Inhalation remains the most frequent and serious comorbid event that occurs in thermally injured patients. A thorough understanding of the pathophysiology enables individualization of therapy and appropriate triage of patients. We summarize our current knowledge of the pathophysiology, diagnosis, and treatment of inhalation injury, with a focus on newer treatment strategies that are evolving secondary to laboratory research.
Get full access to this article
View all access options for this article.
References
1.
PruittBAJrGoodwinCWJrPruittSKBurns: including cold, chemical, and electric injuries. In: SabistonDCJr, ed. Textbook of surgery, 14th ed. Philadelphia: W.B. Saunders, 1991:178–179.
2.
GrubeBJMarvinJAHeimbachDM.Therapeutic hyperbaric oxygen: help or hindrance in burn patients with carbon monoxide poisoning?J Burn Care Rehabil1988;9: 249–252.
3.
BaudFJBarriotPToffisVElevated blood cyanide concentrations in victims of smoke inhalation. N Engl J Med1991;325: 1761–1765.
4.
PrienTTraberDL.Toxic smoke compounds and inhalation injury—a review. Burns1988;14: 451–460.
5.
PruittBAJrCioffiWGShimazuTEvaluation and management of patients with inhalation injury. J Trauma1990;30 (suppl 12):S63–S69.
6.
ShiraniKZPruittBAJrMasonADJr.The influence of inhalation injury and pneumonia on burn mortality. Ann Surg1987;205: 82–87.
7.
TredgetEEShankowskyHATaerumTVThe role of inhalation injury in burn trauma: a Canadian experience. Ann Surg1990;212: 720–727.
8.
Deposition and retention models for internal docemitry of the human respiratory tract.Mass group on lung dynamics. Health Physics1966;12: 173–207.
9.
TraberDLLinaresHAHerndonDN.The pathophysiology of inhalation injury—a review. Burns1988;14: 357–364.
10.
HuangYHLiANYangZC.Effect of smoke inhalation injury on thromboxane levels and platelet counts. Burns1988;14: 440–446.
11.
XieEFLiAYangZCJiangKY.Dynamic balance changes between elastase and antiprotease in the early stages after smoke inhalation injury. Burns1992;18: 362–367.
12.
DoupnikCALeikaufGD.Acrolein stimulates eicosanoid release from bovine airway epithelial cells. Am J Physiol1990;259: L222–L229.
13.
DemlingRHLalondeC.Moderate smoke inhalation produces decreased oxygen delivery, increased oxygen demands and systemic but not lung parenchymal lipid peroxidation. Surgery1990;108: 544–552.
CoxCSJrZvischenbergerJBTraberDLHeparin improves oxygenation and minimizes barotrauma after severe smoke inhalation in an ovine model. Surg Gynecol Obstet1993;176: 339–349.
16.
HalesCABarkinPJungWBronchial artery ligation modifies pulmonary edema after exposure to smoke with acrolein. J Appl Physiol1989;67: 1001–1006.
17.
BasadreJOSugiKTraberDLThe effect of leukocyte depletion on smoke inhalation injury in sheep. Surgery1988;104: 208–215.
18.
GhioAJKennedyTPHatchGETepperJS.Reduction of neutrophil influx diminishes lung injury and mortality following phosgene inhalation. J Appl Physiol1991;71: 657–665.
19.
HalesCABarkinPWJungWSynthetic smoke with acrolein but not HCl produces pulmonary edema. J Appl Physiol1988;64: 1121–1133.
20.
AbdiSHerndonDNTraberLDLung edema formation following inhalation injury: role of the bronchial blood flow. J Appl Physiol1991;71: 727–734.
21.
BarrowREMorrisSEBasadreJOHerndonDN.Selective permeability changes in the lungs and airways of sheep after toxic smoke inhalation. J Appl Physiol1990;68: 2165–2170.
22.
IsagoTNoshimaSTraborDLAnalysis of pulmonary microvascular permeability after smoke inhalation. J Appl Physiol1991;71: 1403–1408.
23.
ClarkWRNiemanGHakimTS.Distribution of extravascular lung water after acute smoke inhalation. J Appl Physiol1990;68: 2394–2402.
24.
NiemanGFClarkWRJrWaxSDWebbSR.The effect of smoke inhalation on pulmonary surfactant. Ann Surg1980;191: 171–181.
