Airway Management and Inhalation Injury

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Airway Management and Inhalation Injury

• Richard L. Gamelli, M.D.
• Professor and Chairman
• Department of Surgery
• Director, Burn Shock Trauma Institute
• Chief, Burn Center

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Smoke poisoning inhalation injury
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O2
Pulmonary Injury
CO
CO2
Products of Combustion or Pyrolysis
Smoke
Heat
Toxic Gases
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Risk Factorsfor Inhalation Injury

• Enclosed Space Fire
• Burns of the Head and Neck
• CO gt 15

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Determinants of Injury

• Type concentration of inhalants
• Duration of exposure
• Rate depth of respirations
• Associated injuries

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Injury Classification

• Time post event
• Anatomic location
• Causative agent

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Chemical Damage

• Direct cytotoxicity
• Irritants
• Lower Upper

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Toxic Compounds in House Fire Smoke
Adapted from the American College of Surgeons.
1988-91.
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--- CO ---
Hb Affinity -- CO 200 X O2
O2 Transport 50 with CO 0.1
-- Myoglobin Binding
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CO Poisoning

• O2 Delivery
• Inhibited cellular respiration
• Cardiovascular dysfunction
• Pa O2 O2 Saturation
• Hemoglobin CO Affinity

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Cyanide Poisoning

• Hydrogen Cyanide Rapidly Absorbed
• Cellular Metabolic Inhibition
• Blood Lactate gt 10 mmol/L ? Cyanide Intoxication

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Injury Pattern
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Upper Airway

• Edema
• Erythema
• Ulceration
• Airway obstruction

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Thermal Damage

• gt 150o C
• Upper gt Lower
• Steam vs. Air 40001

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Effect of Edema on AirwayCross-Sectional Area
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Lower Airway

• Edema
• Erythema
• Mucosal Sloughing
• Mucociliary Activity
• Bronchospasm

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Parenchymal Injury

• Endothelial Cell Injury
• Alveolar Cell Injury
• Surfactant Destruction?
• Neutrophil Sequestration
• Oxygen Free Radicals

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Mediators of Lung Injury
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Inhalation Injury
Bronchoconstriction Airway Obstruction
Alveolar Hypoxia
Hypoxic Vasoconstriction
Chemical Irritants
Neutrophil Sequestration
Pulmonary Macrophages

Degranulation
Proteolytic Enzymes
Oxygen Free Radicals
Fibronectin Degradation
Antiprotease Inhibition
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Pathophysiologic Mechanisms

• ? Airway clearance
• Airway obstruction
• ? Bronchial circulation

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Pathophysiologic Mechanisms

• ? Surfactant
• Neutrophil Sequestration

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Asphyxiation

• Lower Airway

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Alcohol and Drugs LUMC
plt0.001, plt0.01, plt0.04 JOT 1995
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Post-Inhalation InjuryComplications
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Pneumonia

• 15 to 60
• of hospitalized burn patients
• with inhalation

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Cumulative Incidence of Pneumonia vs. Days
Intubated
Adapted from the American College of Surgeons.
1968-91.
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Infection
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Factors Associated with the Development of ARDS

• Direct Pulmonary Injury
• Aspiration
• Pneumonia
• Inhaled Toxins
• Smoke, Phosgene, Nitrogen Oxides
• Oxygen Toxicity
• Near Drowning

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Factors Associated with the Development of ARDS

• Systemic Insult
• Sepsis/Bacteremia
• Cutaneous Burn
• Shock
• Hypovolemic, Cardiogenic
• Disseminated Intravascular Coagulation
• Multiple Blood Transfusions
• Drug Toxicity
• Ethchlorvynol, Heroin, Acetylsalicylic Acid
• Pancreatitis
• Fat Embolism

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Management Priorities

• Airway
• 100 FiO2
• Mechanical Ventilation
• Therapeutically
• ? Prophylactically
• Pulmonary Toilet
• -Mucolytics
• -Aerosolized Heparin?
• Fluid Management
• Infection Early Diagnosis and Treatment

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Treatment ProtocolforInhalation Injury
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Minimize Risk of Infection

• Strict adherence to sterile techniques
• Early mobilization and ambulation
• Aggressive debridement of devitalized tissues
• Aggressive pulmonary toilet
• Tracheobronchial suctioning as required
• Frequent chest physiotherapy
• Liberal use of bronchoscopy
• Humidification of inspired air and oxygen
• Thorough decontamination of respiratory equipment
  (Ventilators, etc.)

