Nebulized heparin and N-acetylcysteine for smoke inhalational injury

Abstract

Rationale:Every year, ∼40,000 people suffer burn-related injuries in the United States. Despite recent advances, the odds of dying from exposure to fire, flames, or smoke are one in ∼1500. Smoke inhalation causes injury to the airways via a complex physiological process, and the treatment is mainly supportive. Many recent interventions aim to decrease the formation of fibrin casts, the main cause of airway damage in these patients. Among these, treatment with a combination of nebulized heparin and N-acetylcysteine (NAC) has shown benefit.Patient concerns:We describe the case of a 58-year-old man who presented after smoke inhalation during a fire. Soot was found in the nostrils when he was admitted to our hospital, and after he began coughing up carbonaceous material, he was electively intubated and placed on volume assist control ventilation.Diagnosis:Bronchoscopy on the first day of intensive care confirmed the injury from smoke inhalation and revealed mucosal edema and soot involving the tracheobronchial tree.Interventions and outcomes:Inhaled unfractionated heparin of 10,000 IU in 3 mL of 0.9% normal saline alternating every 2 hours with 3 mL of 20% NAC was started 48 hours after admission and continued for 7 days. Bronchoscopy on the fifth day of intensive care showed significant improvement in airway edema and a resolution of soot.Lessons:On the basis of our experience with this case and limited literature, we posit that nebulized heparin and NAC may be of benefit in patients with inhalational smoke-induced lung injury and mild-to-severe lung injury scores.

Future Trends in Nebulized Therapies for Pulmonary Disease

“…However, a 2016 meta-analysis provided no convincing evidence for benefit of heparin nebulization in intubated and ventilated ICU patients [149], while others suggest that nebulized heparin, possibly in combination with mucolytics such as N-acetylcysteine (NAC) may be beneficial in reducing mechanical ventilation duration but has no survival benefit in ARDS patients [108]. Heparin combined with NAC showed significant improvement in airway edema and a resolution of soot in patients with inhalational smoke-induced lung injury and mild-to-severe lung injury scores [150]. A recent case study described the use of nebulized NAC as a life-saving mucolytic following failed conventional mucolytic therapy [151].…”

Nebulized Heparin for Post-COVID-19-Related Hypoxia

“…There are no reports of major (or even minor) even with a maximum 120,000 IU unfractionated heparin per day. [6][7][8] The main reason for the long-time hospital stay of our first case was the high need for O 2 (10 L). So, after informing the patient about nebulized UFH trials, she accepted our suggestion.…”

“…These trials were all safe and successful somewhat. [6][7][8] Here, we report two cases of post-COVID-19-related disabling respiratory distress conditions that were treated with nebulized unfractionated heparin administration.…”

The Role of N-acetylcysteine in the Treatment of Accidental Submersion of the Hands in Liquid Nitrogen

“…This patient was administered NAC as recommended by poison control. NAC has been used successfully in the treatment of acetaminophen overdose, smoke inhalation injury, and burns, among other conditions [ 5 , 8 - 9 ]. NAC exerts its healing effects by acting as an antioxidant as well as an inflammatory mediator, making it a reasonable recommendation for conditions where salvage of damaged or at-risk tissues is necessary [ 4 ].…”