Elsevier

Burns

Volume 33, Issue 6, September 2007, Pages 681-692
Burns

Review
Inhalation injury: Pathophysiology and clinical care: Proceedings of a Symposium Conducted at the Trauma Institute of San Antonio, San Antonio, TX, USA on 28 March 2006

https://doi.org/10.1016/j.burns.2006.11.009Get rights and content

Introduction

Despite advances in critical care in general and in mechanical ventilation in particular, inhalation injury continues to impose an unacceptable burden of morbidity and mortality on burn patients. The recent conflict in Iraq has produced an increase in the number of patients with inhalation injury treated here at the U.S. Army Burn Center, and has led to new observations concerning the many complications of inhalation injury such as the risk of laryngeal sequelae. Meanwhile, ongoing research has continued to expand our understanding of the pathophysiology of inhalation injury. In March 2006, we conducted a multidisciplinary conference under the auspices of the Trauma Institute of San Antonio (TRISAT) which was broadcast from this center at the U.S. Army Institute of Surgical Research, via videoteleconference, to our sister institutions, Wilford Hall Medical Center and the University of Texas Health Science Center at San Antonio. Our purpose was to review both current clinical practice and recent laboratory investigations.

Section snippets

Ventilation–perfusion (V/Q) heterogeneity

Attempts to investigate ventilation–perfusion (V/Q) heterogeneity have been made for about 100 years and initially were based on calculations of the pulmonary venous admixture [1] and dead space ventilation [2], and assessment of regional distribution of blood flow and ventilation by radioactive tracer techniques [3], [4]. These methods unveiled considerable information on V/Q relationships, but were limited in resolution both at the lower and upper scales of the V/Q ratios [5].

Multiple Inert Gas Elimination Technique (MIGET)

With the

Oxidants affect the lining fluid of the respiratory tract where antioxidant concentrations vary

As it is currently understood, oxidants, such as inhaled components of smoke, gaseous air pollutants, particulate matter, or other toxicants, react first with the lining fluid that covers the surfaces of the respiratory tract. This lining fluid contains a number of compounds with antioxidant properties, both enzymatic and non-enzymatic, that serve as a major line of defense against oxidative injury [16]. However, the concentrations of these antioxidants vary along the respiratory tract such

Evaluation of CT scan in inhalation injury in an animal model

The presence of inhalation injury is currently diagnosed by bronchoscopy or by xenon lung scan. No method, however, is available for grading the severity of injury. The objective of this study [22] was to evaluate the utility of CT scan in assessing the severity of injury. Twenty anesthetized sheep evenly divided into 4 groups, consisting of controls, mild, moderate, and severe injuries, underwent inhalation of wood bark smoke. After injury, the sheep were mechanically ventilated for 48 h in the

Emergency ventilation with insufflated oxygen (Ian H. Black, MD)

Insufflation of oxygen has been used as a rescue technique for airway obstruction and as an adjunctive technique for acute lung injury (ALI). What is the rationale for tracheal gas insufflation, the efficacy of tracheal gas insufflation, and some of its problems in a clinical setting? Before addressing these questions it is important to clarify some nomenclature. Apneic oxygenation (AO) usually refers to supraglottic airway delivery. Tracheal insufflation of oxygen (TRIO) is either supra- or

Clinical care of patients with inhalation injury (Rubén Gómez, MD, PhD)

This section reviews the clinical care of patients with inhalation injury. Where appropriate, a rating for the quality of evidence is provided. Inhalation injury is present in 8–15% of burn-center admissions [37], was associated with a mean mortality of 56% in two large series [37], [38], and, when suspected, is considered one of the major criteria for burn-center referral according to the American Burn Association and the American College of Surgeons [39]. Inhalation injury below the glottis

Vocal cord paresis in lung injury

We present results of a recent evaluation of the laryngeal sequelae seen in burn patients. Upon request by burn-center surgeons, a total of 52 patients underwent evaluation by a speech pathologist at the U.S. Army Burn Center. Twenty-five of these were diagnosed with vocal-cord paresis. Patients who were intubated overseas (mostly patients from the current conflict in Iraq) had a 4.5-fold increase in the incidence of vocal-cord paresis. In addition, the risk of vocal-cord paresis increased with

Extracorporeal membrane oxygenation (ECMO)

