Insignificant Difference in Early Post-injury Gene Expression Between Patients with Burns Only and Those with Inhalation Injury: A Bioinformatics Analysis.

Airway obstruction is fatal but common among burn patients in the early period after inhalation injury, during which most tracheotomies are performed within 48 h post-injury. Inflammation is common in laryngoscopy; however, the related gene expression has rarely been studied. In this study, we obtained the data of healthy control and patient samples collected within 8-48 hours post-injury from the Gene Expression Omnibus database and classified them into 10 inhalation-injury patients, 6 burn-only, and 10 healthy controls. Differential gene expression was identified between the patient groups; however, principal component analysis and cluster analysis indicated a similarity between groups. Furthermore, enrichment analysis, Kyoto Encyclopedia of Genes and Genomes, and gene set enrichment analyses showed no significant differences in immune regulation and cell adjustment between the patient groups; but differences were shown when comparing either patient group to the healthy control group, including prominent regulation in inflammatory cells, infection, and cell adjustment. Thus, the gene expression in inhalation injury and burn-only patients does not significantly differ in the early period after injury, especially in inflammation, indicating the absence of specific diagnostic markers or anti-inflammatory treatment in inhalation injury patients, with the potential to identify more subtle differences. Further research is warranted.

Laryngotracheal Reconstruction in the Pediatric Burn Patient: Surgical Techniques and Decision Making.

The management of laryngotracheal stenosis (LTS) in the pediatric burn patient is complex and requires a multidisciplinary approach. The mainstay of treatment for LTS is laryngotracheal reconstruction (LTR), however, limited reports of burn-specific LTR techniques exist. Here, we provide insight into the initial airway evaluation, surgical decision making, anesthetic challenges, and incision modifications based on our experience in treating patients with this pathology. The initial airway evaluation can be complicated by microstomia, trismus, and neck contractures-the authors recommend treatment of these complications prior to initial airway evaluation to optimize safety. The surgical decision making regarding pursuing single-stage LTR, double-stage LTR, and 1.5-stage LTR can be challenging-the authors recommend 1.5-stage LTR when possible due to the extra safety of rescue tracheostomy and the decreased risk of granuloma, which is especially important in pro-inflammatory burn physiology. Anesthetic challenges include obtaining intravenous access, securing the airway, and intravenous induction-the authors recommend peripherally inserted central catheter when appropriate, utilizing information from the initial airway evaluation to secure the airway, and avoidance of succinylcholine upon induction. Neck and chest incisions are often within the TBSA covered by the burn injury-the authors recommend modifying typical incisions to cover unaffected skin whenever possible in order to limit infection and prevent wound healing complications. Pediatric LTR in the burn patient is challenging, but can be safe when the surgeon is thoughtful in their decision making.

Early Surgical Management of Thermal Airway Injury: A Case Series.

Inhalation injury is an independent risk factor in burn mortality, imparting a 20% increased risk of death. Yet there is little information on the natural history, functional outcome, or pathophysiology of thermal injury to the laryngotracheal complex, limiting treatment progress. This paper demonstrates a case series (n = 3) of significant thermal airway injuries. In all cases, the initial injury was far exceeded by the subsequent immune response and aggressive fibroinflammatory healing. Serial examination demonstrated progressive epithelial injury, mucosal inflammation, airway remodeling, and luminal compromise. Histologic findings in the first case demonstrate an early IL-17A response in the human airway following thermal injury. This is the first report implicating IL-17A in the airway mucosal immune response to thermal injury. Their second and third patients received Azithromycin targeting IL-17A and showed clinical responses. The third patient also presented with exposed tracheal cartilage and underwent mucosal reconstitution via split-thickness skin graft over an endoluminal stent in conjunction with tracheostomy. This was associated with rapid abatement of mucosal inflammation, resolution of granulation tissue, and return of laryngeal function. Patients who present with thermal inhalation injury should receive a thorough multidisciplinary airway evaluation, including early otolaryngologic evaluation. New early endoscopic approaches (scar lysis and mucosal reconstitution with autologous grafting over an endoluminal stent), when combined with targeted medical therapy aimed at components of mucosal airway inflammation (local corticosteroids and systemic Azithromycin targeting IL-17A), may have potential to limit chronic cicatricial complications.