25.
PetroffPAHanderEWClaytonWHPruittBAJr.Pulmonary function studies after smoke inhalation. Am J Surg1976;132: 346–351.
26.
LeeBPMortonRFLeeLY.Acute effects of acrolein on breathing: role of vagal bronchopulmonary afference. J Appl Physiol1992;72: 1050–1056.
27.
ShimazuTYukiokaTHubbardGBA dose-responsive model of smoke inhalation injury. Ann Surg1987;206: 89–98.
28.
ShimazuTYukiokaTHubbardGBInequality of VA/Q ratios following smoke inhalation injury and effects of angiotensin analogue: Part I. Multiple inert gas elimination technique using a gas chromotography-mass spectrometer. Ann Res Prog Report, U.S. Army Institute of Surgical Research, Fort Sam Houston, TX, 1985;430–433.
29.
ShimazuTIkeuchiHHubbardGBInequality of VA/Q ratios following smoke inhalation injury and effects of angiotensin analogue: effects of positive end expiratory pressure (PEEP) and oxygen on ventilation-perfusion (VA/Q) distribution after smoke inhalation injury. Ann Res Prog Report, U.S. Army Institute of Surgical Research, Fort Sam Houston, TX 1987;214–231.
30.
OguraHCioffiWGJrJordanBSThe effect of inhaled nitric oxide on smoke inhalation injury in an ovine model. J Trauma1994;37: 294–301.
31.
IkeuchiHSakanoTSanchezJThe effect of platelet-activating factor (PAF) and a PAF antagonist (CV3988) on smoke inhalation injury using an ovine model—physiologic change. Presented at the annual meeting of the American Burn Association, Las Vegas, NV, Mar 28–31, 1990.
32.
ClarkWRBonaventuraMMyersW.Smoke inhalation and airway management at a regional burn unit: 1974 to 1983: I. Diagnosis and consequences of smoke inhalation. J Burn Care Rehabil1989;10: 52–62.
33.
HuntJLAgeeRNPruittBAJr.Fiberoptic bronchoscopy in acute inhalation injury. J Trauma1975;15: 641–649.
34.
MoylanJAJrWilmoreDWMoutonDEPruittBAJr.Early diagnosis of inhalation injury using 133Xenon lung scan. Ann Surg1972;176: 477–484.
35.
AgeeRNLongJMIIIHuntJLUse of 133Xenon in early diagnosis of inhalation injury. J Trauma1976;16: 218–224.
36.
RueLWIIICioffiWGMcmanusWFPruittBAJr.Improved survival of burn patients with inhalation injury. Arch Surg1993;128: 772–780.
37.
CoxCSJrZwischenbergerJBTraberDLImmediate positive pressure ventilation with positive end-expiratory pressure (PEEP) improves survival in ovine smoke inhalation injury. J Trauma1992;33: 821–827.
38.
VenusBMatsudaTCopiozoJD.Prophylactic intubation and continuous positive airway pressure in the management of inhalation injury in burn victims. Crit Care Med1981;9: 519–523.
39.
FreemanGR.A comparative analysis of endotracheal intubation in neonates, children and adults: complications, prevention and treatment. Laryngoscope1972;80: 1385–1398.
40.
LundTGoodwinCWMcmanusWFUpper airway sequelae in burn patients requiring endotracheal intubation or tracheostomy. Ann Surg1985;201: 374–382.
41.
SchulenJJMunsterAM.The Parkland formula in patients with burns and inhalation injury. J Trauma1982;22: 869–871.
42.
SchusterDP.The case for and against fluid restriction and occlusion pressure reduction in adult respiratory distress syndrome. New Horizons1993;1: 478–488.
43.
HerndonDNTraberDLTraberLD.The effect of resuscitation on inhalation injury. Surgery1986;100: 248–251.
44.
NavarroPDSaffleJRWardenGD.Effect of inhalation injury on fluid resuscitation requirements after thermal injury. Am J Surg1985;150: 716–720.
45.
GravesTACioffiWGMcmanusWFFluid resuscitation of infants and children with massive thermal injury. J Trauma1988;28: 1656–1659.
46.
StoneHHRhameDWCorbittJDRespiratory burns: a correlation of clinical and laboratory results. Ann Surg1967;165: 157–168.
47.
