Elsevier

Burns

Volume 33, Issue 1, February 2007, Pages 2-13
Burns

Review
Respiratory management of inhalation injury

https://doi.org/10.1016/j.burns.2006.07.007Get rights and content

Abstract

Advances in the care of patients with major burns have led to a reduction in mortality and a change in the cause of their death. Burn shock, which accounted for almost 20 percent of burn deaths in the 1930s and 1940s, is now treated with early, vigorous fluid resuscitation and is only rarely a cause of death. Burn wound sepsis, which emerged as the primary cause of mortality once burn shock decreased in importance, has been brought under control with the use of topical antibiotics and aggressive surgical debridement.

Inhalation injury has now become the most frequent cause of death in burn patients. Although mortality from smoke inhalation alone is low (0–11 percent), smoke inhalation in combination with cutaneous burns is fatal in 30 to 90 percent of patients. It has been recently reported that the presence of inhalation injury increases burn mortality by 20 percent and that inhalation injury predisposes to pneumonia. Pneumonia has been shown to independently increase burn mortality by 40 percent, and the combination of inhalation injury and pneumonia leads to a 60 percent increase in deaths. Children and the elderly are especially prone to pneumonia due to a limited physiologic reserve.

It is imperative that a well organized, protocol driven approach to respiratory care of inhalation injury be utilized so that improvements can be made and the morbidity and mortality associated with inhalation injury be reduced.

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.

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