[Analysis on treatment of extremely severe burn patients with severe inhalation injury in August 2nd Kunshan factory aluminum dust explosion accident].

Objective: To summarize the measures and experience in diagnosis and treatment of extremely severe burn patients with severe inhalation injury in dust explosion accident. Methods: The medical records of 13 patients with extremely severe burn complicated with severe inhalation injury in August 2nd Kunshan factory aluminum dust explosion accident who were treated at the First Affiliated Hospital of Soochow University (hereinafter referred to as our hospital) on August 2nd, 2014, were retrospectively analyzed. All the patients were transferred to our hospital 3-8 hours after injury under the condition of inhalation of pure oxygen. Twelve patients underwent tracheotomy within 5 hours after admission, while 1 patient underwent tracheotomy before admission. All the patients were in ventilator-assisted respiration, with synchronized intermittent mandatory ventilation combined with positive end expiratory pressure. All the patients underwent thorax or limbs escharotomy on the second day after admission, so as to reduce the restrictive ventilatory dysfunction caused by the contraction of thorax eschar and the terminal circulation disorder caused by the contraction of limbs eschar. All the patients underwent electronic bronchoscopy within 48 hours after admission, airway secretion were cleared and airway lavage were carried out under electronic bronchoscope according to the patients' condition, and the sputum, lavage solution, pathological tissue were collected for microbiological culture. All the patients underwent chest X-ray examination on the second day after admission and reexamination as required. Patients were all treated with a combination of broad-spectrum antibiotics early after admission to control lung and systemic infection. One patient was treated with extracorporeal membrane oxygenation for acute respiratory distress syndrome 1 week after admission. Results: One patient suffered from cardiopulmonary arrest during tracheotomy, which recovered autonomous respiration and cardiac impulse after cardiopulmonary resuscitation. Three patients showed decreased pulse oxygen saturation (SpO(2)) within 48 hours after injury, and the SpO(2) returned to normal after sputum aspiration, scab removal and lavage under electronic bronchoscope. During the course of disease, bacteria were cultured from wound exudate of 7 patients, bacteremia occurred in 10 patients, and sputum microbiological culture results of 13 patients were positive. Eight of the 13 patients in this group survived, and 5 died. One patient died 19 days after injury, and 4 patients died 33-46 days after injury. The main cause of death was multiple organ dysfunction syndrome induced by severe septic shock eventually. Conclusions: For this batch of patients with extremely severe burn complicated with severe inhalation injury caused by dust explosion accident, the treatment and cure measures including early definite diagnosis and timely tracheotomy, the application of effective ventilation, the effective treatment of respiratory system complications, and rational use of antibiotics for the control of lung infection obtained quite good curative effect.

[Reflection on rescue and treatment of mass burn patients involved in August 2nd Kunshan factory aluminum dust explosion accident].

The treatment of mass burn patients is related to social stability, life saving, and disability reducing. It is also an important opportunity to accumulate, summarize, and improve clinical rescue and treatment experience. Aiming at August 2nd Kunshan factory aluminum dust explosion, this article reviews and summarizes experience and problems about rescue reserve, first-aid system, multidisciplinary cooperation, and integration of usual time and emergent time treatment, so as to propose corresponding strategies and provide reference for the treatment of mass burn patients and critically burned patients.

Operative utilization following severe combat-related burns.

