今日の臨床サポート

気道熱傷

著者: 松本優 兵庫県立尼崎総合医療センター 救急集中治療科

監修: 志賀隆 国際医療福祉大学 医学部救急医学/国際医療福祉大学病院 救急医療部

著者校正/監修レビュー済:2021/10/13
患者向け説明資料

概要・推奨   

  1. 気道熱傷の診断に気管支ファイバースコープを施行することが勧められる(推奨度1)。
  1. 気道熱傷を合併した全身熱傷においては非合併例より多くの初期輸液量が必要であり、それを考慮して輸液を行うことが勧められる(推奨度1)。
  1. 気道熱傷にステロイド投与は勧められない(推奨度3)。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となりま
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が 必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となり
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
松本優 : 未申告[2021年]
監修:志賀隆 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 気道熱傷患者の初期診療において、ヘパリンのネブライザー吸入を行うことを推奨する。
  1. 気道熱傷患者の初期診療において、N-アセチルシステインのネブライザー吸入を行うことを推奨する。
  1. 上記のごとく、ヘパリンおよびN-アセチルシステインのネブライザー吸入の推奨レベルが改訂された。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 気道熱傷とは、火災や爆発の際に生じる煙や有毒ガス<図表>、高温水蒸気等を吸入することによって惹起される種々の呼吸器障害の総称である[1]
 
一部の毒性化合物の発生源

火災環境に応じて、さまざまな有毒ガスや毒性化合物が発生することがある。

 
  1. 気道熱傷は、①一酸化炭素中毒 ②声帯より口側の損傷 ③声帯より肺側の損傷 ――に分けられる[2]
  1. 米国では熱傷センターに入院する20~50%の熱傷患者に気道熱傷が合併し、その60~70%が死亡している。生命予後を左右する因子の1つである[2]
  1. 外観からは気道熱傷の有無や損傷の程度の判断が難しいため、まず疑うことが診断の第一歩である。
問診・診察のポイント  
  1. 外観からは診断がつきづらくまずは疑うことが重要である。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

著者: P Hantson, R Butera, J L Clemessy, A Michel, F J Baud
雑誌名: Chest. 1997 Mar;111(3):671-5.
Abstract/Text OBJECTIVE: To evaluate the incidence of early pulmonary complications and the value of initial clinical signs and paraclinical investigations in victims of smoke inhalation not suffering from burns following structural fires.
DESIGN: Retrospective chart review.
SETTING: Thirteen-bed ICU.
PATIENTS: Sixty-four victims of smoke inhalation following household fires were admitted to the ICU between January 1987 and December 1992. Exclusion criteria from the study were patients with cutaneous burns or multiple trauma or blast injury, and patients found in cardiac arrest.
METHODS: Clinical, biological, and radiologic parameters were collected over a 5-day period.
RESULTS: The mortality rate in relation to progressive respiratory failure was 3.1%. Mean ICU stay was 5.8 days (range, 1 to 33 days), and was longer in the patients presenting with soot deposits in the oropharynx (p = 0.02), dysphonia (D) (p = 0.05), or ronchi (R) (p = 0.0004) at the first examination, and in those having a positive sputum bacteriologic analysis (p = 0.003) or requiring parenteral bronchodilator agents for more than 24 h (p = 0.04). Thirty-five patients underwent mechanical ventilation (MV) for a mean of 101.2 h (range, 8 to 648 h). Mean MV duration was higher in the patients presenting initially with R (p = 0.003), high carbon monoxide (but not cyanide) levels (p = 0.02), or a positive bacteriologic sample (p = 0.0001). Positive bacteriologic sampling correlated with the presence of D (p = 0.02) or R (p = 0.04) and with immediate intubation (p = 0.0003). No correlation was found with chest radiograph.
CONCLUSIONS: In this selected series of fire victims without cutaneous burns, respiratory injury was frequent. The initial clinical signs may be helpful to predict pulmonary complications.

PMID 9118707  Chest. 1997 Mar;111(3):671-5.
著者: Frederick W Endorf, Richard L Gamelli
雑誌名: J Burn Care Res. 2007 Jan-Feb;28(1):80-3. doi: 10.1097/BCR.0B013E31802C889F.
Abstract/Text Inhalation injury (INHI) associated with thermal injury has been shown to increase the rate of mortality. Several investigators have shown that patients with inhalation and burn injuries will require increased fluid volumes during acute resuscitation when compared with patients with burn injury alone. Other groups have examined the use of lung compliance and airway resistance as predictors of outcome in patients with INHI. We hypothesized that increased fluid requirements would more closely correlate with perturbations in pulmonary performance than with mere presence or absence of INHI or the degree of injury by bronchoscopic criteria. We performed a retrospective chart review during a period of 3 years. We identified 80 patients with suspected INHI that required intubation, mechanical ventilation, and fiber optic bronchoscopy in the first 24 hours of their admission. Variables collected included age, sex, weight and %TBSA burned, as well as blood alcohol level, the presence of head and neck burns and escharotomies, and admission carbon monoxide levels. Patients were classified into five groups according to a grading system of INHI (0, 1, 2, 3, and 4), derived from findings at initial bronchoscopy and based on AIS criteria. The following pulmonary parameters were noted at regular intervals: mode of ventilation, tidal volume, peak inspiratory pressures, mean airway pressures, and compliance. The P:F ratio also was recorded at regular intervals. Total fluid volume infused was noted at 0-, 24-, and 48-hour intervals, and was calculated as ml/kg/%TBSA. Outcomes were measured by in-hospital survival, ventilator days, intensive care unit days, and total length of stay. Patients were well matched for %TBSA among the different bronchoscopic grades of INHI, and those with grades 2, 3, and 4 injuries had a significantly worse survival than those with grades 0 or 1 (P = .03). However, grades 2, 3, and 4 did not have increased acute fluid requirements when compared with grades 1 and 2 injuries. Initial pulmonary compliance likewise did not correlate with acute fluid requirements. However, those patients with a P:F ratio less than 350 at presentation had a statistically significant increase in ml/kg/%TBSA compared with those with P:F >350 (P = .03). They did not have more ventilator days or a statistically worse survival. Fiber optic bronchoscopy is useful in the diagnosis of INHI, and overall survival is worse in those patients with worse grades of injury by bronchoscopic criteria. However, the P:F ratio may be a more accurate predictor of increased fluid requirements during the acute resuscitation.

