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Management of Inhalation Injury and Respiratory Complications in Burns Intensive Care Unit

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Management of Inhalation Injury and Respiratory Complications in Burns Intensive Care Unit Turkish Journal of Trauma & Emergency Surgery Ulus Travma Acil Cerrahi Derg 2012;18 (4):333-338 Original Article Klinik Çalışma doi: 10.5505/tjtes.2012.09735 Management of inhalation injury and respiratory complications in Burns Intensive Care Unit Yanık yoğun bakım ünitesinde inhalasyon yaralanması ve solunum komplikasyonlarının yönetimi Afife Ayla KABALAK, Ahmet Çınar YASTI BACKGROUND AMAÇ Inhalation injury has high mortality and carries a signifi- İnhalasyon yaralanması yüksek mortalite oranlarına sahip- cant risk of permanent pulmonary dysfunction. Inhalation tir ve belirgin kalıcı pulmoner fonksiyon bozukluğu ris- injury and its consequences impose difficulties for the re- ki taşımaktadır. İnhalasyon yaralanması ve sonuçları, kli- spiratory therapists, nurses and doctors who play a central nik yönetiminde ana rol oynayan solunum terapistlerine, role in its clinical management. In this study, we aimed to hemşirelere ve doktorlara ciddi zorluklar oluşturur. Çalış- report our clinical experience and the role of non-invasive mamızda inhalasyon yaralanmalı hasta serimizdeki klinik mechanic ventilatory (NIMV) support in a series of inhala- tecrübelerimizi ve noninvazif mekanik ventilatör (NIMV) tion-injured patients. desteğinin rolünü bildirmeyi amaçladık. METHODS GEREÇ VE YÖNTEM Patients hospitalized at Ankara Numune Training and Ankara Numune Eğitim ve Araştırma Hastanesi Yanık Yo- Research Hospital’s Burns Intensive Care Unit between ğun Bakım Ünitesi’nde Mart 2009 - Mart 2011 yılları ara- March 2009 and March 2011 was reviewed, and patients sında yatarak tedavi alan hastalardan inhalasyon hasa- with required respiratory support due to inhalation injury rı nedeniyle solunum desteğine ihtiyaç duyanlar çalışma- were included in the study. ya alındı. RESULTS BULGULAR Among the patients, 37 had inhalation injury, and their Bu hastaların 37’sinde inhalasyon yaralanması vardı, mor- mortality was 13.5%. Of the 37 patients, 16 had manda- talite oranı %13,5 olarak bulundu, hastaların 16’sında zo- tory intubation (6 in the first 6 hours and 10 in the clinical runlu entübasyon uygulanırken (altı hastada ilk 6 saatte ve course); however, others (67.8%) had only NIMV sup- 10 hastada klinik seyir sürecinde) diğer hastalara sadece port. (%67,8) NIMV desteği uygulandı. CONCLUSION SONUÇ Application of NIMV support with proper modes decreases NIMV desteğinin uygun modlarda uygulanması, inhalas- the need for invasive procedures in inhalation-injured pa- yon yaralanmalı olgularda invaziv yöntemlerin gerekliliği- tients. Based on our results, we propose the application of ni azaltmaktadır. NIMV desteğinin inhalasyon yaralanmalı NIMV support in inhalation-injured burn patients. yanık hastalarında uygulanmasını önermekteyiz. Key Words: Inhalation injury; medical treatment; respiratory Anahtar Sözcükler: İnhalasyon yaralanması; medikal tedavi; so- management; ventilatory support. lunum yönetimi; ventilatör desteği. Burns Treatment Center, Ankara Numune Eğitim ve Araştırma Hastanesi Ankara Numune Training and Research Hospital, Ankara, Turkey. Yanık Tedavi Merkezi, Ankara. Correspondence (İletişim): Afife Ayla Kabalak, M.D. Ankara Numune Hastanesi, Anesteziyoloji ve Reanimasyon Kliniği, Sıhhiye 06030 Ankara, Turkey. Tel: +90 - 312 - 508 42 29 e-mail (e-posta): [email protected] 333 Ulus Travma Acil Cerrahi Derg Inhalation injury is very common in patients who chest radiography, and serial fiberoptic bronchoscopy sustain burns and it has high morbidity and mortal- in all cases. Indication for the endotracheal intubation ity rates. Even isolated inhalation injury can carry a and ventilation and PaO2/FiO2 values of the patient just significant risk of mortality or permanent pulmonary prior to institution of invasive positive pressure ven- dysfunction. When combined with cutaneous burns, tilation (IPPV) and/or non-invasive positive pressure inhalation injury increases fluid requirements for re- ventilation (NIPPV) were noted. The cause of respira- suscitation,[1] the incidence of pulmonary complica- tory failure, ventilator modes, pressures, and whether tions,[2] and the mortality rate.[2-4] intubation/re-intubation was done were also recorded. The diagnosis of pneumonia was made regarding pres- Inhalation injury is produced by either thermal or ence of hyperthermia (>38.2°C), leukocytosis (white chemical irritation due to inspiration of smoke, burn- blood cells [WBC] >15x109/L), positive sputum cul- ing embers, steam, or other irritant or cytotoxic mate- tures, and radiographic identification of infiltrates. rials in the form of fumes, mists, particulates, or gases. [3,5,6] The damage can be the result of direct cytotoxic IPPV and NIPPV were delivered using Nellcor effects of the aspirated materials or a consequence of Prutan Bennett 840 ventilators. The BiLevel Positive the inflammatory response. In addition to damage to Airway Pressure+Pressure Control mode with timed the airways and pulmonary parenchyma, inhalation of cycling (BiLevel+PC) was used for IPPV. Bilevel+PC toxic substances such as carbon monoxide or cyanide ventilation provides two ventilatory pressures: The can produce detrimental systemic effects.