The goal of burn surgical therapy is to minimize mortality and to return survivors to their preinjury state. Prompt removal of the burn eschar, early durable coverage, and late corrections of functional deformities are the basic surgical principles. The operative burden, while presumed to be substantial and significant, is neither well described nor quantified. The burn registry at the U.S. Institute of Surgical Research Burn Center was queried from March 2003 to August 2011 for all active duty burn admissions; active duty subjects were chosen to eliminate subject follow-up as a significant variable. Subject demographics including age, sex, branch of service, injury type, injury severity score, transfusion, allograft use, length of stay, mechanism of injury, and survival were tabulated as were their percentage TBSA, specific body region involvement, and nature and dates of operations performed. Univariate analysis and multiple logistic regressions were performed to determine independent factors which predict early and late operative burden. In the 8-year study period, 864 active duty patients were admitted to the burn center. Among them, 569 (66%) were operative in nature. The operations that were performed during acute hospitalization were 62%, while the remaining 38% were performed following discharge. A linear relationship exists between TBSA and the number of acute operations with an average of one acute operation required per 5% TBSA. No direct relationships however were found between TBSA and the number of reconstructive operations. Based on multiple logistic regression, battle vs nonbattle (odds ratio [OR], 0.559; 95% confidence interval [CI], 0.298-1.050; P = .0706), injury severity score (OR, 1.021; 95% CI, 1.003-1.039; P = .0222), intensive care unit length of stay (OR, 1.076; 95% CI, 1.053-1.099; P ≤ .0001), allograft use (OR, 2.610; 95% CI, 1.472-4.628; P = .0010), and TBSA of the trunk (OR, 0.982; 95% CI, 0.965-1.000; P = .0439) (but not overall TBSA) were associated with a high acute operative burden. Battle vs nonbattle (OR, 0.546; 95% CI, 0.360-0.829; P = .0045), and TBSA of the upper extremities (OR, 1.008; 95% CI, 1.002-1.013; P = .0042) were noted to be significant variables in predicting late reconstruction operations. The operative burden of burn, not previously well characterized, consists of operations performed during as well as after the initial hospitalization. While injury severity and truncal involvement are significant determinants of acute surgical therapy, the presence of upper extremity burns is a significant determinant of reconstruction following discharge.

Tracheostomy in pediatric burn patients.

BACKGROUND: Tracheostomy is often performed in the pediatric burn population to establish secure airways. Tracheostomy is safe in this population, but the duration of tracheostomy may be related to age and extent and severity of burn. We hypothesized that burn related factors and not age determine the time to removal of a tracheostomy in pediatric burn patients. METHODS: A 5-year retrospective review was performed for pediatric burn patients (age ≤18 years) who underwent tracheostomy. Patients were divided into three groups by age (group 1: 0 to ≤2 years, group 2: >2 to ≤12 years, group 3: >12 to ≤18 years). Data collected included: age, total body surface area burn injured (TBSA), gender, mechanism of injury, diagnosis of inhalation injury, mortality, time from injury to admission, time from admission to placement of tracheostomy, time of injury to placement of tracheostomy, duration of tracheostomy, days of mechanical ventilation, and tracheostomy related complications. RESULTS: 45 patients were reviewed. There were no differences in TBSA, length of ICU stay, length of hospital stay, and mortality between the three groups. Additionally, there were no differences in ventilator days and duration of tracheostomy. Multivariate linear regression analysis indicated that TBSA and not age independently increased the duration of tracheostomy. CONCLUSION: Tracheostomy duration is dependent on the extent of burn in pediatric burn patients.

[Analysis of clinical characteristics of 443 patients with inhalation injury].