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Document Infection

• Evaluate the respiratory system
• Identify changes in sputum
• Identify chest radiographic changes
• Bronchoscopic evaluation w/brushings for culture
• BAL
• Serial blood cultures
• Rule out other sources of infection
• Evaluate intravenous sites
• Change indwelling catheters and culture
• Evaluate all cutaneous burn sites
• Maintain high index of suspicion for remote sites

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Antibiotic Therapy

• Directed use for documented infection only or in
  highly suspect clinical circumstance
• Regimen guided by organism sensitivities and
  institutional epidemiology

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Loyola Burn Center-Burn and Trauma Patients
Ventilator Associated PneumoniaJBCR 2006
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Loyola Burn Center-Burn and Trauma Patients
Ventilator Associated PneumoniaJBCR 2006
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Microbial Contamination in Burn Patients
Undergoing Urgent Intubation as Part of Their
Early Airway Management
61 Pathogenic Organisms 17.5 gt100,00 cfus
Loyola Burn Unit Cultures Done within 24 Hours of
Injury n57 Patients
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STERIODS
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Ventilator Management Strategies

• Gentle Lung Ventilation
• Minimize
• Barotrauma
• Volutrauma
• Shear Stress
• Maximize O2 delivery
• Limit Oxygen Toxicity

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PEEP
Alveolar Recruitment
FRC
Intrapulmonary Shunt
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Inverse Ratio Ventilation
Inspiratory Phase (IE lt 1)
auto PEEP
Mean Airway Pressure
s Peak Pressure
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Pressure Controlled Ventilation (/- IRV)
Inspired Gas Flow _at_ Constant Pressure for a Fixed
Portion of Respiratory Cycle
Peak Pressure /- Mean Airway Pressure
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The Metabolic Cost of Inhalation Injury

• Basal Energy Expenditure
• Inhalation Injury 134?5
• Burn Only 144?3
• Inhalation Injury Burn 147?4
• 
  Breznak, et al
• 
  ABA 2004

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Influence of Inhalation Injury on Resting
Expenditure in Severely Burned Children(gt 40
TBSA Burn)

• Burn vs. Burn Inhalation Injury
• At Admission
• Day 7 Post Burn
• At Discharge
• ?
• REE and O2 Consumption
• 
  Fram et al
• 
  ABA
  2006

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Enteral Nutrition with EPA, ?-Linolenic Acid, and
Antioxidants in Patients with ARDS

• Reduction in Alveolar Inflammatory Mediators and
  Protein Influx
• ? IL-8 and LTB4 in BAL fluid
• ? Membrane Protein Permeability and BAL
  Ceruloplasmin at Day 4
• ? BAL Fluid PMN Count
• ? PaO2/FiO2 Ratio
• Pacht
  et al Crit Care Med 2003

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Effects of Enteral Feeding with EPA Acid, ?-
Linolenic Acid and Antioxidants in Ventilated
Patients with Sepsis
Kaplan-Meier Curve of Survival Days 1-28

Pontes-Arruda al Crit Care Med 2006
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Oxygenation Status of Septic Patients Fed an
Enteral Diet Enriched with EPA and ?- Linolenic
Acid
Pontes-Arruda et al Crit Care Med 2006
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Ventilator Free Days in Septic Patients Fed a
Diet with EPA Acid, ?- Linolenic Acid and
Antioxidants
Number of Ventilator-Free Days 1-28
Mean ? SE Pontes-Arruda
Crit Med 2006
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ICU Free Days in Septic Patients Fed a Diet with
EPA Acid, ?- Linolenic Acid and Antioxidants
ICU-Free Days Mean
SE Days 1-28

Pontes-Arruda Crit Care Med 2006
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Organ Failure in Septic Patients Fed EPA Acid, ?-
Linolenic Acid and Antioxidants

Pontes-Arruda Crit Care Med 2006
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Evaluation of an Anti-inflammatory Enteral
Formula in the Treatment of Pediatric Burn
Patients with Respiratory Failure

Mayes et al NCP 2005
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Effect of Fish Oil and Arginine in Thermally
Injured PatientsWibbenmeyer et al JBCR 2006

• FAD Faster Healing Times vs Standard Diet
• Infectious Complications
• 11 in 7 Standard Patients (1 Patient
  Inhalation/ARDS)
• 2 Pneumonias - time to Pneumonia 6.01.4 days
• 18 in 9 FAD Patients (3 Patients Inhalation/ARDS)
• 5 Pneumonias - time to Pneumonia 3.81.6 days

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Airway Management

• Endotracheal Intubation
• Tracheostomy

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Centers Use of Cuffed Endotracheal TubesSilver
et al JBCR 2004
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Length of Time on Ventilator before Tracheostomy
Silver et al JBCR 2004
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Frequency of Tracheostomy Silver et al JBCR 2004
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Tracheostomy
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Tracheostomy
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Tracheostomy

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Long Term Sequale

• Tracheal stenosis Intubation ???
• Bronchiectasis - Bronchial Dilatation
• Bronchiolitis obliterans Bronchiolar
  obliteration
• Nitrogen Oxides, Hydrogen Chloride, Sulfur
  Dioxide, Chlorine
• Ammonia, Phosgene,
• Endobronchial Polyposis

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Inhalation InjuryImpact on Burn Mortality
TBSA
Inhalation Injury
Mortality
Age