ReviewRespiratory management of inhalation injury
Introduction
Respiratory complications caused by smoke inhalation, burns, and their treatment epitomize the challenges which confront clinicians caring for burn patients. Smoke inhalation injury and its sequelae impose demands upon the respiratory therapists, nurses and doctors who play a central role in its clinical management. These demands may range from intubation and resuscitation of victims in the emergency room to assistance with diagnostic bronchoscopies, monitoring of arterial blood gases, airway maintenance, chest physiotherapy, and mechanical ventilator management [1]. Additional demands may be placed upon the clinical care team in the rehabilitation phase in determining disability or limitations diagnosed by pulmonary function studies or cardiopulmonary stress testing. In some countries outside the United States, the duties of the respiratory therapist are augmented by a combination of physicians, nurses, and physiotherapists. It is imperative that a well organized, protocol-driven approach to respiratory management of burn care be utilized so that improvements can be made, and the morbidity and mortality associated with inhalation injury can be reduced. This article provides an overview of the common hands-on approaches to the treatment of inhalation injury with emphasis on pathophysiology, diagnosis, management techniques to include bronchial hygeine therapy, pharmacologic adjuncts, mechanical ventilation, late complications and cardiopulmonary exercise rehabilitation.
Section snippets
Pathophysiology
Upper airway injury that results in obstruction during the first 12 h after-insult is caused by direct thermal injury as well as chemical irritation. The pathophysiologic changes in the parenchyma of the lungs that are associated with inhalation injury are not the result of direct thermal injury. Only steam, with a heat-carrying capacity many times that of dry air, is capable of overwhelming the extremely efficient heat-dissipatory capabilities of the upper airways [2]. Nor is the carbonaceous
Diagnosis
The clinical diagnosis of inhalation injuries has traditionally rested upon a group of indirect observations. These include facial burns, singed nasal vibrissae, and a history of injury in an enclosed space [12]. Taken individually, each of these signs has a high incidence of false positivity, but as a group they have been found to actually underestimate the true incidence of inhalation injury.
Carbonaceous secretions represent another classic sign of smoke inhalation that is a less exact
Airway issues
Acute upper airway obstruction (UAO) occurs in approximately one-fifth to one-third of hospitalized burn victims with inhalation injury and is a major hazard because of the possibility of rapid progression from mild pharyngeal edema to complete upper airway obstruction with asphyxia [19]. The worsening of upper airway edema is most prominent in supraglottic structures. Serial nasopharyngoscopic evaluations demonstrate obliteration of the aryepiglotic folds, arytenoid eminences, and
Tracheal stenosis
Tracheal complications are commonly seen and consist of tracheitis, tracheal ulcerations, and granuloma formation. The location of the stenosis is almost invariably subglottic and occurs at the site of the cuff of the endotracheal or tracheostomy tube [65].
Several problems arising after extubation represent sequelae of laryngeal or tracheal injury incurred during the period of intubation. While tracheal stenosis or tracheomalacia are usually mild and asymptomatic, in some patients they can
Conclusion
Inhalation injury and associated major burns provide a challenge for health care workers who provide direct hands-on care. The technical and physiologic problems which complicate the respiratory management of these patients require an orderly, systematic approach. Successful outcomes require careful attention to treatment priorities, protocols and meticulous attention to details.
References (75)
Inhalation injury in burns
Am J Surg
(1980)- et al.
Effects of suctioning on mucociliary transport
Chest
(1980) Mechanical ventilation. American College of Chest Physicians’ Consensus Conference
Chest
(1993)- et al.
The inspiratory work of breathing during assisted mechanical ventilation
Chest
(1985) - et al.
Intermittent mandatory ventilation: a new approach to weaning patients from mechanical ventilators
Chest
(1973) Respiratory function during pressure support ventilation
Chest
(1986)- et al.
Pressure support compensation for inspiratory work due to endotracheal tubes and demand continuous positive airway pressure
Chest
(1988) - et al.
Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine
Chest
(2001) - et al.
Using the exercise test to develop the exercise prescription in health and disease
Prim Care
(1994) Smoke Inhalation Injury: some priorities for respiratory care professionals
Resp Care
(1992)
The effects of inhaled heat on the air passages of lungs: an experimental investigation
Am J Pathol
What is clinical smoke poisoning?
Ann Surg
Short-term exposure to nitrogen dioxide. Effects on pulmonary ultrastructure, compliance, and the surfactant system
Arch Intern Med
Physiological and toxicological aspects of smoke produced during the combustion of polymeric materials
Environ Health Perspect
Fire and protection
Sci Am
Experimental inhalation injury in the goat
J Trauma
Prophylactic intubation and continuous positive airway pressure in the management of inhalation injury in burn victims
Crit Care Med
The effect of smoke inhalation on pulmonary surfactant
Ann Surg
Ventilation and perfusion alterations after smoke inhalation injury
Surgery
Inhalation injury--an increasing problem
Ann Surg
Pulmonary injury associated with thermal burns
Surg Gynecol Obstet
Radiographic manifestations of acute smoke inhalation
Am J Roentgenol
Early recognition of upper airway obstruction following smoke inhalation
Am Rev Respir Dis
Fiberoptic bronchoscopy following thermal injury
Surg Gynecol Obstet
Early diagnosis of inhalation injury using 133 xenon lung scan
Ann Surg
Measurement of extravascular lung water in sheep during colloid and crystalloid resuscitation from smoke inhalation
Am Surg
Acute upper airway injury in burn patients. Serial changes of flow-volume curves and nasopharyngoscopy
Am Rev Respir Dis
Upper airway function in burn patients. Correlation of flow-volume curves and nasopharyngoscopy
Am Rev Respir Dis
Respiratory treatment of the adult patient with spinal cord injury
Phys Ther
Effects of hydration and physical therapy on tracheal transport velocity
Am Rev Respir Dis
Acute lobar atelectasis: a prospective comparison of fiberoptic bronchoscopy and respiratory therapy
Am Rev Respir Dis
Effects of postural drainage, exercise, and cough on mucus clearance in chronic bronchitis
Am Rev Respir Dis
Positional hypoxemia in unilateral lung disease
N Engl J Med
A hassle free guide to suctioning a tracheostomy
RN
Decreasing respiratory compromise during infant suctioning
Am J Nurs
Cited by (175)
An Introduction to Burns
2022, Physical Medicine and Rehabilitation Clinics of North AmericaPediatric burn review
2022, Seminars in Pediatric SurgerySmoke inhalation
2022, Small Animal Critical Care Medicine