OBJECTIVE: To explore the epidemiological characteristics of inhalation injury and to summarize the clinical application experience of diagnostic standard of burn of larynx. METHODS: Medical records of 443 patients with inhalation injury admitted to our burn unit from January 1999 to June 2013 were analyzed, including gender, age, severity of inhalation injury, complications and diseases before injury; total area and that of full-thickness burn injury, admission time after burn, and burn condition of larynx of patients with different degrees of inhalation injury; treatment and outcome including rate, time, and complication of tracheotomy, mortality, and cause of death. Data were processed with nonparametric Kruskal-Wallis test and chi-square test. The relationship between severity of inhalation injury and total burn area, degree of burn of larynx, tracheotomy rate, and mortality was assessed by Spearman correlation analysis. RESULTS: (1) Among the patients, there were 353 (79.7% ) male and 90 (20.3% ) female, with the ratio of male to female 4:1. There were 64 (14.4%) patients younger than or equal to 20 years, 203 (45.8%) patients older than 20 years and younger than or equal to 40 years, 144 (32.5%) patients older than 40 years and younger than or equal to 60 years, and 32 (7.2%) patients older than 60 years. The numbers of patients with mild, moderate, and severe inhalation injury were respectively 297, 108, and 38. Seven patients suffered from complications, and 21 patients had diseases before injury. There were statistically significant differences among the patients with different degree of inhalation injury in regard to total burn area and full-thickness burn area (with H values respectively 73.752 and 142.830, P values below 0.01), while no statistically significant difference was observed in admission time after burn ( H = 1.528, P > 0.05). Correlation analysis showed that severity of inhalation injury was positively correlated with total burn area (r = 0.399, P < 0.001). Among the patients with mild inhalation injury, incidences of patients with mild, moderate, and severe burn of larynx were respectively 68.0% (202/297), 32.0% (95/297), and 0, and those among the patients with moderate inhalation injury were respectively 0,53.7% (58/108), and 46.3% (50/108). There were statistically significant differences in degree of burn of larynx of patients with different degree of inhalation injury (χ2 = 336.703, P < 0.001). Correlation analysis showed that severity of burn of larynx was positively correlated with severity of inhalation injury (r = 0.700, P < 0.001). (2) The rate of tracheotomy was 37.02% (164/443). The rates of tracheotomy in patients with mild, moderate, and severe inhalation injury were respectively 10.44% (31/297), 87.96% (95/108), and 100.00% (38/38), χ2 = 271.654, P < 0.001. Correlation analysis showed that the rate of tracheotomy was positively correlated with severity of inhalation injury (r = 0.784, P < 0.001). Tracheotomy was done mainly within 6 h post burn (63.4%, 104/164). The incidence rate of complication of tracheotomy was 5.5% (9/164). (3) Thirty-one patients died, with a mortality rate of 7.00%. The mortality rates of patients with mild, moderate, and severe inhalation injury were respectively 1.01% (3/297), 12.96% (14/108), and 36.84% (14/38), H = 74.273, P < 0.001. It was found that the mortality was positively correlated with severity of inhalation injury (r = 0.371, P < 0.001). The causes of death of the patients were respectively sepsis (14, 45.2%), respiratory failure (7, 22.6%), airway obstruction (2, 6.5%), airway hemorrhage (2, 6.5%), cerebral hemorrhage (2, 6.5%), cardiac accident (2, 6.5%), and diabetes insipidus (1, 3.2%), and 1 (3.2%) patient quit treatment and discharged from hospital for economic reason. CONCLUSIONS: Among the patients with inhalation injury, male is dominated in number, and the young adults formed the highest constituent ratio. The severity of inhalation injury was correlated with total burn area, severity of burn of larynx, tracheotomy rate, and mortality. With the guidance of diagnostic criteria of burn of larynx and indication of tracheotomy, the risk of laryngeal obstruction can be eliminated. The early preventive tracheotomy can decrease the difficulty and risk of the operation.

[Analysis of extubation time and late complications after early tracheotomy in patients with inhalation injury].

