Intubación orotraqueal en el trauma por quemaduras en Uruguay: rol de la intubación profiláctica / Orotracheal intubation in burn trauma in Uruguay: the role of prophylactic intubation / Intubação orotraqueal no trauma por queimaduras no Uruguai: papel da intubação profilática

Introducción: La Intubación orotraqueal (IOT) profiláctica en pacientes con sospecha de Injuria Inhalatoria (II) es una práctica clínica extendida en nuestro país. La misma puede estar asociada a complicaciones y a un aumento de los costos asistenciales. Objetivo: caracterizar a la población de pacientes que ingresaron con IOT al Centro Nacional de Quemados, determinar la incidencia de Intubación orotraqueal no necesaria (IOTNN) así como las complicaciones vinculadas a la misma. Método: Estudio retrospectivo, observacional, analítico. Se incluyeron todos los pacientes con quemadura térmica ingresados al CENAQUE con vía aérea artificial entre enero de 2015 y julio 2023. Se determinaron características demográficas, circunstancias de la injuria, lugar y técnico que realizo la IOT, porcentaje de superficie corporal total quemada (SCTQ), scores de severidad, días de ARM, estado al alta y diagnóstico de II por fibrobroncoscopía. Se analizaron las complicaciones asociadas a la IOT y ARM. Dichas variables fueron contrastadas entre el grupo extubado exitosamente en las primeras 48 horas (IOTNN) y aquellos extubados luego de las 48 horas (IOTP). Resultados: Se incluyeron 562 pacientes. La incidencia de IOTNN fue 41,7% e II 46,7%. Se observaron diferencias significativas entre IOTNN y IOTP para edad [34 (24-48) versus 45 (30-62); p <0,001, para SCTQ [4% (1-11) versus 20% (6-36); p <0,001], ABSI [4 (3-5) versus 7 (5-9) p<0,001], Rev. Baux [48 (33-62) versus 77 (60-99), p <0,001], incidencia de II (32% versus 56,6%, p <0,001). La aspiración de VA (30% versus 20,2% p 0,018), extubación durante el traslado (2% versus 0% p 0,043) e incidencia de NA (Neumonía aspirativa) y NAVP (neumonía asociada a la ventilación mecánica precoz) (56,3% versus 15% p <0,001) fueron mayores en el grupo IOTP. Conclusiones: La IOTNN en los pacientes con quemaduras es frecuente en nuestro medio y se asocia a complicaciones. La misma es realizada por médicos sin formación en el manejo de la vía aérea.

Introduction: Prophylactic Orotracheal Intubation (OTI) in patients with suspected Inhalation Injury (II) is a widespread clinical practice in our country. It can be associated with complications and increased healthcare costs. Objective: To characterize the population of patients admitted with OTI to the National Burn Center, determine the incidence of unnecessary Orotracheal Intubation (UOTI), and the associated complications. Method: Retrospective, observational, analytical study. All patients with thermal burns admitted to the National Burn Center (CENAQUE) with an artificial airway between January 2015 and July 2023 were included. Demographic characteristics, injury circumstances, location, and technician performing the OTI, percentage of total body surface area burned (TBSA), severity scores, days on mechanical ventilation, discharge status, and diagnosis of II by fibrobronchoscopy were determined. Complications associated with OTI and mechanical ventilation were analyzed. These variables were compared between the group extubated successfully within the first 48 hours (UOTI) and those extubated after 48 hours (necessary OTI, NOTI). Results: 562 patients were included. The incidence of UOTI was 41,7% and II 46,7%. Significant differences were observed between UOTI and NOTI in age [34 (24-48) versus 45 (30-62); p <0.001], TBSA [4% (1-11) versus 20% (6-36); p <0,001], ABSI [4 (3-5) versus 7 (5-9) p<0,001], Baux score [48 (33-62) versus 77 (60-99), p <0,001], incidence of II (32% versus 56.6%, p <0,001). Aspiration of the airway (30% versus 20,2% p 0,018), extubation during transport (2% versus 0% p 0,043), and incidence of aspiration pneumonia (AP) and early ventilator-associated pneumonia (VAP) (56,3% versus 15% p <0,001) were higher in the NOTI group. Conclusions: UOTI in burn patients is frequent in our setting and is associated with complications. It is performed by physicians without training in airway management.

Introdução: A intubação orotraqueal (IOT) profilática em pacientes com suspeita de lesão por inalação (LI) é uma prática clínica difundida em nosso país. Esta prática pode estar associada a complicações e ao aumento dos custos assistenciais. Objetivo: Caracterizar a população de pacientes que ingressaram com IOT no Centro Nacional de Queimados, determinar a incidência de intubação orotraqueal desnecessária (IOTD) e as complicações associadas. Método: Estudo retrospectivo, observacional, analítico. Foram incluídos todos os pacientes com queimadura térmica admitidos no CENAQUE com via aérea artificial entre janeiro de 2015 e julho de 2023. Foram determinadas características demográficas, circunstâncias da lesão, local e técnico que realizou a IOT, porcentagem da superfície corporal total queimada (SCTQ), escores de gravidade, dias de ventilação mecânica, estado na alta e diagnóstico de LI por fibrobroncoscopia. Complicações associadas à IOT e à ventilação mecânica foram analisadas. Essas variáveis foram comparadas entre o grupo extubado com sucesso nas primeiras 48 horas (IOTD) e aqueles extubados após 48 horas (IOTP). Resultados: Foram incluídos 562 pacientes. A incidência de IOTD foi de 41,7% e LI de 46,7%. Diferenças significativas foram observadas entre IOTD e IOTP em relação à idade [34 (24-48) versus 45 (30-62); p <0,001], SCTQ [4% (1-11) versus 20% (6-36); p <0,001], ABSI [4 (3-5) versus 7 (5-9) p<0,001], índice de Baux [48 (33-62) versus 77 (60-99), p <0,001], incidência de LI (32% versus 56,6%, p <0,001). A aspiração de via aérea (30% versus 20,2% p 0,018), extubação durante o transporte (2% versus 0% p 0,043) e incidência de pneumonia aspirativa (PA) e pneumonia associada à ventilação mecânica precoce (NAVM) (56,3% versus 15% p <0,001) foram maiores no grupo IOTP. Conclusões: A IOTD em pacientes com queimaduras é frequente em nosso meio e está associada a complicações. A mesma é realizada por médicos sem formação no manejo da via aérea.