Extracorporeal membrane oxygenation (ECMO) has been available for many years, but is costly and cumbersome. ECMO has a significant complication rate, and is labor- and equipment-intensive. Increasingly, instead of ECMO for the treatment of patients with ARDS, simpler technologies are being proposed. These include intravenous devices such as the Hattler catheter, and extracorporeal devices such as those for arteriovenous CO2 removal (AVCO2R) and the venovenous Paracorporeal Respiratory Assist

Inhalation injury: summary and conclusions (Steven E. Wolf, MD)

Inhalation injury is associated with increased mortality in burn patients [60]. Thus, inhalation injury is often included in multivariate predictors of burn mortality, along with factors such as burn size and age [61]. Clinically, however, the diagnosis of inhalation injury is very difficult. Dr. Park's data summarize what we know from clinical experience: that inhalation injury is readily managed unless the injury is severe, in which case mortality increases substantially [22].

Dr. Gomez gave a

Acknowledgements

The authors gratefully acknowledge Ms. Amy Newland for help in preparing this manuscript, and Ms. Gabrietta Roney and Josie Soliz for transcribing the proceedings.

First page preview

First page preview
Click to open first page preview

References (69)

  • S. Berggren

    The oxygen deficit of arterial blood caused by nonventilating parts of the lung

    Acta Physiol Scand Suppl

    (1942)
  • C. Bohr

    Ueber die Lungenathmung

    Scand Arch Physiol

    (1891)
  • N.A. Dyson et al.

    Studies of regional lung function using radioactive oxygen

    Br Med J

    (1960)
  • W.C.J. Ball et al.

    Regional pulmonary function studied with xenon 133

    J Clin Invest

    (1962)
  • M.P. Hlastala

    Multiple inert gas elimination technique

    J Appl Physiol

    (1984)
  • P.D. Wagner et al.

    Measurement of continuous distributions of ventilation–perfusion ratios: theory

    J Appl Physiol

    (1974)
  • J.B. West

    Pulmonary gas exchange

    Int Rev Physiol

    (1977)
  • T. Shimazu et al.

    Ventilation–perfusion alterations after smoke inhalation injury in an ovine model

    J Appl Physiol

    (1996)
  • G.B. Hubbard et al.

    The morphology of smoke inhalation injury in sheep

    J Trauma

    (1991)
  • A.I. Batchinsky et al.

    Acute respiratory distress syndrome secondary to inhalation of chlorine gas

    J Trauma

    (2006)
  • P.D. Wagner et al.

    Distribution of ventilation–perfusion ratios in dogs with normal and abnormal lungs

    J Appl Physiol

    (1975)
  • R. Markello et al.

    Assessment of ventilation–perfusion inequalities by arterial–alveolar nitrogen differences in intensive-care patients

    Anesthesiology

    (1972)
  • D.R. Dantzker et al.

    Ventilation–perfusion distributions in the adult respiratory distress syndrome

    Am Rev Respir Dis

    (1979)
  • L.C. Cancio

    Current concepts in the pathophysiology and treatment of inhalation injury

    J. Trauma

    (2005)
  • R. Dueck et al.

    Effects of positive end-expiratory pressure on gas exchange in dogs with normal and edematous lungs

    Anesthesiology

    (1977)
  • C.E. Cross et al.

    Environmental oxidant pollutant effects on biologic systems: a focus on micronutrient antioxidant-oxidant interactions

    Am J Respir Crit Care Med

    (2002)
  • M.A. Dubick et al.

    Antioxidant status of bronchoalveolar lavage fluid and lungs from rats subjected to burn and/or smoke inhalation

    Toxicologist

    (1998)
  • M.S. Park et al.

    Assessment of severity of ovine smoke inhalation injury by analysis of computed tomographic scans

    J Trauma

    (2003)
  • L. Gattinoni et al.

    What has computed tomography taught us about the acute respiratory distress syndrome?

    Am J Respir Crit Care Med

    (2001)
  • T. Shimazu et al.

    A dose-responsive model of smoke inhalation injury. Severity-related alteration in cardiopulmonary function

    Ann Surg

    (1987)
  • A. Nahum

    Tracheal gas insufflation as an adjunct to mechanical ventilation

    Respir Care Clin North Am

    (2002)
  • N. Patroniti et al.

    Glottic-modulated lung ventilation during continuous transtracheal gas insufflation: an experimental study

    Crit Care Med

    (2003)
  • A.B. Adams

    Catheters for tracheal gas insufflation

    Respir Care Clin North Am

    (2001)
  • J.J. Jacoby et al.

    Transtracheal resuscitation

    JAMA

    (1956)
  • Cited by (0)

    View full text