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Inhalation

Injury
Arek Wiktor M.D.
Burn Fellow
University of Colorado
Hospital
Outline
Background
Smoke
Pathophysiology
Diagnosis
Treatment
Specific Lethal Compounds

http://spanishlakefd.com/firealarms/
Learning Objectives
Describe the pathophysiology of
inhalation injury
How is inhalation injury diagnosed?
What adjunctive measures are used
to treat inhalation injury?
What is the treatment for carbon
monoxide and cyanide poisoning?
A Sunday afternoon stroll thru
the fire

http://www.aeromedix.com/product-exec/parent_id/1/category_id/12/product_id/1074/nm/Safe_Escape_S
Epidemiology
15-30% of burn admissions have
inhalation injury
Independent predictor of mortality,
by 20%
Increases pneumonia risk
Leading diagnosis of those
hospitalized and treated on 9/11,
World Trade Center attack
Anatomic Classification

Upper airway
Lower airway

Systemic toxicity

http://www.monroecc.edu/depts/pstc/backup/parasan4.htm
SMOKE
Variable, changes with time burning
Toxic gases and low ambient oxygen
Ingredients:
Aldehydes (formaldehyde, acrolein), ammonia,
hydrogen sulfide, sulfur dioxide, hydrogen chloride,
hydrogen fluoride, phosgene, nitrogen dioxide, organic
nitriles
Particulate matter

Prien et al. Burns 1988; 14:451-460


Pathophysiology
Cilia loss, respiratory epithelial
sloughing
Neutrophilic infiltration
Atelectasis, occlusion by
debris/edema
Pseudomembranes
Bacterial colonization at 72 hrs

Hubbard et al. J Trauma 1991; 31:1477-1486


Bartley et al. Drug Design,
Development and Therapy. 2008; 2: 916.
Secondary Lung Injury
Unilateral smoke inhalation damages
contralateral lung
Immune response, increased
permeability
Oxygen-derived free radicals
NO mediated damage (chemotactic
factor neuts)
Eiscosanoids (TXA2TXB2)
Reduced phagocytosis in macrophages
Systemic Effects
Larger fluid resuscitation (25cc/kg/
%)
Additive effect to burns
12% pts inhalation injury alone
require intubation*
62% pts burn + inhalation injury
intubated*

Clark et al. J Burn Care Rehabilitation, 1990; 11:121-134


Miller et al. Journal of Burn Care Research. 2009; 30(2)
249-256
Diagnosis
Clinical findings:
Facial burns (96%)
Wheezing (47%)
Carbonaceous sputum (39%)
Rales (35%)
Dyspnea (27%)
Hoarsness (26%)
Tachypnea (26%)
Cough (26%)
Cough and hypersecretion (26%)

DiVincenti et al. Journal of Trauma, 1971; 11:109-117


NO ONE FINDING IS
SUFFICIENTLY
SENSITIVE OR
SPECIFIC!
Must use clinical
judgment!
Tools for Diagnosis

Bronchoscopy
Pulmonary function testing
Xenon133 lung scan
Grades of Inhalation
Injury

Endorf and Gamelli. Journal of Burn Care and Research. 2007; 28:80-
83
Treatments
Airway Control
Chest physiotherapy
Suctioning
Therapeutic bronchoscopy
Ventilatory strategies
Pharmacologic adjuncts
Treatment
Control the
Airway!!!
40% burn
Transport

http://www.burnsurgery.com/Betaweb/Modules/initial/bsinitialsec2.htm
Ventilator Strategies
Airway pressure release ventilation
(APRV)
Intrapulmonary percussive
ventilation (IPV)
High-frequency percussive
ventilation (HFPV)
High frequency oscillatory
ventilation (HFOV)
Single center, prospective randomized
trial 2006-2009
387 pts screened
31 pts HFPV, 31 pts LTV (ARDSnet)

Chung et al. CCM; 2010: 38(10) 1970-1977


Results
No significant difference in mortality or
ventilator free days
Significant difference in Rescue
Therapy
Results
No significant difference in mortality or
ventilator free days
Significant difference in Rescue
Therapy
P/F ratio vs Ventilator
Mode

Chung et al. CCM; 2010: 38(10) 1970-1977


Study Conclusions
Study stopped for safety concerns in
LTV group
Gas exchange goals met in all HFPV
pts, and not in 1/3 of LTV pts
Trend for less barotrauma, less VAP,
less sedation
Strict application of LTV may be
suboptimal in the burn population
Pharmacologic
Intervention

Bartley et al. Drug Design, Development and Therapy. 2008; 2: 916.


Pharmacologic
Intervention

Bartley et al. Drug Design, Development and Therapy. 2008; 2: 916.