Epidemiologia de queimaduras na face em pacientes internados em hospital de referência em queimados / Epidemiology of facial burns in patients admitted to a burn referral hospital

OBJETIVO: Este estudo tem como objetivo descrever o perfil epidemiológico de pacientes vítimas de queimaduras da face em um unidade de referência em atendimento em queimaduras. MÉTODO: O trabalho consiste no estudo de dados observacional, descritivo, retrospectivo, de uma população de 92 pacientes vítimas de queimaduras na região da face, internados em hospital de referência em atendimento a pacientes vítimas de queimaduras, no período de 2 anos, entre julho de 2015 e junho de 2017. Foram analisados dados como: idade, sexo, agente etiológico, áreas de superfície corporal queimada, profundidade da queimadura, regiões do corpo acometidas pela queimadura, óbito, queimaduras de vias inalatórias, tempo de internação em unidade de terapia intensiva de queimados e tempo de internação hospitalar. Os dados foram tabulados e descritos no texto. RESULTADOS: Dos 92 pacientes atendidos, a maioria (61,95%) foi do sexo masculino, havendo quatro óbitos, dos quais três apresentavam lesão inalatória, com período de maior prevalência no outono. Tempo de internação médio foi de 20,5 dias, sendo o agente mais comum o álcool, atingindo, em média, 13%, a maioria com queimadura profunda. CONCLUSÃO: Os pacientes vítimas de queimaduras em face são em sua maioria do sexo masculino, com agente etiológico álcool, com média de queimadura profunda de 13%, estando o óbito relacionado com associação de lesão de vias aéreas. Ações de prevenção podem ajudar a diminuir a incidência de acidentes na população observada.

OBJECTIVE: This study aims to describe the epidemiological profile of patients victims of facial burns in a referral unit in care for burns. METHODS: The work consists of the study of observational, descriptive, retrospective data from a population of 92 patients suffering from burns in the face region, admitted to a reference hospital in care of burn victims, in a period of 2 years, between July 2015 and June 2017. Data such as: age, sex, etiological agent, burnt body surface areas, burn depth, body regions affected by the burn, death, inhaled tract burns, length of stay in the therapy unit were analyzed intensive care unit for burns and length of hospital stay. Data were tabulated and described in the text. RESULTS: Of the 92 patients, the majority (61.95%) were male, with four deaths, three of which had inhalation injury, with a period of greatest prevalence in autumn. Average hospital stay was 20.5 days, the most common agent being alcohol, reaching an average of 13%, with the majority with deep burns. CONCLUSION: Patients suffering from facial burns are mostly male, with alcohol as the etiologic agent, with an average deep burn of 13%, and death is related to an association with airway injury. Prevention actions can help to reduce the incidence of accidents in the observed population.

Principais complicações respiratórias no adulto queimado internado em um hospital de referência do estado de Minas Gerais / Main respiratory complications in burned adult in a reference hospital of Minas Gerais State / Principales complicaciones respiratorias de los adultos quemados admitidos a un hospital de referencia del estado de Minas Gerais

OBJETIVO: Descrever as principais complicações respiratórias do adulto queimado admitido em um centro de terapia intensiva de um hospital de referência do estado de Minas Gerais. MÉTODO: Estudo transversal, no qual foram incluídos todos os pacientes admitidos no setor de terapia intensiva da Unidade de Tratamento de Queimados de 1º de janeiro a 30 de junho de 2017 deste hospital. Os dados coletados foram submetidos à análise estatística com o uso do software Microsoft® Office Excel 2010 e pelo Minitab® versão 18. O estudo foi aprovado no Comitê de Ética em Pesquisa da Instituição, com parecer número 2.698.566. RESULTADOS: Foram analisados 62 registros de pacientes, a maioria do sexo masculino (64,52%, n=40). A média de idade dos pacientes foi de 43,90±16,57 anos, sendo a faixa etária mais prevalente entre 18 e 34 anos (35,48%, n=22). A maior parte dos pacientes necessitou de suporte avançado de vida, sendo que 74,20% (n=46) foram submetidos à intubação orotraqueal e, destes, 50% (n=23) foram traqueostomizados posteriormente. As complicações respiratórias foram observadas em 51,61% (n=32), sendo as principais: pneumonia (25,81%, n=16), lesão de via aérea (24,19%, n=15), atelectasia (17,74%, n=11), congestão pulmonar (12,90%, n=8) e síndrome do desconforto respiratório agudo (8,06%, n=5). CONCLUSÃO: As principais complicações respiratórias foram pneumonia e lesão de via aérea. Tais complicações contribuíram para maior tempo de internação hospitalar e de ventilação mecânica.