[7,8] Inspiratory Positive Airway Pressure (PEEPhigh) and In recent decades, there has been a dramatic de- the Expiratory Positive Airway Pressure (PEEPlow). cline in the mortality of large burns. In contrast, de- Pressure support ventilation has been shown to spite considerable advances in our knowledge of the improve tidal volume, gas exchange, respiratory rate, pathophysiology of inhalation injury, there are few and diaphragmatic activity in proportion to the amount specific therapeutic options, and patient care is mainly of pressure supplied. The Continuous Positive Airway supportive. Although several studies have suggested a Pressure (CPAP) ventilation mode was used for NIP- decrease in the mortality associated with inhalation in- PV at spontaneous breathing. CPAP prevents or helps jury, these changes would result from overall improve- re-open collapsed alveoli and atelectasis of lung zones ments in care and not so much from interventions and is often used to facilitate weaning. aimed specifically at inhalation injury. It is imperative NIPPV was applied to patients who were hemo- that a well-organized, protocol-driven approach to re- dynamically stable, conscious and alert. IPPV is the spiratory management of burn care be utilized so that choice of procedure at endotracheal intubation to pro- improvements can be made, and the morbidity and tect the airway (large facial burn, obstructive airway mortality associated with inhalation injury can be re- edema) or to remove excessive tracheobronchial se- duced. cretions or in case of large facial burn. Evidence of The goal of this study was to assess whether early acute respiratory failure had to be exhibited by the pa- application of non-invasive mechanical ventilation tient, and this was defined as acute hypoxemia where (NIMV), medical treatment, respiratory physiothera- the PaO2/FiO2 ratio was ≤40 kPa. This value is part of py, and nutritional support is effective in a series of the definition for an acute lung injury (ALI). inhalation-injured patients. The pressures for NIPPV (CPAP) set on the ven- MATERIALS AND METHODS tilator were kept low initially (Ppeak = 8-10 cmH2O, PEEP = 8 cmH O). NIPPV was used every 2 hours The medical records of all patients with inhalation 2 (h) for 15-minute (min) periods. Most patients were injury hospitalized at the Ankara Numune Training and allowed to remove their masks for a few minutes for Research Hospital, Burn Treatment Center between 1 talking, mobilization or in some cases to drink small March 1 2009 and 1 March 2011 were reviewed. A to- amounts of water. tal of 697 patients were hospitalized, and of them, 234 were inpatients in the intensive care unit (ICU) of the The pressures for IPPV (BiLevel + PC) set on the Burns Center. Of the ICU patients, 97 required respi- ventilator were low initially (PEEP high: PEEP low + ratory support due to acute respiratory failure. While Psupport = 10-12 cmH2O, PEEP low = 4-6 cmH2O). inhalation injury was the diagnosis in 37 patients, oth- The pressures were titrated upwards according to the ers had secondary pulmonary damage, acute respirato- patient’s tolerance and arterial blood gas results (the ry distress syndrome (ARDS), sepsis, and multi-organ maximum pressures used were PEEP high: PEEPlow failure on their first admission to hospital. + Psupport = 23 cmH2O, PEEP low = 8 cmH2O). Inhalation injury was documented based on history, All patients received chest physiotherapy while on physical findings, arterial blood gas monitoring, serial NIPPV and IPPV to assist expectoration of secretions 334 Temmuz - July 2012 Management of inhalation injury and respiratory complications in Burns Intensive Care Unit and reversal of atelectasis, twice daily in routine prac- Table 1. Demographics and clinical course of tice and additionally where required. A saline nebuliz- the patients er was in the circuit and, if prescribed, bronchodilator, heparin, N-acetylcysteine (NAC), and corticosteroid Variable Patients was given. Bed positions were changed frequently in Number of patients 37 all patients. Fluid-electrolyte replacement, intravenous Age (mean, in year) 41.38 (range: 21-76) vitamin C and nutritional support with a high content Female/Male 4/27 of protein were performed in all patients. TBSA (mean %) 28.2 (range: 18-54) Facial burns (extensive/mild) 6/21 Age, sex, burned total body surface area (TBSA), Burns surgery
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