WelchGWLullRJPetroffPA.The use of steroids in inhalation injury. Surg Gynecol Obstet1977;145: 539–544.
48.
LevineBAPetroffPASladeCL.Prospective trials of dexamethasone and aerosolized gentamicin in the treatment of inhalation injury in the burned patient. J Trauma1978;18: 118–193.
49.
MoylanJAAlexanderAG.Diagnosis and treatment of inhalation injury. World Surg1978;2: 185–191.
50.
CoxCSJrZwischenbergerJBTraberDLHeparin improves oxygenation and minimizes barotrauma after severe smoke inhalation in an ovine model. Surg Gynecol Obstet1993;176: 339–349.
51.
DreyfussDSolerPBassetGSaumonG.Respective effects of high airway pressure, high tidal volume and positive end-expiratory pressure. Am Rev Respir Dis1988;137: 1159–1164.
52.
TsunoKPratoPKolobowT.Acute lung injury from mechanical ventilation at moderately high airway pressures. J Appl Physiol1990;69: 956–961.
53.
LachmannBJonsonBLindrothMRobertsonB.Modes of artificial ventilation in severe respiratory distress syndrome. Lung function and morphology in rabbits after washout of alveolar surfactant. Crit Care Med1982;10: 724–732.
54.
CioffiWGRueLWIIIGravesTAProphylactic use of high frequency ventilators in patients with inhalation injury. Ann Surg1991;213: 575–582.
55.
CioffiWGGravesTAMcmanusWFPruittBAJr.High frequency percussive ventilation in patients with inhalation injury. J Trauma1989;29: 350–354.
56.
CioffiWGDelemosRACoalsonJJDecreased pulmonary damage in primates with inhalation injury treated with high frequency ventilation. Ann Surg1993;218: 328–337.
57.
KawanoTMoriSCybulskyMEffect of granulocyte depletion in ventilated surfactant-depleted lung. J Appl Physiol1987;62: 27–33.
58.
ShiraniKZMoylenJAPruittBAJr.Diagnosis and treatment of inhalation injury in burn patients. In: LokeJ, ed. Pathophysiology and treatment of inhalation injuries. Basel: Marcel Dekker, 1988:239–280.
59.
KlasterskyJBogaertsAMNotermanJInfections caused by Providence bacilli. Scand J Infect Dis1974;6: 153–160.
60.
AthertonSTWhiteDJ.Stomach as a source of bacteria colonizing respiratory tract during artificial ventilation. Lancet1978;2: 968–969.
61.
DriksMRCravenDECelliBRNosocomial pneumonia in intubated patients randomized to sucralfate versus antacids and/or histamine type 2 blockers: the role of gastric colonization. N Engl J Med1987;317: 1376–1382.
62.
TrybaM.Risk of acute stress bleeding and nosocomial pneumonia in ventilated intensive care unit patients: sucralfate vs antacids. Am J Med1987;83 (suppl 3B):117–124.
63.
CioffiWGMcmanusARueLWIIIComparison of acid neutralizing with non-acid neutralizing stress ulcer prophylaxis in thermally injured patients. J Trauma1994;36: 544–545.
64.
CioffiWGJordanBSMasonADEffect of surfactant replacement on VA/Q in sheep with inhalation injury. In: PruittBA, ed. US Army Institute of Surgical Research Annual Research Progress Report for Fiscal Year 1991. San Antonio: US Government Printing Office, 1992:560–576.
65.
OguraHCioffiWGOkerbergCVThe effects of pentoxifylline on pulmonary function following smoke inhalation. J Surg Res1994;56: 242–250.
66.
NiehausGDKimuraRTraberLDAdministration of a synthetic antiprotease reduces smoke-induced lung injury. J Appl Physiol1990;62: 694–699.
67.
CoxCSJrZwischenbergerJBTraberLDUse of an intravascular oxygenator/carbon dioxide removal device in an ovine smoke inhalation injury model. ASAIO Trans1991;37: M411–413.
68.
ZwischenbergerJBCoxCSJrMinifeePKPathophysiology of ovine smoke inhalation injury treated with extracorporeal membrane oxygenation. Chest1993;103: 1582–1586.
69.
RichmanPSWolfsonMRShafferTH.Lung lavage with oxygenated per pleura chemical liquid in acute lung injury. Crit Care Med1993;21: 768–774.