Objective: To describe main pulmonary complications in burned adults admitted to intensive care unit of a burn center of Minas Gerais State. METHODS: Cross-sectional study, which included all patients admitted to the intensive care unit of a burn unit, from January, 1st until June, 30th. Collected data were submitted to statistical analyzes using software Microsoft® Excel 2010 and Minitab® version 18. The study was approved by Research Ethics Committee of the institution, with opinion number 2698566. RESULTS: 62 patients records were analyzed, most male (64.52%, n=40), mean age of patients was 43.90±16.57 years, being most prevalent age group between 18 and 34 years (35.48%, n=22). Most patients needed advanced life support, 74.20% (n=46) used endotracheal tube and, of these, 50% (n=23) were tracheostomized later. Pulmonary complications were observed in 51.61% (n=32), and the main ones were: pneumonia (25.81%, n=16), airway injury (24.19%, n=15), atelectasis (17.74%, n=11), pulmonary congestion (12,90%, n=8) and acute respiratory distress syndrome (8.06%, n=5). CONCLUSION: Main pulmonary complications were pneumonia and airway injury. Such complications have contributed to increase time of hospitalization and mechanical ventilation.

Objetivo: Describir las principales complicaciones respiratorias de los adultos quemados admitidos en el centro de cuidados intensivos de un hospital de referencia del estado de Minas Gerais. Método: Estudio transversal, que incluyó a todos los pacientes ingresados en el sector de cuidados intensivos de la Unidad de Quemados de este hospital, del 1º enero hasta 30 junio de 2017. Los datos recolectados fueron sometidos al análisis estadístico utilizando los programas Microsoft® Office Excel 2010 y por Minitab® versión 18. El estudio fue aprobado por el Comité de Ética de Investigación de la institución - dictamen nº 2.698.566. Resultados: 62 pacientes participaron del estudio, en su mayoría hombres (64,52%, n=40), con media de edad de 43,90±16.57 años, siendo más prevalente el grupo de edad comprendido entre 18 y 34 años (35,48%, n=22). La mayoría de los pacientes necesitó apoyo vital avanzado, conun 74,20% (n=46) sometidos a intubación orotraqueal y, de estos, 50% (n=23) fueron traqueostomizados posteriormente. Se observaron complicaciones respiratorias en un 51,61% (n=32) de los pacientes, siendo las principales: neumonía (25,81%, n=16), lesiones de las vías respiratorias (24,19%, n=15), atelectasia (17,74%, n=11), congestión pulmonar (12,90%, n= 8) y síndrome de dificultad respiratoria aguda (8,06%, n=5). Conclusión: Las principales complicationes respiratorias fueron neumonía y lesiones de las vías respiratorias. Tales complicaciones han contribuido a estancias más largas en el hospital y utilización de ventilación mecánica.

A Case Report of Emergency Cricothyroidotomy Due to Tracheal Intubation Failure in the Patient with Posterior Glottic Stenosis Due to Inhalation Burn / 계명의대학술지

Injuries of the larynx are common in patients with a history of inhalation burns. When anesthesia is performed in such patients, the possibility of tracheal intubation should be thoroughly checked in advance, and preparation should be made in case of possible failure. 73-year-old woman who underwent laser cordotomy due to posterior glottic stenosis due to inhalation burn. Her height and weight were 140 cm and 58.9 kg. We proceeded anesthesia, because preoperative fiberoptic laryngoscopy and otolaryngology consultation showed that tracheal intubation was possible. However, the intubation failed and the manual ventilation was not performed afterwards, so the cricothyroidotomy was performed as an emergency. Anesthesia in patients with posterior glottic stenosis due to inhalation burns requires a great deal of attention and, above all, thorough evaluation in order to confirm the possibility of tracheal intubation. If this is not possible, you should look for alternatives and be prepared, and even if you think it's possible, try anesthesia with thorough preparation for the possible failure.

National experts consensus on clinical diagnosis and treatment of inhalation injury (2018 version) / 中华烧伤杂志

Inhalation injury is caused by inhalation of heat, toxic or irritating gases which lead to respiratory and pulmonary parenchyma damage. At present, the clinical understanding about it is still limited and lack of effective diagnosis and treatment standard. Based on the experience of diagnosis and treatment of domestic inhalation injury, combined with reports of international researches, criteria (expert consensus) for inhalation injury were systematically discussed from pathological and pathophysiological changes, clinical diagnosis and evaluation, and clinical treatment, which provides reference for clinical diagnosis and treatment of patients inflicted with inhalation injury.

National experts consensus on clinical diagnosis and treatment of inhalation injury (2018 version) / 中华烧伤杂志

Inhalation injury is caused by inhalation of heat, toxic or irritating gases which lead to respiratory and pulmonary parenchyma damage. At present, the clinical understanding about it is still limited and lack of effective diagnosis and treatment standard. Based on the experience of diagnosis and treatment of domestic inhalation injury, combined with reports of international researches, criteria (expert consensus) for inhalation injury were systematically discussed from pathological and pathophysiological changes, clinical diagnosis and evaluation, and clinical treatment, which provides reference for clinical diagnosis and treatment of patients inflicted with inhalation injury.

Anesthetic management with extracorporeal membrane oxygenation in a patient with acute airway obstruction after inhalation burn injury: A case report

A 36-year-old woman was admitted to the intensive care unit because of an inhalation burn injury. Five days after admission, she developed dyspnea and hypercarbia. Therefore, fiberoptic bronchoscopy was performed through the endotracheal tube, which revealed foreign bodies in the tube. Tracheostomy was performed to remove, albeit incompletely, the foreign bodies (endotracheal debris). As sudden movement of the patient or airway reaction could cause the foreign bodies to move deeper into the bronchus during manipulation of the rigid bronchoscope, general anesthesia was induced and maintained by using total intravenous anesthesia with extracorporeal membrane oxygenation (ECMO). The foreign bodies were successfully removed without any other complications. This case showed that sloughed endobronchial debris after an inhalation burn injury caused acute airway obstruction. In such cases, alternative ventilation methods such as tracheostomy and ECMO may have to be applied, which can support a surgeon to focus on the procedure regardless of prolonged procedural time.