Airway Obstructive Casts
Mucus secretions
Denuded airway epithelial cells
Inflammatory cells
Fibrin
-Solidifies airway content
Several studies shown reduction in
size of casts with fibrinolytic agents
(tPA)
Casts

Enkhbaatar et al.,
Theory Behind Inhaled
Heparin
Animals with Burn + ARDS have
decreased levels of antithrombin in
plasma and BAL specimens
Heparin potentiates antithrombin by
2000x
Prevention of fibrin deposition in lungs
Heparin inhibits antihrombins anti-
inflammatory effect - ? systemic rhAT ?
Shriners Protocol
Since 1990 (560+ patients
treated)

Mlcak RP et al. Burns, 2007;33:2-13


Evidence (Pro)
Desai et al. 1998
Pediatric burns (90 pts total)
1985-1989 (43) vs 1990-1994 (47pts)
reintubation, atelectasis, and mortality
Miller et al. 2009
30 patients over 5 years, retrospective review
Tx 10,000 units heparin, 20% NA, 0.5 ml AS q4
hrs
Survival benefit, improved LIS scores, compliance
Number needed to treat 2.73
Evidence (Con)
Holt et al. 2008
Retrospective review 1999-2005, 150 pts total
Burn size, LOS, time on vent, mortality SAME
Only 68% pts had bronchoscopy,
Attending discretion which treatment to use
TOXIC GASES
Carbon Monoxide (CO)
CO from incomplete combustion
CO + Hb COHb (affinity 200-250x)
LEFT shift of oxy-Hb curve (Haldane
effect)
CO binding to intracellular cytochromes
and metalloproteins (myoglobin)
Two compartment pharmacokinetics
Animal experiment 64% COHb transfusion
CO Toxicity Symptoms

Cherry-red lips, cyanosis, retinal


hemorrhage- rare
CNS and Cardiovascular
RR, HR, dysrhythmias, MI, BP, coma,
seizures
Delayed neuropsychiatric syndrome (3-
240d)
Cognitive/personality
changes/parkinsonianism
Spontaneous resolution
Signs and Symptoms

Weaver LK. N Engl J Med 2009;360:1217-25.


CO Toxicity Diagnosis
Pulse oximetry false COHb Symptoms
HIGH SpO2 %
Need cooximetry 0-5 Normal
direct measurement 15-20 Headache,
of COHb confusion,
Older ABG analyzers fatigue
(estimate off dissolved PO2) 20-40 Hallucination,
MRI lesions globus vision s
pallidus/basal 40-60 Combative,
ganglia/deep white coma
matter 60 + Cardiopulmonar
y arrest
CO Toxicity Diagnosis
Pulse oximetry false COHb Symptoms
HIGH SpO2 %
Need cooximetry 0-5 Normal
direct measurement 15-20 Headache,
of COHb confusion,
Older ABG analyzers fatigue
(estimate off dissolved PO2) 20-40 Hallucination,
MRI lesions globus vision s
pallidus/basal 40-60 Combative,
ganglia/deep white coma
matter 60 + Cardiopulmonar
y arrest
CO Toxicity Treatment
OXYGEN
Half-life COHb (min)
RA 100 100%
1ATM % O2 O2 2.5
ATM
Male 240 47 22
Fema 168 33 15
le
Carbogen normobaric, normocapnic,
hyperventilation (4.5-4.8% CO2)
Hyperbaric oxygen???
Cyanide (CN)
Combustion of synthetics (plastics,
foam, varnish, paints, wool, silk)
Binds to cytochrome c oxidase dose
dependent
Uncouple mitochondria
Aerobic anaerobic = Lactic acid
Half-life 1-3 hours
CN Toxicity Symptoms
Dyspnea
Tachypnea
Vomiting
Bradycardia
Hypotension
Giddiness/Coma/Siezures
Death
* The smell of bitter almonds on the breath
suggests exposure (cannot be detected by 60%
of the population)
CN Toxicity Diagnosis
No rapid assay
High lactate (>10mmol/L) (s/s, 87%/94%)

Metabolic acidosis

Elevated mixed venous saturation

(<10% a-v) difference


High index of suspicion

** Also get: COHb and Methemoglobin


levels
CN Treatment

Cyanokit (Hydroxocobalamin)
70mg/kg dose (5g vials)
Combines with cyanide to from
cyanocobalamin (Vit B12)
Red membranes/urine

Hypertension, Anaphylaxis

5% increase COHb, interfere with HD


LFTs/Cr/Fe levels
Cyanide Antidote Kit (CAK)
Amyl nitrite pearls, sodium nitrite, and sodium thiosulfate

Amyl nitrate and sodium nitrate induce


methemoglobin
Methemoglobin+cyanidereleases cyanide from CC
Sodium thiosulfate enhances
cyandidethiocynaterenal excretion
Avoid nitrate portion in pts with inhalation
injury (COHb >10%)
Vasodilation and hypotension
Acquired
Methemolgobinemia
NO2, NO, benzene gases oxidation
of iron
Fe2+ Fe3+
Shift curve to LEFT
Blood Chocolate brown color
Normal PaO2, pulse ox >85%
Tx: Methylene blue (1-2 mg/kg Q
30-60min)
Final Thoughts
Inhalation injury is bad
Support the airway
Frequent bronchoscopy and
monitoring
Different ventilatory strategies
Adjunctive measures need further
investigation
The Toilet Snorkel

http://www.icbe.org/2006/01/18/the-toilet-snorkel/
Thank You!
Learning Objectives
Describe the pathophysiology of
inhalation injury
How is inhalation injury diagnosed?
What adjunctive measures are used
to treat inhalation injury?
What is the treatment for carbon
monoxide and cyanide poisoning?