OBJECTIVE: To investigate the appropriate extubation time and treatment of late complications after early tracheotomy in patients with moderate or severe inhalation injury. METHODS: One hundred and fifty patients (105 males and 45 females) with inhalation injury were admitted to our hospital from January 2000 to January 2009. Among them, 109 out of 129 cases with moderate inhalation injury received early tracheotomy, and all 21 cases with severe inhalation injury received early tracheotomy. Data were collected for analysis as follows: (1) incidence of re-intubation due to suffocation and pneumonia incidence after extubation within 2 weeks or after 2 weeks post inhalation injury (PII), and mortality rate within the first week after injury were recorded. (2) Conservative treatments including expectorant, oral antibiotics, and absolute bedrest were recommended for patients who had severe cough, hoarseness or poor pulmonary function after late extubation and closure of tracheostomy wound. Fiberoptic bronchoscopy findings (tracheostenosis degree, granuloma formation rate, vocal cord paralysis rate) and pulmonary function index (FEV(1)) data were collected and analyzed in 30 cases with moderate inhalation injury and 10 cases with severe inhalation injury within 3 months after injury for follow-up. Data were processed with t test or chi-square test. RESULTS: There was no obvious difference in the rate of re-intubation after extubation in patients with moderate inhalation injury between those done within 2 weeks PII (15/70, 21.4%) and those done after 2 weeks PII (2/25, 8.0%) (χ(2) = 1.52, P > 0.05). Pneumonia incidence in patients of moderate inhalation injury with extubation within 2 weeks PII (21/70, 30.0%) was lower than those with extubation after 2 weeks PII (15/25, 60.0%) (χ(2) = 7.04, P < 0.05). Levels of above-mentioned indexes in patients with severe inhalation injury extubated in different stages were similar to those of patients with moderate inhalation injury. Within the first week after injury, mortality rate of patients with severe inhalation injury was higher than that of patients with moderate inhalation injury (χ(2) = 11.90, P < 0.05). During follow-up, tracheostenosis rate in patients with moderate or severe inhalation injury was 100.0%; granuloma formation rate and vocal cord paralysis rate in patients with severe inhalation injury were higher than those of patients with moderate inhalation injury (with χ(2) value respectively 4.59, 13.47, P values all below 0.05). The FEV(1) value of patients with moderate inhalation injury in the 1st, 2nd, 3rd month after injury was respectively higher than that of patients with severe inhalation injury (with t value respectively 5.48, 12.10, 6.25, P values all below 0.05). The values recovered to normal level in the 3rd month after injury. CONCLUSIONS: Extubation time of tracheotomy for patients with moderate or severe inhalation injury within 2 weeks or after 2 weeks PII has its own advantage and disadvantage, and it should be performed according to specific conditions of each patient. Conservative treatment is optional for late complications of respiratory system.

[Surgery of traumatic tracheal and tracheobronchial injuries]. / Chirurgie traumatischer trachealer und tracheobronchialer verletzungen.

Tracheal injuries are altogether rare events and can be divided into three broad categories: tracheobronchial injuries caused by external violence, iatrogenic ruptures of the trachea and inhalation trauma. Successful management of tracheobronchial injuries requires a fast and straightforward diagnostic evaluation. In all severely injured patients with cervicothoracic involvement an injury of the tracheobronchial system should be actively excluded. Although it is commonly agreed that posttraumatic injuries require surgical intervention the management of iatrogenic injuries is presently shifting towards a more conservative treatment.

Fire-eater's lung complicated by an infectious abscess requiring surgical treatment.

We describe a case of fire-eater's pneumonia that was complicated by an infectious lung abscess with substantial haemoptysis. Conservative treatment was inadequate. Surgical resection was necessary and proved to be successful.

Tracheostomy in burns patients revisited.

OBJECTIVE: The use of tracheostomy in burns patients has been controversial. A retrospective study was conducted to assess the use, complications and outcome of tracheostomy in ventilated adult burns patients. METHODS: Data was collected retrospectively regarding the extent of injury in each patient, the indication for tracheostomy, and outcome in terms of length of stay, days of mechanical ventilation, airway and pulmonary complications and survival. Patients were followed until discharge from the unit or death. RESULTS: Comparing patients who received tracheostomy to those who had translaryngeal intubation showed similar age distribution and no significant difference in the total burn surface area (TBSA). The use of tracheostomy was significantly higher in patients with TBSA >60%. Inhalation injury was significantly higher and mean probability of survival (ABSI), significantly lower in patients receiving tracheostomy. Duration of mechanical ventilation, length of stay in HDU/ITU and the incidence of pulmonary sepsis were significantly higher in tracheostomy group patients. However, there was no significant difference in mortality between the two groups. CONCLUSION: Burn survivors with TBSA >60% are more likely to undergo repeated surgery and have burns to the head and neck region, therefore increasing the requirement for tracheostomy. Tracheostomy is a safe procedure with minimal perioperative complications. Late complications in this patient group may be related to duration of intubation and mechanical ventilation and the presence of an airway burn. Tracheostomy was associated with a higher prevalence of chest infection. We suspect that the cause of this is multifactorial, possibly due to a higher incidence of inhalation injury, greater burn size and prolonged mechanical ventilation in this group.