Advances in the research of pathogenesis and treatment of severe smoke inhalation injury / 中华烧伤杂志

Among the fire victims, respiratory tract injury resulted from smoke inhalation is the major cause of death. Particulate substances in smoke, toxic and harmful gas, and chemical substances act together would rapidly induce the occurrence of dramatic pathophysiologic reaction in the respiratory tract, resulting in acute injury to the respiratory tract, thus inducing serious injury to it and acute respiratory distress syndrome, leading to death of the victims. In recent years, the pathophysiologic mechanism of severe smoke inhalation injury has been gradually clarified, thus appreciable advances in its treatment have been achieved. This paper is a brief review of above-mentioned aspects.

Características dos pacientes que apresentaram queimadura de face em hospital de referência na região amazônica / Características de los pacientes con quemaduras faciales en hospital de referencia en la región amazônica / Characteristics of patients with facial burns in a reference hospital in the Amazon region

Objetivo: Identificar as características dos pacientes que apresentaram queimaduras de face no Centro de Tratamento de Queimados do Hospital Metropolitano de Urgência e Emergência. Método: Estudo de abordagem quantitativa, do tipo observacional, retrospectivo e descritivo. Foram consultados 47 prontuários de internações de agosto de 2010 a maio de 2012 e coletados dados por meio de ficha contendo dados referentes a identificação, história da doença, exames complementares e tempo de internação. Os dados foram analisados por meio de médias, frequência e tabulação das variáveis de interesse. Resultados: O sexo masculino foi o mais acometido, entre a faixa etária de 18 a 40 anos, sendo que 40,4% apresentaram lesão inalatória e a exposição a líquidos inflamáveis como principal agente causador, acarretando em sua maioria lesões de 2º grau e apenas 32% realizaram broncoscopia. A média de internação foi menor que 30 dias, havendo 46 altas e apenas um óbito. Conclusão: Identificou-se que 51% da amostra sofreu lesão inalatória associada à queimadura de face, sendo os adultos jovens do sexo masculino o grupo mais acometido. Tais dados são importantes para o conhecimento da comunidade científica e para que sejam difundidos programas de prevenção a grupos de risco para este tipo de lesão, já que esta é a melhor forma de evitar as queimaduras e suas complicações.

Objective: To identify the characteristics of patients with facial burns at the Burns Treatment Center of the Hospital Metropolitano de Urgência e Emergência. Method: The study was a quantitative approach, observational, retrospective and descriptive. Analyzed 47 medical records during the period from August 2010 to May 2012. Data were collected related to identification, history of the disease, laboratory tests and length of stay, among others. Data were analyzed using mean, frequency and tabulation of the variables of interest. Results: Males were the most affected, between the age group of 18 to 40 years, and 40.4% had inhalation injury having as the main causative agent exposure to flammable liquids, resulting mostly injury 2nd degree and only 32% underwent bronchoscopy. The average hospital stay was less than 30 days, with 46 discharge and only one death. Conclusion: These data are important for understanding the scientific community and that prevention programs are broadcast to risk groups for this type of injury, identified as males, aged 18-45 years, mostly suffered second degree injuries, generating an average hospital stay less than 30 days, with only one death.

Objetivo: Identificar las características de los pacientes con quemaduras del rostro en el Centro de Tratamiento de Quemados del Hospital Metropolitano de Urgência e Emergência. Método: Estudio de abordaje cuantitativo, de tipo observacional, retrospectivo y descriptivo. Fueron analizados 47 archivos médicos de pacientes atendidos entre agosto de 2010 a mayo de 2012, a través de un formulario en el que se recogieron los datos relativos a la identificación, la historia de la enfermedad, las pruebas de laboratorio y tiempo estancia hospitalaria. Realizados análisis descriptivos de media, frecuencia y la tabulación de las variables de interés. Resultados: Los hombres fueron los más afectados, entre el grupo de edad de 18 a 40 años y 40,4% tuvieron lesiones por inhalación después de exposición a líquidos inflamables, siendo este el principal agente causal, lo que resulta sobre todo en lesiones segundo en grado; e sólo el 32% tuvieron que realizar broncoscopía. La estancia media hospitalaria fue de menos de 30 días, con 46 altas y apenas una muerte. Conclusión: Se identificó que el 51% de la muestra sufrió lesiones por inhalación asociado con quemaduras faciales, siendo los adultos jovenes del sexo masculino los más afectados. Estos datos son importantes para la comprensión de la comunidad científica y para que sean difundidos programas de prevención para grupos de riesgo para este tipo de lesiones, ya que esta es la mejor forma de evitar as quemaduras y sus complicaciones.

Comparison of the effects of TripleGates and Gates-Glidden burs on cervical dentin thickness and root canal area by using cone beam computed tomography

The search for new instruments to promote an appropriate cervical preparation has led to the development of new rotary instruments such as TripleGates. However, to the best of the authors' knowledge, there is no study evaluating TripleGates effect on the “risk zone” of mandibular molars. Objectives : The aim of this study was to evaluate the effects of a crown-down sequence of Gates-Glidden and TripleGates burs on the remaining cervical dentin thickness and the total amount of dentin removed from the root canals during the instrumentation by using cone beam computed tomography. The number of separated instruments was also evaluated. Material and Methods : Mesial roots of 40 mandibular first molars were divided into 2 equal groups: crown-down sequence of Gates-Glidden (#3, #2, #1) and TripleGates burs. Cervical dentin thickness and canal area were measured before and after instrumentation by using cone beam computed tomography and image analysis software. Student’s t-test was used to determine significant differences at p<0.05. Results : No significant differences (p>0.05) were observed between the instruments, regarding the root canal area and dentin wall thickness. Conclusion : Both tested instruments used for cervical preparation were safe to be used in the mesial root canal of mandibular molars. .

