Foncerrada G, Culnan DM, Capek KD, González-Trejo S, Cambiaso-Daniel J, Woodson LC, Herndon DN, Finnerty CC, Lee JO, et al.
Annals of plastic surgery. Date of publication 2018 Mar 1;volume 80(3 Suppl 2):S98-S105.
1. Ann Plast Surg. 2018 Mar;80(3 Suppl 2):S98-S105. doi:
10.1097/SAP.0000000000001377.
Inhalation Injury in the Burned Patient.
Foncerrada G, Culnan DM, Capek KD, González-Trejo S, Cambiaso-Daniel J, Woodson
LC, Herndon DN, Finnerty CC, Lee JO.
Inhalation injury causes a heterogeneous cascade of insults that increase
morbidity and mortality among the burn population. Despite major advancements in
burn care for the past several decades, there remains a significant burden of
disease attributable to inhalation injury. For this reason, effort has been
devoted to finding new therapeutic approaches to improve outcomes for patients
who sustain inhalation injuries.The three major injury classes are the following:
supraglottic, subglottic, and systemic. Treatment options for these three
subtypes differ based on the pathophysiologic changes that each one
elicits.Currently, no consensus exists for diagnosis or grading of the injury,
and there are large variations in treatment worldwide, ranging from observation
and conservative management to advanced therapies with nebulization of different
pharmacologic agents.The main pathophysiologic change after a subglottic
inhalation injury is an increase in the bronchial blood flow. An induced mucosal
hyperemia leads to edema, increases mucus secretion and plasma transudation into
the airways, disables the mucociliary escalator, and inactivates hypoxic
vasocontriction. Collectively, these insults potentiate airway obstruction with
casts formed from epithelial debris, fibrin clots, and inspissated mucus,
resulting in impaired ventilation. Prompt bronchoscopic diagnosis and multimodal
treatment improve outcomes. Despite the lack of globally accepted standard
treatments, data exist to support the use of bronchoscopy and suctioning to
remove debris, nebulized heparin for fibrin casts, nebulized N-acetylcysteine for
mucus casts, and bronchodilators.Systemic effects of inhalation injury occur both
indirectly from hypoxia or hypercapnia resulting from loss of pulmonary function
and systemic effects of proinflammatory cytokines, as well as directly from
metabolic poisons such as carbon monoxide and cyanide. Both present with
nonspecific clinical symptoms including cardiovascular collapse. Carbon monoxide
intoxication should be treated with oxygen and cyanide with
hydroxocobalamin.Inhalation injury remains a great challenge for clinicians and
an area of opportunity for scientists. Management of this concomitant injury lags
behind other aspects of burn care. More clinical research is required to improve
the outcome of inhalation injury.The goal of this review is to comprehensively
summarize the diagnoses, treatment options, and current research.
DOI: 10.1097/SAP.0000000000001377
PMCID: PMC5825291 [Available on 2019-03-01]
PMID: 29461292
