Inhalation Injury: Which Providers Can Assess the Need for Intubation?

Previous studies have suggested that many burn patients undergo unnecessary intubation due to concern for inhalation injury. We hypothesized that burn surgeons would intubate burn patients at a lower rate than non-burn acute care surgeons (ACSs). We performed a retrospective cohort study of all patients admitted to an American Burn Association-verified burn center who presented emergently following burn injury from June 2015 to December 2021. Patients excluded include polytrauma patients, isolated friction burns, and patients intubated prior to hospital arrival. Our primary outcome was intubation rates between burn and non-burn ACSs. 388 patients met inclusion criteria. 240 (62%) patients were evaluated by a burn provider and 148 (38%) were evaluated by a non-burn provider; the groups were well-matched. In total, 73 (19%) of patients underwent intubation. There was no difference in the rate of emergent intubation, diagnosis of inhalation injury on bronchoscopy, time to extubation, or incidence of extubation within 48 hours between burn and non-burn ACSs. We found no difference between burn and non-burn ACSs in the airway evaluation and management of burn patients. Surgical providers with acute care surgery backgrounds and Advanced Trauma Life Support training are well-equipped for initial airway management in burn patients. Further studies should seek to compare other types of provider groups to identify opportunities for intervention and education in preventing unnecessary intubations.

Inhalation Injury: Unmet Clinical Needs and Future Research.

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.

Preventing Unnecessary Intubations: A 5-Year Regional Burn Center Experience Using Flexible Fiberoptic Laryngoscopy for Airway Evaluation in Patients With Suspected Inhalation or Airway Injury.

The decision to intubate acute burn patients is often based on the presence of classic clinical exam findings. However, these findings may have poor correlation with airway injury and result in unnecessary intubation. We investigated flexible fiberoptic laryngoscopy (FFL) as a means to diagnose upper airway thermal and inhalation injury and guide airway management. A retrospective chart review of all burn patients who underwent FFL from 2013 to 2017 was performed. Their charts were reviewed to determine the indications for FFL including the historical data and physical exam findings that indicated airway injury as well as patient age, TBSA, type and depth of burn injury, carboxyhemoglobin level, and clinical course. Fifty-one patients underwent FFL, with an average TBSA of 6.5% (range 0.5-38.0%) and carboxyhemoglobin level of 3.5%. Burn mechanism was flame (35.3%) or flash (51.0%), with 50% occurring in enclosed spaces. In all cases, the decision to perform FFL was based on physical exam findings meeting criteria for intubation, including facial burns, singed nasal hairs, nasal soot, voice change, throat pain or abnormal sensation, shortness of breath, carbonaceous sputum, wheezing, or stridor. Based on FFL, 9 patients (17.7%) were treated with steroids, 28 patients (54.9%) received supportive care, and 6 patients (11.8%) had repeat FFL for monitoring. One patient was intubated after repeat FFL examination. All patients who underwent FFL met traditional criteria for intubation based on exam, however 98% were monitored without issues based on FFL findings. FFL is a valuable tool that can lead to fewer intubations in acute burn patients with a stable respiratory status for whom history and physical exam suggest upper airway injury.

Pulmonary Tumor Thrombotic Microangiopathy Mimicking Inhalation Lung Injury.

Pulmonary tumor thrombotic microangiopathy (PTTM) is a complication characterized by dyspnea, pulmonary hypertension, and occasionally sudden death. We encountered a man who developed PTTM and had an inhalation history of chemical herbicides and abnormal findings on chest computed tomography, mimicking chemical inhalation lung injury. He was diagnosed with PTTM with adenocarcinoma by a transbronchial lung biopsy and received chemotherapy and anticoagulant therapy. He survived for one month. An autopsy revealed primary gastric cancer with PTTM that can have a presentation similar to diffuse pulmonary diseases, including chemical inhalation lung injury. The examination of a biopsy specimen is crucial in such patients.

Determining the role of nasolaryngoscopy in the initial evaluation for upper airway injury in patients with facial burns.