Estratégias ventilatórias no paciente com lesão inalatória: revisão de literatura / Estrategias ventilatorias en pacientes con lesiones por inhalación: revisión de la literatura / Ventilatory strategies in patient with inhalation injury: literature review

A lesão inalatória (LI) é a principal causa da mortalidade em pacientes queimados ou vítimas de incêndio, pois resulta de um processo inflamatório nas vias aéreas após a inalação de subprodutos da combustão. Aproximadamente 33% dos pacientes que sofreram queimaduras extensas apresentam LI, à qual o risco se eleva na proporção da superfície corpórea queimada, e que vem se tornando um fator predominante de mortalidade em pacientes queimados. Objetivo: Este artigo tem como objetivo analisar as estratégias ventilatórias no paciente com lesão inalatória. Método: O método adotado para a pesquisa foi a revisão do tipo descritiva, com estratégia de busca elaborada utilizando artigos indexados nas bases de dados LILACS, SciELO, PubMed e Medline no período de 2009 a 2014. Resultados: Dentre os artigos selecionados, todos utilizaram oxigenoterapia com FiO2 a 100%, três artigos relataram a necessidade de intubação orotraqueal precoce (IOT) como estratégia de proteção de via aérea superior (VAS) e dois artigos relataram a experiência com ventilação não invasiva, com objetivo de evitar a IOT, obtendo sucesso. Conclusão: Neste artigo foi visto que as estratégias ventilatórias na LI devem ser iniciadas o mais precoce possível, visando assegurar ventilação, oxigenação e perfusão tecidual adequada. No entanto, a escassez de produções científicas atuais sobre a temática não deixa claro a melhor definição sobre o assunto. Logo, as pesquisas que procuram ratificar e aumentar as evidências acerca das estratégias ventilatórias nos pacientes com LI são pertinentes...

La lesión por inhalación (LI) es la principal causa de mortalidad en los pacientes quemados o víctimas de incendios, como el resultado de un proceso inflamatorio en las vías respiratorias después de la inhalación de los subproductos de la combustión. Aproximadamente el 33% de los pacientes que sufrieron quemaduras extensas presente LI, que el riesgo aumenta en proporción a la superficie corporal quemada, y que se está convirtiendo en un factor predominante de la mortalidad en los pacientes quemados. Objetivo: El presente artículo tiene como objetivo analizar las estrategias de ventilación en pacientes con lesiones por inhalación. Método: El método adoptado para la investigación fue revisar descriptiva, con elaborada estrategia de búsqueda utilizando artículos indexados en las bases de datos LILACS, SciELO, PubMed y Medline desde 2009 hasta 2014. Resultados: Entre los artículos seleccionados, todos los tratamientos con oxígeno utilizado con FiO2 al 100%, tres artículos informó la necesidad de principios de la intubación (IOT) y la estrategia de protección de la vía aérea (VA) y dos artículos reportado la experiencia con ventilación no invasiva, con el fin de evitar IOT. Conclusión: En este artículo se vio que las estrategias de ventilación en LI debe iniciarse tan pronto como sea posible con el fin de asegurar la ventilación, la oxigenación y la adecuada perfusión tisular. Sin embargo, la escasez de la producción científica actual sobre el tema, no borra la mejor definición al respecto. Por lo tanto, la investigación en busca de ratificar y aumentar la evidencia sobre las estrategias de ventilación en pacientes con LI son relevantes...

Inhalation injury (LI) is the leading cause of mortality in burned patients or fire victims, as the result of an inflammatory process in the airways following inhalation of combustion by-products. Approximately 33% of patients who suffered extensive burns present LI, which the risk increases in proportion to the burned body surface, and that is becoming a predominant factor of mortality in burned patients. Objective: This article aims to analyze the ventilation strategies in patients with inhalation injury. Method: The method adopted for the research was to review descriptive, with elaborate search strategy using articles indexed in the databases LILACS, SciELO, PubMed and Medline from 2009 to 2014. Results: Among the selected articles, all used oxygen therapy with FiO2 to 100%, three articles reported the need for early intubation (IOT) and Airway protection strategy (VA) and two articles reported the experience with Non-Invasive Ventilation, in order to avoid IOT succeeding. Conclusion: This article it was seen that the ventilation strategies in LI should be initiated as early as possible in order to ensure ventilation, oxygenation and adequate tissue perfusion. However, the shortage of current scientific production on the subject, not clear the best definition about it. Therefore, research seeking to ratify and increase the evidence about the ventilation strategies in patients with LI are relevant...

Advances in the research of clinical features and treatment of ammonia burns / 中华烧伤杂志

Ammonia is commonly used in industry and agriculture. It is also one of the most frequently accidentally spilled chemicals. Exposure to ammonia can cause severe cutaneous burn or freezing injury, ocular injury, and inhalation injury, among them inhalation injury is the most lethal one. Although the diagnosis and treatment of ammonia burns have been improved, the long-term prognosis is not satisfactory. In this article, we reviewed the literature concerning ammonia burns, in order to summarize the clinical features and treatment of such injury.

