Inhalation Injury: Unmet Clinical Needs and Future Research

Abstract

Pulmonary and systemic insults from inhalation injury can complicate the care of burn patients and contribute to significant morbidity and mortality. However, recent progress in diagnosis and treatment of inhalation injury has not kept pace with the care of cutaneous thermal injury. There are many challenges unique to inhalation injury that have slowed advancement, including deficiencies in our understanding of its pathophysiology, the relative difficulty and subjectivity of bronchoscopic diagnosis, the lack of diagnostic biomarkers, the necessarily urgent manner in which decisions are made about intubation, and the lack of universal recommendations for the application of mucolytics, anticoagulants, bronchodilators, modified ventilator strategies, and other measures. This review represents a summary of critical shortcomings in our understanding and management of inhalation injury identified by the American Burn Association’s working group on Cutaneous Thermal Injury and Inhalation Injury in 2018. It addresses our current understanding of the diagnosis, pathophysiology, and treatment of inhalation injury and highlights topics in need of additional research, including 1) airway repair mechanisms; 2) the airway microbiome in health and after injury; and 3) candidate biomarkers of inhalation injury.

Microbiome in the setting of burn patients: implications for infections and clinical outcomes

“…It predisposes the patient to secondary pneumonia and acute respiratory distress syndrome and often requires mechanical ventilation [ 41 ]. Currently, very little is known about airway microbiota after burn and inhalation injury [ 42 ].…”

Diagnosis and Management of Inhalation Injuries in U. S. Children

“…У пациентов, как правило, наблюдаются покраснение и припухлость ротоглотки, повышенная секреция слизи в дыхательных путях, появляется мокрота с примесью копоти, осиплость голоса. Это косвенные признаки отека дыхательных путей с последующей их обструкцией [8,9].…”

“…В результате сочетанного воздействия теплового и химического факторов повреждающего агента и возникающих при этом вторичных эффектов возможно прямое повреждение паренхимы легких. Эти механизмы включают в себя: 1) повышение проницаемости сосудистой стенки с последующим отеком легких; 2) альвеолярный коллапс в результате отека легких; 3) повреждение клетки от АФК; 4) обструкция и окклюзия из-за продуктов горения и развившихся отеков; 5) снижение уровня поверхностно-активного вещества (ПАВ) (Поверхностно-акти́вные вещества́ (ПАВ) -химические соединения, которые, концентрируясь на поверхности раздела термодинамических фаз, вызывают снижение поверхностного натяжения); 6) формирование ателектазов; 7) снижение фагоцитоза макрофагами [9,8,13]. Вместе эти процессы способствуют неадекватной вентиляционной перфузии и уменьшению эластичности легких [5,8].…”

Inhalation Injury Is Associated With Endotheliopathy and Abnormal Fibrinolytic Phenotypes in Burn Patients: A Cohort Study

“…Transmission of thermal energy mostly occurs in the supraglottic airway, whereas chemical irritants in smoke affect the lower airways and lung parenchyma. 4 , 7 …”

“…8,9 Several studies have demonstrated high levels of proinflammatory, procoagulant, and antifibrinolytic biomarkers in bronchoalveolar lavage fluid from the respiratory tracts of patients with IHI. 4,8,[10][11][12] IHI has also been shown to induce systemically measurable effects. Davis et al showed that inflammatory plasma cytokines were present early after injury and correlate with injury severity and mortality.…”