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Smoke Inhalation and Thermal Injury RT: For Decision Makers in Respiratory Care - June 2008
Effects Vary
The effects of inhalation injury can be divided into immediate and delayed. The immediate effects are predominately related to the chemical composition of the smoke
and the associated particulate matter on the epithelial cells lining the entire airway. The effects are also related to the thermal damage to the upper and, to a lesser extent,
lower airways. Hyperemia is present in the mucosa, along with increased secretion of mucus, increased permeability of the mucosal microvasculature, and the migration
of inflammatory cells to the affected areas. This is normally followed rapidly (within 15 minutes in animal models) by an epithelial exfoliation that, combined with the
mucous secretions, is responsible for the formation of casts in the airway.4,9 There is a positive correlation between the dose of smoke the patient received and the
severity of pseudomembrane formation and exfoliation.1 These effects are also often localized during the immediate postinjury period. This has been attributed to
variability in the degree of bronchospasm occurring in various portions of the lungs.10-12
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Inhalation Injury Is Not Always the Culprit
Deleterious changes in pulmonary function in any patient with thermal surface injury—particularly after the initial resuscitation period—should not be assumed to be due
solely to the presence of an inhalation injury, and other causes should be actively sought out and excluded. These include abdominal compartment syndrome,27
pulmonary embolus, and exacerbations of underlying medical conditions. When the index of suspicion is high for an inhalation injury, however, immediate and aggressive
action to clear the airways could be life-saving.
Suctioning and lavage through traditional means might be insufficient, and bronchoscopic removal of secretions might be required to stabilize some patients. Even the
traditional forceps for foreign-object removal in the airways may fall short of being adequate for the task, and, in at least one case report, endoscopic basket forceps more
commonly used for biliary tract procedures were required to effect debris and secretion removal.17 In fact, the same authors advocated bronchoscopy as a diagnostic
procedure at the time of hospital admission for patients with inhalation injury. Similarly, they mention that intubation to increase the ease of pulmonary toilet can be
potentially beneficial.
An understanding of the underlying pathophysiology of inhalation injury is key to early diagnosis and effective treatment. Given the complex and often variable nature of this
condition and the frequent existence of complicating factors such as toxic gas exposures and secondary infections, respiratory therapists tending to such patients must
be well versed in all aspects of their identification, management, and, where possible, prevention. In fact, given the potentially lethal nature of inhalation injury, respiratory
therapists should strongly consider becoming more involved in burn prevention efforts.
Stephen L. Richey, CRT, was trained as a cardiopulmonary technician during his service with the US Air Force. He is currently a research project leader investigating
aviation-related injury patterns at Saginaw Valley State University, University Center, Mich.
References
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