BACKGROUND: Upper airway injuries can be fatal in burn patients if not recognized, a scenario that causes a significant amount of anxiety for physicians providing initial assessment of burn patients. Early elective intubation is often performed; sometimes unnecessarily. However, some providers employ nasolaryngoscopy for patients presenting with facial burns or signs/symptoms of upper airway injury in order to assess the need for intubation, but this practice is not considered standard of care and may also be unnecessary. Evidence is currently lacking about the utility of nasolaryngoscopy as an adjuvant assessment during evaluation of potential upper airway burn injuries. The objective of this study was to determine if nasolaryngoscopy provides additional information to the history and physical in making the decision to electively intubate patients with facial burns. METHODS: This study was a retrospective analysis of all patients who underwent fiberoptic nasolaryngoscopy after facial burn injury to evaluate for upper airway injury associated with burns over a 2 year period at a regional burn center. During this time period, all patients who presented with facial burns, soot, or carbonaceous sputum underwent nasolaryngoscopy to look for upper airway injury regardless of mechanism of injury. Patients intubated prior to arrival were excluded from the study. Patients were considered to have signs/symptoms of airway injury (symptomatic) if they presented with dyspnea, tachypnea, hypoxia, or significant burns to buccal mucosa. Procedure notes were used to determine if supraglottic/glottic injury (erythema or edema) was present on nasolaryngoscopy. Presence of pathologic changes and whether they led to intubation were evaluated in the asymptomatic and the symptomatic groups of patients. Select individual records were inspected further to help determine if the nasolaryngoscopy findings altered management plans and if intubation was ultimately necessary based upon the presence or absence of a cuff leak and the duration of intubation. RESULTS: Twenty-two patients were symptomatic upon presentation, 14 of which had positive findings on laryngoscopy and 7 (50%) were intubated. One-hundred and eighty-eight patients were asymptomatic, 58 (31%) of which had either erythema or edema or carbonaceous debris on nasolaryngoscopy, and only 2 (1%) were intubated. These patients were both extubated within two days. None of the 130 asymptomatic patients with negative nasolaryngoscopy were intubated. CONCLUSIONS: This study showed disparity between signs and symptoms of airway injury and nasolaryngoscopy findings. Asymptomatic patients showed pathologic changes in 30% of scopes, but this finding only changed management 1% of the time. Furthermore, the two patients in this group were extubated quickly, suggesting they may have been suitable for observation without intubation. These results indicate that the presence of erythema or edema is of questionable clinical significance in asymptomatic patients and nasolaryngoscopy is of limited benefit in this group. Only 50% of the symptomatic patients with airway injury evident on nasolaryngoscopy were actually intubated, also bringing into question the significance of the pathologic changes in this group. However, negative nasolaryngoscopy may have had some benefit in preventing intubation in a few, select symptomatic patients. This study suggests that a thorough history and physical is the best tool to identify patients at higher risk of upper airway injury who need intubation, but this should be further studied in prospective trials to determine the definitive role of nasolaryngoscopy.

Inhalation Injury: Pathophysiology, Diagnosis, and Treatment.

The classic determinants of mortality from severe burn injury are age, size of injury, delays of resuscitation, and the presence of inhalation injury. Of the major determinants of mortality, inhalation injury remains one of the most challenging injuries for burn care providers. Patients with inhalation injury are at increased risk for pneumonia (the leading cause of death) and multisystem organ failure. There is no consensus among leading burn care centers in the management of inhalation injury. This article outlines the current treatment algorithms and the evidence of their efficacy.

Management of Pulmonary Failure after Burn Injury: From VDR to ECMO.

This article highlights the challenges in managing pulmonary failure after burn injury. The authors review several different ventilator techniques, provide weaning parameters, and discuss complications.

Inhalation Injury: State of the Science 2016.

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.

Incidence of Sinusitis in Burn Victims and Association With Inhalational Injury.

