Airway Management and Smoke Inhalation Injury in the Burn Patient

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Airway management

The indications for endotracheal intubation in patients who have II include decreased mental status resulting from inhalation of metabolic asphyxiants (see the later discussion in this article) or from other injuries, airway obstruction caused by II or generalized postburn edema, and pulmonary failure resulting from subglottic II. Direct thermal injury to the upper airway (including the larynx, oropharynx, mouth, and tongue) causes edema formation, which may progress to complete airway

Diagnosis of inhalation injury

Before transferring a patient to a burn center, it is sufficient to identify the patient's risk for airway and breathing problems and to protect the airway, and it is not usually necessary to make a definitive diagnosis as to the presence or absence of II. For this purpose, fiberoptic laryngoscopic examination (see the previous discussion in this article), patient history and physical examination, and carboxyhemoglobin levels (if available) are used. The mechanism of injury, signs, symptoms,

Mechanical ventilation

The best mode of mechanical ventilation for patients who have II has not been determined. Although the Lower Tidal Volume Trial (ARMA) conducted by the ARDS Network showed that lower tidal volumes (eg, 6 mL/kg) are associated with improved survival in patients who have acute respiratory distress syndrome (ARDS), the study excluded patients who had burns in excess of 30% of their TBSA.33 There is reason to believe that the ARMA results may not be fully applicable to patients who have II. The

Fluid and pharmacologic therapy

Fluid resuscitation of patients who have II is likely to be difficult. Patients who have isolated II rarely have prodigious fluid resuscitation requirements. It is well known, however, that the addition of II in patients who have cutaneous burns greatly increases the fluid resuscitation requirements during the first 48 hours postburn.43 In one study, patients who were resuscitated using the modified Brooke formula (which advises the use of 2 mL/kg/TBSA burned as the lactated Ringer's dose for

Metabolic asphyxiants

Along with smoke, patients can inhale compounds that impair oxygen delivery to, or use by, the tissues. Chief among these is carbon monoxide, which is produced by the partial combustion of carbon-containing compounds such as cellulosics (eg, wood, paper, coal, charcoal), natural gases (eg, methane, butane, propane), and petroleum products. Carbon monoxide poisoning is a common cause of death at fire scenes53, 54 and is also a leading cause of non–fire-related deaths in the United States.55 In

Burn center referral

The presence of II is one of the American Burn Association criteria for burn center referral.69 Many of the modalities mentioned in this article are not routinely available outside of burn centers, including the expertise of respiratory therapists and other health care professionals who have the experience to provide optimal care to patients who have this highly lethal injury. Certainly, smoke-exposed patients who have an unremarkable physical examination, who show alert mental status, and who

Long-term complications

Plastic surgeons who perform reconstructive surgery for patients who have burns may encounter those with long-term airway and pulmonary complications resulting from II (see Box 1). This is an area about which little has been published.71 Regardless of the route chosen for airway control (and even in the absence of intubation), patients who have II are at risk for long-term glottic, subglottic, and tracheo-bronchial complications from the combination of injury, intubation, infection, and chronic

Summary

II remains a important independent predictor of postburn death.78 Attention to the principles highlighted in this article (eg, aggressive airway management, gentle mechanical ventilation, careful titration of fluid resuscitation, appropriate treatment of carbon monoxide and HCN poisoning, early diagnosis and treatment of pneumonia, early burn center referral, and long-term follow-up) has resulted in a significant reduction in mortality for patients who have II in the time since the 1942

Acknowledgments

The author gratefully acknowledges the assistance of Ms. Gerri Trumbo, Ms. Helen Wessel, and Dr. Corina Moraru in conducting this review.

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      The secondary outcome, hospital-free days till day 30, was also significantly associated with the PDI scores, as shown by a coefficient for fewer hospital-free days of 1.8. Although several investigators have attempted to construct an optimal method for predicting the need for delayed intubation after inhalation injury, no prediction strategy has been validated and accepted across burn centers in different regions [12,19,22,26,27]. A prospective study demonstrated that a 2-h interval between two laryngoscopic examinations was sufficient to predict upper airway compromise in patients with inhalation injury [9], but the observation period was inadequate, inasmuch as airway obstruction can progress until more than 24 h after injury.

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    The opinions or assertions contained herein are the private views of the author, and are not to be construed as official or as reflecting the views of the Department of the Army or Department of Defense.

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