inhalation injury.

Methods

Data collected by the Burn Model System National Database from 1993 to 2019 were analyzed. Demographic and clinical characteristics for adult burn survivors with and without inhalation injury were examined. Outcomes included employment status, Short Form-12/Veterans Rand-12 Physical Composite Score (SF-12/VR-12 PCS), Short Form-12/Veterans Rand-12 Mental Composite Score (SF-12/VR-12 MCS), and Satisfaction With Life Scale (SWLS) at 24 months post-injury. Regression models were used to assess the impacts of sociodemographic and clinical covariates on long-term outcome measures. All models controlled for demographic and clinical characteristics.

Results

Data from 1,871 individuals were analyzed (208 with inhalation injury; 1,663 without inhalation injury). The inhalation injury population had a median age of 40.1 years, 68.8% were male, and 69% were White, non-Hispanic. Individuals that sustained an inhalation injury had larger burn size, more operations, and longer lengths of hospital stay (p<0.001). Individuals with inhalation injury were less likely to be employed at 24 months post-injury compared to survivors without inhalation injury (OR = 0.63, p = 0.028). There were no significant differences in PCS, MCS, or SWLS scores between groups in adjusted regression analyses.

Conclusions

Burn survivors with inhalation injury were significantly less likely to be employed at 24 months post-injury compared to survivors without inhalation injury. However, other health-related quality of life outcomes were similar between groups. This study suggests distinct long-term outcomes in adult burn survivors with inhalation injury which may inform future resource allocation and treatment paradigms.

Physical therapy performance in the rehabilitation of survivors of the Kiss nightclub tragedy: an experience report

Abstract Introduction : As a result of a fire in the Kiss nightclub that occurred in the city of Santa Maria - RS, 242 people were killed, of whom 235 died on the day of the episode, asphyxiated by the inhalation of toxic smoke. Approximately 1,000 more were injured. Objective : To report the experience of a group of physical therapists, professors at the Federal University of Santa Maria (UFSM), in the rehabilitation of survivors of the fire, victims of burns and inhalation injury. Materials and methods : Quantitative and qualitative study, in which an evaluation protocol of physical functional ability was designed to identify rehabilitation needs. Results : Two hundred seventy patients (147 men, mean age 26.72 ± 9.5 years) were examined, of which approximately 70% had some type of clinical modification or functional impairment that indicated the need for rehabilitation. The most prevalent respiratory signs and symptoms were: dry or productive cough (59.2%); abnormal respiratory pace (11.4%); fatigue (35.92%); dyspnea (17.7%); and chest pain (16.6%). Neurological symptoms such as persistent headache (88.51%), memory loss (11.4%), and paresthesia (8.1%) were also reported. Musculoskeletal injuries (14.7%) and extensive burns (8.8%) were also observed. One hundred and eighty-nine patients were referred to outpatient physical therapy and, of these, 22 still remain at the Outpatient Physical Therapy Unit of the University Hospital of (HUSM). Conclusions : Despite the vast professional experience of this group of physical therapists, the situations experienced were unique and unprecedented, both professionally and personally, and reinforced the importance of joining forces within an emergency care unit, as well as the importance of comprehensive and multi-professional outpatient monitoring.

Smoke inhalation injury during enclosed-space fires: an update

In view of the tragic fire at a nightclub in the city of Santa Maria, Brazil, which culminated in the sudden death of 232 young people, we decided to review the literature regarding smoke inhalation injury caused by enclosed-space fires, which can be divided into direct thermal damage, carbon monoxide poisoning, and cyanide poisoning. Such injuries often call for immediate orotracheal intubation, either due to acute airway obstruction or due to a reduced level of consciousness. The diagnosis and the severity of the thermal injury can be determined by fiberoptic bronchoscopy. The levels of gases and gas by-products in the bloodstream should be assessed as rapidly as possible, even while still at the scene of the incident. First responders can also treat carbon monoxide poisoning, with immediate administration of oxygen at 100%, as well as cyanide poisoning, with oxygen therapy and hydroxocobalamin injection.