The purpose of this study is to determine the incidence of sinusitis in mechanically ventilated burn victims and to examine if the presence of inhalational injury increases the likelihood of developing sinusitis. The authors hypothesize that the incidence of sinusitis will be increased in burn victims who have concomitant inhalational injury. A retrospective chart analysis was performed on all patients who were admitted to the Nathan Speare Regional Burn Treatment Center over a 24-month time frame. Patients who were mechanically ventilated for greater than 24 hours were then selected, resulting in a total of 137 patients for analysis. Multiple variables including number of days on mechanical ventilation, presence of confirmed inhalational injury by bronchoscopy, and method of diagnosis were examined. Of 137 patients, a diagnosis of sinusitis was made in 32 patients (23%). In patients with sinusitis, 87.5% had inhalational injury confirmed with bronchoscopy, compared with only 33.3% of patients without sinusitis (P < .01). Rates of nasotracheal/nasogastric intubation, nasoenteric feeding, and length of mechanical ventilation before sinusitis diagnosis were not significantly different. Patients with sinusitis were found to have suffered inhalational injury at a significantly higher rate than those who did not develop sinusitis. This suggests that inhalational injury is a significant risk factor for developing sinusitis.

Laryngeal Trauma Following an Inhalation Injury: A Review and Case Report.

The primary concern when managing a patient with inhalation injury is security of the airway. Airflow may be impeded by both edema of the upper airway and reduction of oxygen delivery to the lower respiratory tract. Although there has been much discussion regarding management of the latter, the focus of this article is the management of the former. This review aimed to determine the optimum management in burn victims with upper airway inhalation injury as an attempt to prevent laryngeal trauma leading to long-term voice disorders and upper airway dyspnea. We describe the case of a 57-year-old woman with significant inhalation injury and discuss the natural progression of her injuries and the laryngeal controversies surrounding her care. We conclude with advice on the optimal management of this condition based on our experience, combined with current best evidence.

Fibrobroncoscopia negra en el contexto de un incendio / Black fiberoptic bronchoscopy after a fire

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The wound/burn guidelines - 6: Guidelines for the management of burns.

Burns are a common type of skin injury encountered at all levels of medical facilities from private clinics to core hospitals. Minor burns heal by topical treatment alone, but moderate to severe burns require systemic management, and skin grafting is often necessary also for topical treatment. Inappropriate initial treatment or delay of initial treatment may exert adverse effects on the subsequent treatment and course. Therefore, accurate evaluation of the severity and initiation of appropriate treatment are necessary. The Guidelines for the Management of Burn Injuries were issued in March 2009 from the Japanese Society for Burn Injuries as guidelines concerning burns, but they were focused on the treatment for extensive and severe burns in the acute period. Therefore, we prepared guidelines intended to support the appropriate diagnosis and initial treatment for patients with burns that are commonly encountered including minor as well as moderate and severe cases. Because of this intention of the present guidelines, there is no recommendation of individual surgical procedures.

Initial evaluation and management of the critical burn patient / Evaluación inicial y manejo del paciente quemado crítico

The major improvement in burn therapy is likely to focus on the early management of hemodynamic and respiratory failures in combination with an aggressive and early surgical excision and skin grafting for full-thickness burns. Immediate burn care by first care providers is important and can vastly alter outcomes, and it can significantly limit burn progression and depth. The goal of prehospital care should be to cease the burning process as well as prevent future complications and secondary injuries for burn shock. Identifying burn patients appropriate for immediate or subacute transfer is an important step in reducing morbidity and mortality. Delays in transport to Burn Unit should be minimized. The emergency management follows the principles of the Advanced Trauma Life Support Guidelines for assessment and stabilization of airway, breathing, circulation, disability, exposure and environment control. All patients with suspected inhalation injury must be removed from the enclosure as soon as possible, and immediately administer high-flow oxygen. Any patient with stridor, shortness of breath, facial burns, singed nasal hairs, cough, soot in the oral cavity, and history of being in a fire in an enclosed space should be strongly considered for early intubation. Fibroscopy may also be useful if airway damage is suspected and to assess known lung damage. Secondary evaluation following admission to the Burn Unit of a burned patient suffering a severe thermal injury includes continuation of respiratory support and management and treatment of inhalation injury, fluid resuscitation and cardiovascular stabilization, pain control and management of burn wound (AU)

