The Use of a Simple Three-Level Bronchoscopic Assessment of Inhalation Injury to Predict in-Hospital Mortality and Duration of Mechanical Ventilation in Patients with Burns

Abstract

Major burn centres in Australia use bronchoscopy to assess severity of inhalation injuries despite limited evidence as to how best to classify severity of inhalational injury or its relationship to patient outcomes. All patients with burns who were admitted to the intensive care unit (ICU) at The Alfred Hospital between February 2010 and July 2014 and underwent bronchoscopy to assess inhalational injury, were reviewed. Age, total body surface area burnt, severity of illness indices and mechanisms of injury were extracted from medical histories and local ICU and burns registries. Inhalational injury was classified based on the Abbreviated Injury Score and then grouped into three categories (none/mild, moderate, or severe injury). Univariable and multivariable analyses were undertaken to examine the relationship between inhalational injury and outcomes (in-hospital mortality and duration of mechanical ventilation). One hundred and twenty-eight patients were classified as having none/mild inhalational injury, 81 moderate, and 13 severe inhalation injury. Mortality in each group was 2.3% (3/128), 7.4% (6/81) and 30.7% (4/13) respectively. Median (interquartile range) duration of mechanical ventilation in each group was 26 (11-82) hours, 84 (32-232) hours and 94 (21-146) hours respectively. After adjusting for age, total body surface area burnt and severity of illness, only the severe inhalation injury group was independently associated with increased mortality (odds ratio 20.4 [95% confidence intervals {CI} 1.74 to 239.4], P=0.016). Moderate inhalation injury was independently associated with increased duration of ventilation (odds ratio 2.25 [95% CI 1.53 to 3.31], P <0.001), but not increased mortality. This study suggests that stratification of bronchoscopically-assessed inhalational injury into three categories can provide useful prognostic information about duration of ventilation and mortality. Larger multicentre prospective studies are required to validate these findings.

Treatment of Anaemia in Patients with Acute Burn Injury: A Study of Blood Transfusion Practices

“…These registries provided demographic data, including patient age and sex, mechanism of burn, date of injury, %TBSA burn, intensive care unit (ICU) length of stay, surgical management, and ventilation requirements. The presence and severity of inhalation injury was also extracted from the VABS database, and was diagnosed using a standardized bronchoscopy scoring system based on the abbreviated injury score, as previously reported [ 14 ].…”

Critical care management in burns: a review of current evidence and guidelines - Part 2

“…The place for bronchoscopy and broncho-alveolar lavage in the diagnosis and treatment of inhalational injury was also studied [31,32]. Bronchoscopy allows visualization of the upper airway and proximal parts of lower airways and may be useful in suctioning of debris.…”

“…Bronchoscopy allows visualization of the upper airway and proximal parts of lower airways and may be useful in suctioning of debris. Studies have shown the correlation between bronchoscopy classification of severity of the inhalational injury and in-hospital mortality and duration of the mechanical ventilation [31]. In severe subglottic inhalational injuries, bronchoscopy and pulmonary toileting and nebulization using fibrinolytic and mucolytics were shown to be beneficial [32].…”

A Critical Update of the Assessment and Acute Management of Patients with Severe Burns

“…This is important because inhalational injury confirmed by bronchoscopy and stratified by severity according to the Abbreviated Injury Score has been shown to predict inpatient mortality after a burn. 93 Regression models derived from data based on the clinical examination are used to predict clinical outcomes following a burn. Examples of scores derived from these models include the Baux score, 94 the Zawacki score, 95 the Abbreviated Burn Severity Index, 96 Roi's model, 97 and the Unit Burn Standard Index.…”