Effects of high frequency oscillatory ventilation combined with incremental positive end-expiratory pressure on myocardial ischemia and hypoxia and apoptosis of cardiomyocytes in dogs with smoke inhalation injury / 中华烧伤杂志

<p><b>OBJECTIVE</b>To compare the effects of high frequency oscillatory ventilation (HFOV) combined with incremental positive end-expiratory pressure (IP) and those of pure HFOV on myocardial ischemia and hypoxia and apoptosis of cardiomyocytes in dogs with smoke inhalation injury.</p><p><b>METHODS</b>Twelve healthy male dogs were divided into group HFOV and group HFOV+IP according to the random number table, with 6 dogs in each group. After being treated with conventional mechanical ventilation, dogs in both groups were inflicted with severe smoke inhalation injury, and then they received corresponding ventilation for 8 hours respectively. After treatment, the blood samples were collected from heart to determine the activity of creatine kinase-MB (CK-MB) and lactate dehydrogenase 1 (LDH1) in plasma. The dogs were sacrificed later. Myocardium was obtained for determination of content of TNF-α per gram myocardium by ELISA, apoptotic rate of cardiomyocytes by flow cytometer, degree of hypoxia with HE staining, and qualitative and quantitative expression of actin (denoted as integral absorbance value) with streptavidin-biotin-peroxidase staining. Data were processed with t test. The relationship between the content of TNF-α per gram myocardium and the apoptotic rate of cardiomyocytes was assessed by Spearman linear correlation analysis.</p><p><b>RESULTS</b>(1) After treatment for 8 h, the values of activity of CK-MB and LDH1 in plasma of dogs in group HFOV+IP were respectively (734 ± 70) and (182 ± 15) U/L, which were both lower than those in group HFOV [(831 ± 79) and (203 ± 16) U/L, with t values respectively 2.25 and 2.35, P values below 0.05]. (2) Compared with that in group HFOV [(0.060 ± 0.018) µg], the content of TNF-α per gram myocardium of dogs in group HFOV+IP after treatment for 8 h was decreased significantly [(0.040 ± 0.011) µg, t=2.32, P<0.05]. (3) Compared with that in group HFOV [(33.4 ± 2.2)%], the apoptotic rate of cardiomyocytes of dogs in group HFOV+IP after treatment for 8 h was significantly decreased [(28.2 ± 3.4)%, t=3.15, P<0.05]. There was a positive correlation between the content of TNF-α per gram myocardium and the apoptotic rate of cardiomyocytes (r=0.677, P<0.05). (4) HE staining showed that myocardial fibers of dogs in both groups were arranged in wave shape in different degrees, indicating there was myocardial hypoxia in different degrees. Compared with that of group HFOV, the degree of hypoxia in group HFOV+IP was slighter. (5) The results of immunohistochemical staining showed that there was less loss of actin in myocardial fibers of dogs in group HFOV+IP than in group HFOV. The expression level of actin in myocardium of dogs in group HFOV+IP after treatment for 8 h (194.7 ± 3.1) was obviously higher than that in group HFOV (172.9 ± 2.6, t=13.20, P<0.01).</p><p><b>CONCLUSIONS</b>Compared with pure HFOV, HFOV combined with IP can alleviate the inflammatory reaction in myocardium of dogs, reduce the apoptosis of cardiomyocytes, and ameliorate the myocardial damage due to ischemia and hypoxia.</p>

Psychological Reactions and Physical Trauma by Types of Disasters: View from Man-Made Disaster / 신경정신의학

A variety of psychological and physical symptoms may appear in disaster victims. The type of disaster as well as individual factors could affect the pattern and severity of symptoms. Several reports have shown that fire survivors suffered from survivor guilt, re-experience, and fear of fire and burn scars associated with depressive symptoms. Inhalation burns are of special interest because of the possibility of delayed systemic complications. Large traffic accident causes more frequent and severe post-traumatic stress symptoms (PTSS), particularly intrusive thoughts, compared to general road traffic accident. Traumatic brain injury and serious physical injuries could increase the PTSS expression. Considering that tragic collapse accidents occurred mainly as a result of careless construction, anger and mistrust are understandable. Legal disputes and compensation issues can provoke social conflict and prolonged suffering. Understanding the psychological characteristics and responses will be required in order to support the mental health of disaster victims.

A Case of Inhalation Burn-Induced Extensive Tracheal Inflammatory Crust Removed by Ventilating Bronchoscopy under Tracheostomy and Extracorporeal Membrane Oxygenation / 대한이비인후과학회지

Foreign body impaction in airway is life-threatening as it can cause total airway obstruction. Such foreign bodies are removed under bronchoscopy in most patients. In some patients, however, the cardiopulmonary condition becomes unstable to undergo ventilating bronchoscopy under general anesthesia to remove the foreign body. In these conditions, extracorporeal membrane oxygenation (ECMO) can be adopted for cardiopulmonary support to stabilize the patient while removing the foreign body. ECMO supports tissue oxygenation and has been shown to improve survival of patients with adult respiratory distress syndrome. ECMO allows lungs to reserve their functions and decreases further lung injuries. The authors report one case of extensive tracheal inflammatory crust removed by ventilating bronchoscopy under tracheostomy and ECMO.

Tracheobronchial Polyps Following Thermal Inhalation Injury / 결핵및호흡기질환

The early pulmonary consequences of inhalation injury are well documented; however, little is known about delayed pulmonary complications following thermal inhalation injury. Although thermal injury below the vocal cords is rare because of effective heat dissipation in the upper airway, inflammatory endobronchial polyps have previously been reported as a delayed complication associated with inhalation injury. We report an extraordinary case of tracheobronchial polyps in patients with smoke inhalation injury. This report shows the delayed development and natural course of tracheobronchial polyps following thermal injury.