Los principales avances en el tratamiento de la quemadura se centran en el manejo precoz de la disfunción hemodinámica y respiratoria junto con la excisión quirúrgica agresiva y precoz y el injerto de piel en quemaduras de espesor total. La atención inmediata a la quemadura puede cambiar el pronóstico, limitando significativamente su progresión y profundidad. El objetivo de la asistencia prehospitalaria es detener el proceso de combustión así como prevenir posteriores complicaciones y daños secundarios al shock por quemadura. Identificar los pacientes quemados subsidiarios de traslado inmediato es importante en términos de morbilidad y mortalidad. La demora en el traslado a una Unidad de Quemados de referencia debe ser minimizada. El manejo emergente debe ser el mismo que para cualquier otro paciente politraumatizado, con evaluación y estabilización de la vía aérea, la respiración, la circulación, la discapacidad y el control ambiental. Todos los pacientes con sospecha de inhalación deben ser trasladados del recinto tan pronto como sea posible y administrar inmediatamente oxígeno a alto flujo. Ante un paciente con estridor, dificultad para respirar, quemaduras faciales, vibrisas quemadas, tos, hollín en la cavidad oral e historia de inhalación de humo en un lugar cerrado debe ser considerada la indicación de intubación precoz. La fibroscopia puede ser útil si se sospecha daño de la vía aérea y para evaluar el daño pulmonar conocido. La valoración secundaria tras el ingreso en la Unidad de un paciente que ha sufrido una lesión térmica grave incluye la continuación del soporte respiratorio y el manejo y tratamiento del daño por inhalación, la reanimación con líquidos y la estabilización cardiovascular, el control del dolor y el manejo de la herida (AU)

Tracheal damage.

Tracheal damage. Blunt/penetrating trauma and inhalation injuries to the trachea can result in acute airway compromise, with life-threatening implications. Early assessment, identification, and prompt and appropriate management are of paramount importance in order to reduce patient morbidity and mortality. Signs and symptoms of these injuries are specific and sometimes subtle, and their seriousness may be obscured by other injuries. Diagnosis can therefore be challenging, requiring a high index of suspicion. Indeed, diagnosis and treatment are often delayed, resulting in attempted surgical repair months or even years after injury. Laryngoscopy, flexible and/or rigid bronchoscopy and computed tomography of the chest are the procedures of choice for a definitive diagnosis. Airway control and appropriate ventilation represent the key aspects of emergency management. Definitive treatment depends on the site and the extent of injury. Surgery, involving primary repair with direct suture or resection and end-to-end anastomosis, is the treatment of choice for patients suffering from tracheal injuries. A conservative approach must be considered for the paediatric population and selected patients with mainly iatrogenic damage. We present a review of the incidence, mechanisms of injury, clinical presentations, diagnosis, initial airway management, anaesthetic considerations and definitive treatment in the case of tracheal damage from blunt/penetrating trauma and inhalation injuries.

An Analysis of Inhalation Injury Diagnostic Methods and Patient Outcomes.

The purpose of this study was to compare patient outcomes according to the method of diagnosing burn inhalation injury. After approval from the American Burn Association, the National Burn Repository Dataset Version 8.0 was queried for patients with a diagnosis of burn inhalation injury. Subgroups were analyzed by diagnostic method as defined by the National Burn Repository. All diagnostic methods listed for each patient were included, comparing mortality, hospital days, intensive care unit (ICU) days, and ventilator days (VDs). Z-tests, t-tests, and linear regression were used with a statistical significance of P value of less than .05. The database query yielded 9775 patients diagnosed with inhalation injury. The greatest increase in mortality was associated with diagnosis by bronchoscopy or carbon monoxide poisoning. A relative increase in hospital days was noted with diagnosis by bronchoscopy (9 days) or history (2 days). A relative increase in ICU days was associated with diagnosis according to bronchoscopy (8 days), clinical findings (2 days), or history (2 days). A relative increase in VDs was associated with diagnosis by bronchoscopy (6 days) or carbon monoxide poisoning (3 days). The combination of diagnosis by bronchoscopy and clinical findings increased the relative difference across all comparison measures. The combination of diagnosis by bronchoscopy and carbon monoxide poisoning exhibited decreased relative differences when compared with bronchoscopy alone. Diagnosis by laryngoscopy showed no mortality or association with poor outcomes. Bronchoscopic evidence of inhalation injury proved most useful, predicting increased mortality, hospital, ICU, and VDs. A combined diagnosis determined by clinical findings and bronchoscopy should be considered for clinical practice.