Inhalation burn injury in children.

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.

Percutaneous versus Conventional Tracheostomy in Burned Patients with Inhalation Injury.

The aim of the study was to compare conventional tracheostomy with percutaneous dilatational tracheostomy in patients with inhalation burn injury. A total of 37 patients with severe burn injuries and associated inhalation injury, underwent percutaneous tracheostomy in our burn unit and were retrospectively compared with 22 patients who underwent conventional surgical tracheostomy. In the first group, 25 of 37 patients and in the second group 17 of 22 patients presented with partial or full-thickness burn injuries (or both) in the neck region. The cost of the procedure, operating time, complications, and incidence of pulmonary infection were recorded. There were no significant perioperative complications in the percutaneous tracheostomy group, and no patient required surgical revision or conversion to surgical tracheostomy. In the conventional tracheostomy group, 2 patients developed tracheal stenosis, 1 had a tracheoesophageal fistula, and 10 had stomal infections. The average procedure time in the first group was 9 minutes, and in the second group it was 22 minutes. The cost of the bedside percutaneous tracheostomy was one-fifth the cost of a conventional tracheostomy. The incidence of pulmonary sepsis was 45% after percutaneous tracheostomy compared to 68% after conventional tracheostomy. With the percutaneous technique, spontaneous closure of the stoma occurred within 1 to 3 days after removal of the tracheostomy tube, whereas with the conventional technique it was within 5 to 7 days. Percutaneous tracheostomy is associated with a lower complication rate and can be safely performed at the bedside. Moreover, it is faster and can be done at a lower cost than conventional open tracheostomy.

[Clinical significance of tracheotomy in children's burns].

OBJECTIVE: To discuss the indications, timing and related issues of tracheotomy in burn together with inhalation injury in children. METHOD: In 45 cases, 12 cases were done in general anesthesia, while 33 cases were done in local anesthesia. Analysis the characters in children anastomosis, the essentials in the operation and timing of pulling out the tracheal cannulas. RESULT: Forty-five cases were under tracheotomy in 1-48 hours after burn in which 16 cases were in urgency. Forty-three cases cured (95.65%) while 2 cases died. CONCLUSION: Tracheotomy in early stage could be a good treatment for burns with inhalation injury children. This is the most important clinical significance of increasing success rate, decreasing complication in respiratory tract and decreasing death rate.

Acute burn injury.

Almost 2 million people in the United States suffer from burns annually. A small percentage of these injuries are fatal, but all require some degree of medical attention. Burn injury is associated with anatomic, physiologic, endocrinologic, and immunologic alterations. These problems need to be identified and treated properly to prevent or minimize the extent of the damage. In recent years, advances in burn treatment have reduced morbidity and mortality and improved the quality of life for burn survivors. These advances have been made in the treatment of the acute injury, the quality of the initial resuscitation, the effectiveness of infection control, and the surgical decision making for improved short- and long-term outcomes.

[Anesthesia and management of recovery for severely burned pediatric patients]. / Anestesia y reanimación del gran quemado pediátrico.

The incidence of burns in children is high. Their severity and high mortality rate, coupled with the complexity of the pathophysiological mechanisms involved mean that burns must be treated exhaustively as soon after injury as possible. The airway must be managed and fluid started in the first hours to preserve vital organ function. Avoiding hypothermia, ischemic infection, and toxicity arising from dead tissue will be other priorities. Placing skin grafts over lesions will be the final stage of surgical treatment. All of these processes will involve management of pain as well as provision of the psychological support these children will need to overcome physical and psychological sequelae and allow them to take up social activities after recovery.