Analysis of clinical characteristics of 443 patients with inhalation injury / 中华烧伤杂志

<p><b>OBJECTIVE</b>To explore the epidemiological characteristics of inhalation injury and to summarize the clinical application experience of diagnostic standard of burn of larynx.</p><p><b>METHODS</b>Medical records of 443 patients with inhalation injury admitted to our burn unit from January 1999 to June 2013 were analyzed, including gender, age, severity of inhalation injury, complications and diseases before injury; total area and that of full-thickness burn injury, admission time after burn, and burn condition of larynx of patients with different degrees of inhalation injury; treatment and outcome including rate, time, and complication of tracheotomy, mortality, and cause of death. Data were processed with nonparametric Kruskal-Wallis test and chi-square test. The relationship between severity of inhalation injury and total burn area, degree of burn of larynx, tracheotomy rate, and mortality was assessed by Spearman correlation analysis.</p><p><b>RESULTS</b>(1) Among the patients, there were 353 (79.7% ) male and 90 (20.3% ) female, with the ratio of male to female 4:1. There were 64 (14.4%) patients younger than or equal to 20 years, 203 (45.8%) patients older than 20 years and younger than or equal to 40 years, 144 (32.5%) patients older than 40 years and younger than or equal to 60 years, and 32 (7.2%) patients older than 60 years. The numbers of patients with mild, moderate, and severe inhalation injury were respectively 297, 108, and 38. Seven patients suffered from complications, and 21 patients had diseases before injury. There were statistically significant differences among the patients with different degree of inhalation injury in regard to total burn area and full-thickness burn area (with H values respectively 73.752 and 142.830, P values below 0.01), while no statistically significant difference was observed in admission time after burn ( H = 1.528, P > 0.05). Correlation analysis showed that severity of inhalation injury was positively correlated with total burn area (r = 0.399, P < 0.001). Among the patients with mild inhalation injury, incidences of patients with mild, moderate, and severe burn of larynx were respectively 68.0% (202/297), 32.0% (95/297), and 0, and those among the patients with moderate inhalation injury were respectively 0,53.7% (58/108), and 46.3% (50/108). There were statistically significant differences in degree of burn of larynx of patients with different degree of inhalation injury (χ2 = 336.703, P < 0.001). Correlation analysis showed that severity of burn of larynx was positively correlated with severity of inhalation injury (r = 0.700, P < 0.001). (2) The rate of tracheotomy was 37.02% (164/443). The rates of tracheotomy in patients with mild, moderate, and severe inhalation injury were respectively 10.44% (31/297), 87.96% (95/108), and 100.00% (38/38), χ2 = 271.654, P < 0.001. Correlation analysis showed that the rate of tracheotomy was positively correlated with severity of inhalation injury (r = 0.784, P < 0.001). Tracheotomy was done mainly within 6 h post burn (63.4%, 104/164). The incidence rate of complication of tracheotomy was 5.5% (9/164). (3) Thirty-one patients died, with a mortality rate of 7.00%. The mortality rates of patients with mild, moderate, and severe inhalation injury were respectively 1.01% (3/297), 12.96% (14/108), and 36.84% (14/38), H = 74.273, P < 0.001. It was found that the mortality was positively correlated with severity of inhalation injury (r = 0.371, P < 0.001). The causes of death of the patients were respectively sepsis (14, 45.2%), respiratory failure (7, 22.6%), airway obstruction (2, 6.5%), airway hemorrhage (2, 6.5%), cerebral hemorrhage (2, 6.5%), cardiac accident (2, 6.5%), and diabetes insipidus (1, 3.2%), and 1 (3.2%) patient quit treatment and discharged from hospital for economic reason.</p><p><b>CONCLUSIONS</b>Among the patients with inhalation injury, male is dominated in number, and the young adults formed the highest constituent ratio. The severity of inhalation injury was correlated with total burn area, severity of burn of larynx, tracheotomy rate, and mortality. With the guidance of diagnostic criteria of burn of larynx and indication of tracheotomy, the risk of laryngeal obstruction can be eliminated. The early preventive tracheotomy can decrease the difficulty and risk of the operation.</p>

Effects of phosphorylated mitogen-activated protein kinases on phosgene inhalation-induced lung injury in rats and its relationship with matrix metalloproteinase / 中华烧伤杂志

<p><b>OBJECTIVE</b>To investigate the effects of phosphorylated mitogen-activated protein kinases (MAPK), including the phosphorylated extracellular signal-regulated protein kinase 1/2 (p-ERK1/2), the phosphorylated protein p38 (p-p38), the phosphorylated c-Jun N-terminal kinase (p-JNK), on phosgene inhalation-induced lung injury and its relationship with matrix metalloproteinase 9 (MMP-9).</p><p><b>METHODS</b>According to the random number table, 30 male Wistar rats were divided into air control group (C), phosgene inhalation group (P), PD98059 (specific inhibitor of ERK1/2) group, SB203580 (specific inhibitor of p38) group, and SP600125 (specific inhibitor of JNK) group, with 6 rats in each group. The number of neutrophils in the bronchoalveolar lavage fluid (BALF) was counted and the lung wet-dry ratio (W/D) was examined. The serum levels of inflammatory factors TNF-α, IL-1β, IL-6, and IL-8 were determined with ELISA. The protein expressions of p-ERK1/2, p-p38, p-JNK, and MMP-9 in lung tissue were detected with Western blotting. The mRNA level of MMP-9 in lung tissue was detected with real-time fluorescence quantitative PCR. Data were processed with one-way analysis of variance (among groups) and SNK method (paired comparison).</p><p><b>RESULTS</b>Compared with those of group C [respectively (2.0 ± 0.7)×10(4) /mL and 3.7 ± 0.6], the number of neutrophils and W/D of group P [respectively (10.7 ± 1.4)×10(4) /mL and 7.6 ± 0.4] were increased. The number of neutrophils in group SB203580 and group SP600125 was respectively (8.3 ± 1.1)×10(4), (7.9 ± 1.3)×10(4)/mL, with W/D respectively 6.1 ± 1.4, 6.1 ± 0.9, all of which decreased as compared with those of group P (with P values all below 0.01). Compared with those of group C, the levels of TNF-a, IL-1β, IL-6, and IL-8 of group P were increased, but decreased in group SB203580 and group SP600125 compared with that of group P, though still higher than those of group C, and the differences were statistically significant (P < 0.05 or P<0.01). Protein quantities of p-p38 and p-JNK were higher in group P (respectively 1.19 ± 0.22 and 1.43 ± 0.14) than in group C (respectively 0.76 ± 0.06 and 0.74 ± 0.05). Compared with those of group P, the protein levels of p-ERK1/2 (0.47 ± 0.05) in group PD98059, p-p38 (0.88 ± 0.07) in group SB203580, and p-JNK (0.91 ± 0.07) in group SP600125 were significantly reduced (P < 0.05 or P < 0.01). The protein and mRNA levels of MMP-9 were higher in group P (respectively 2.23 ± 0.18 and 4.93 ± 0.12) than in group C (respectively 1.26 ± 0.14 and 1.80 ± 0.03). The protein and mRNA levels of MMP-9 in group SB203580 (respectively 1.58 ± 0.14 and 2.96 ± 0.09) and group SP600125 (respectively 1.55 ± 0.30 and 3.00 ± 0.13) were lower than those in group P (P < 0.05 or P < 0.01).</p><p><b>CONCLUSIONS</b>The phosgene inhalation can activate the MAPK signaling protein pathway by increasing expressions of p-p38 and p-JNK, which lead to an up-regulation of MMP-9, and this may contribute to the phosgene inhalation-induced lung injury.</p>