Características dos pacientes que apresentaram queimadura de face em hospital de referência na região amazônica / Características de los pacientes con quemaduras faciales en hospital de referencia en la región amazônica / Characteristics of patients with facial burns in a reference hospital in the Amazon region

Objetivo: Identificar as características dos pacientes que apresentaram queimaduras de face no Centro de Tratamento de Queimados do Hospital Metropolitano de Urgência e Emergência. Método: Estudo de abordagem quantitativa, do tipo observacional, retrospectivo e descritivo. Foram consultados 47 prontuários de internações de agosto de 2010 a maio de 2012 e coletados dados por meio de ficha contendo dados referentes a identificação, história da doença, exames complementares e tempo de internação. Os dados foram analisados por meio de médias, frequência e tabulação das variáveis de interesse. Resultados: O sexo masculino foi o mais acometido, entre a faixa etária de 18 a 40 anos, sendo que 40,4% apresentaram lesão inalatória e a exposição a líquidos inflamáveis como principal agente causador, acarretando em sua maioria lesões de 2º grau e apenas 32% realizaram broncoscopia. A média de internação foi menor que 30 dias, havendo 46 altas e apenas um óbito. Conclusão: Identificou-se que 51% da amostra sofreu lesão inalatória associada à queimadura de face, sendo os adultos jovens do sexo masculino o grupo mais acometido. Tais dados são importantes para o conhecimento da comunidade científica e para que sejam difundidos programas de prevenção a grupos de risco para este tipo de lesão, já que esta é a melhor forma de evitar as queimaduras e suas complicações.

Objective: To identify the characteristics of patients with facial burns at the Burns Treatment Center of the Hospital Metropolitano de Urgência e Emergência. Method: The study was a quantitative approach, observational, retrospective and descriptive. Analyzed 47 medical records during the period from August 2010 to May 2012. Data were collected related to identification, history of the disease, laboratory tests and length of stay, among others. Data were analyzed using mean, frequency and tabulation of the variables of interest. Results: Males were the most affected, between the age group of 18 to 40 years, and 40.4% had inhalation injury having as the main causative agent exposure to flammable liquids, resulting mostly injury 2nd degree and only 32% underwent bronchoscopy. The average hospital stay was less than 30 days, with 46 discharge and only one death. Conclusion: These data are important for understanding the scientific community and that prevention programs are broadcast to risk groups for this type of injury, identified as males, aged 18-45 years, mostly suffered second degree injuries, generating an average hospital stay less than 30 days, with only one death.

Objetivo: Identificar las características de los pacientes con quemaduras del rostro en el Centro de Tratamiento de Quemados del Hospital Metropolitano de Urgência e Emergência. Método: Estudio de abordaje cuantitativo, de tipo observacional, retrospectivo y descriptivo. Fueron analizados 47 archivos médicos de pacientes atendidos entre agosto de 2010 a mayo de 2012, a través de un formulario en el que se recogieron los datos relativos a la identificación, la historia de la enfermedad, las pruebas de laboratorio y tiempo estancia hospitalaria. Realizados análisis descriptivos de media, frecuencia y la tabulación de las variables de interés. Resultados: Los hombres fueron los más afectados, entre el grupo de edad de 18 a 40 años y 40,4% tuvieron lesiones por inhalación después de exposición a líquidos inflamables, siendo este el principal agente causal, lo que resulta sobre todo en lesiones segundo en grado; e sólo el 32% tuvieron que realizar broncoscopía. La estancia media hospitalaria fue de menos de 30 días, con 46 altas y apenas una muerte. Conclusión: Se identificó que el 51% de la muestra sufrió lesiones por inhalación asociado con quemaduras faciales, siendo los adultos jovenes del sexo masculino los más afectados. Estos datos son importantes para la comprensión de la comunidad científica y para que sean difundidos programas de prevención para grupos de riesgo para este tipo de lesiones, ya que esta es la mejor forma de evitar as quemaduras y sus complicaciones.