Effects of high frequency oscillatory ventilation combined with incremental positive end-expiratory pressure on respiratory and circulatory functions of dogs with inhalation injury / 中华烧伤杂志

<p><b>OBJECTIVE</b>To study the effects of high frequency oscillatory ventilation (HFOV) combined with incremental positive end-expiratory pressure (IP) on respiratory and circulatory functions, and lung histopathology of dogs with smoke inhalation injury.</p><p><b>METHODS</b>After being treated with conventional mechanical ventilation, 12 dogs were inflicted with severe smoke inhalation injury and divided into group HFOV and group HFOV+IP according to the random number table, with 6 dogs in each group. Then they received corresponding ventilation for 8 hours respectively. Blood gas analysis results (pH value, PaO2 and PaCO2 levels) and hemodynamic parameters [heart rate, mean arterial pressure (MAP), pulmonary arterial pressure (PAP), central venous pressure (CVP), cardiac output (CO)] were recorded before injury, immediately after injury, and at post ventilation hour (PVH) 2, 4, 6, and 8. The dogs of two groups were sacrificed at PVH 8. A healthy dog without any treatment and a dog with smoke inhalation injury but no subsequent treatment were sacrificed in addition. Lung tissues of all dogs were obtained for histopathological observation. Lung injury score examination was conducted in both groups. Data were processed with rank sum test, analysis of variance of repeated measurement, and LSD- t test.</p><p><b>RESULTS</b>(1) The PaO2 levels in both groups were significantly decreased immediately after injury, compared with those before injury (with t values respectively 4.960, 5.310, P values all below 0.01). The PaO2 levels in both groups from PVH 2 to PVH 8 were significantly increased, compared with those observed immediately after injury (with t values from 4.930 to 6.050, P values all below 0.01). At PVH 2, 4, and 8, PaO2 levels in group HFOV+IP were significantly higher than those in group HFOV (with t values from 3.775 to 5.774, P values all below 0.01); no statistically significant differences were observed in pH value and PaCO2 level at each time point between two groups (with t values from 0.002 to 0.997, P values all above 0.05). (2) There were no statistically significant differences in MAP, PAP, and CVP within two groups at each time point (with F values from 1.316 to 4.959, P values all above 0.05). In group HFOV, heart rate from PVH 2 to PVH 8 was significantly lower than that observed immediately after injury (with t values from 3.780 to 8.970, P values all below 0.01). In group HFOV+IP, CO at PVH 4, 6, and 8 was significantly lower than that observed immediately after injury (with t values from 3.990 to 11.200, P values all below 0.01). There were no statistically significant differences in MAP, PAP, and CVP between two groups at the same time point (with t values from 0.089 to 2.123, P values all above 0.05). At PVH 4, 6, and 8, heart rate in group HFOV+IP was higher than that in group HFOV (with t values from 2.931 to 7.229, P < 0.05 or P < 0.01), while CO was lower (with t values from 4.297 to 11.206, P values all below 0.01). (3) Compared with those of the healthy dog, inflammatory cell infiltration and bleeding in the lung were observed in alveolar space in both group HFOV and group HFOV+IP, while the degree was less serious than that of the dog with smoke inhalation injury only. Compared with those of group HFOV, inflammatory cell infiltration in group HFOV+IP was less significant, the alveolar structure was relatively intact, and no thickening of alveolar walls was observed. The lung injury score in group HFOV [(3.27 ± 0.24) points] was higher than that of group HFOV+IP [(2.79 ± 0.31) points, t = 27, P < 0.05].</p><p><b>CONCLUSIONS</b>HFOV combined with IP can improve gas exchange and alleviate pulmonary injury without any adverse effect on blood gas analysis or hemodynamic parameters. Therefore, it may be considered as an appropriate mode of ventilation for the treatment of smoke inhalation injury.</p>

Respiratory support and treatment of severe inhalation injury / 中华烧伤杂志

Although the study of inhalation injury is deepening gradually, its clinical treatment is still difficult, and its mortality rate remains high due to the complicated pathophysiologic characteristics. This article reviews the recent progress in research and treatment of inhalation injury, acute lung injury, and acute respiratory distress syndrome at home and abroad, focusing on the effect of mechanical ventilation models, including the non-invasive ventilation, lung protective ventilation, liquid ventilation, high frequency ventilation, on respiratory support in early stage of inhalation injury. The effects of medications for inhalation injury are summarized, and the prospect of stem cell therapy for inhalation injury is also discussed.