PMID 17211205  J Burn Care Res. 2007 Jan-Feb;28(1):80-3. doi: 10.1097/・・・
著者: Leopoldo C Cancio
雑誌名: Clin Plast Surg. 2009 Oct;36(4):555-67. doi: 10.1016/j.cps.2009.05.013.
Abstract/Text Smoke inhalation injury, a unique form of acute lung injury, greatly increases the occurrence of postburn morbidity and mortality. In addition to early intubation for upper-airway protection, subsequent critical care of patients who have this injury should be directed at maintaining distal airway patency. High-frequency ventilation, inhaled heparin, and aggressive pulmonary toilet are among the therapies available. Even so, immunosuppression, intubation, and airway damage predispose these patients to pneumonia and other complications.

PMID 19793551  Clin Plast Surg. 2009 Oct;36(4):555-67. doi: 10.1016/j.・・・
著者: J L Hunt, R N Agee, B A Pruitt
雑誌名: J Trauma. 1975 Aug;15(8):641-9.
Abstract/Text Fiberoptic bronchoscopy proved to be a simple, safe, and accurate method of diagnosing acute inhalation injury. Both the anatomic level and the severity of large airway injury were easily identified. The identification of a supraglottic and infraglottic component to inhalation injury was not only helpful in determining the appropriate therapy but also in predicting ultimate pulmonary complications. When bronchoscopy was used in conjunction with the 133Xenon scintiphotoscan, both large and small airway injuries could be identified. The only clinical situation where bronchoscopy failed to identify an inhalation injury was in the immediate postburn period if the patient wasin hypovolemic shock. In this particular clinical circumstance the characteristic mucosal alterations may be absent; yet if bronchoscopy is performed after hypovolemic shock has been corrected, mucosal changes characteristic of inhalation injury will be seen.

PMID 1152086  J Trauma. 1975 Aug;15(8):641-9.
著者: J A Moylan, D W Wilmore, D E Mouton, B A Pruitt
雑誌名: Ann Surg. 1972 Oct;176(4):477-84. doi: 10.1097/00000658-197210000-00005.
Abstract/Text
PMID 5077408  Ann Surg. 1972 Oct;176(4):477-84. doi: 10.1097/00000658・・・
著者: W Y Lin, C H Kao, S J Wang
雑誌名: Eur J Nucl Med. 1997 Feb;24(2):125-9.
Abstract/Text Mortality and morbidity in fire victims are largely a function of injury due to heat and smoke. While the degree and area of burn together constitute a reliable numerical measure of cutaneous injury due to heat, as yet no satisfactory measure of inhalation injury has been developed. In this study, we employed technetium-99m diethylene triamine penta-acetic acid (DTPA) radioaerosol lung scintigraphy (inhalation scan) to evaluate acute inhalation injury in fire victims. Ten normal controls and 17 survivors from a fire accident were enrolled in the study. All patients suffered from respiratory symptoms (dyspnoea and/or cough with sputum). 99mTc-DTPA aerosol inhalation lung scintigraphy was performed in all subjects, using a commercial lung aerosol delivery unit. The degree of lung damage was presented as the clearance rate (k; %/min) calculated from the time-activity curve over the right lungs. In addition, the distribution pattern of the radioactivity in the lungs was evaluated and classified into two groups: homogeneous distribution and inhomogeneous distribution. A plain chest radiograph (CxR) and pulmonary function test (PFT) were performed in the same group of patients. The results showed that 6/17 (35.3%) patients had inhomogeneous distribution of radioactivity in their inhalation scans, and 11/17 (64.7%) had homogeneous scans. Five of the six patients with inhomogeneous scans were admitted for further management, and all patients with homogeneous scans were discharged from the emergency department and needed no further intensive care. The clearance rates of the right lung were 0.73%+/-0.13%/min for normal controls and 1.54%+/-0.58%/min for fire victims. The difference was significant, with a P value of less than 0.01. Using a cut-off value of 0.9%/min (all normal subjects were below 0. 9%/min), 14 (82.4%) patients had abnormal clearance rates of 99mTc-DTPA from the lung. In contrast, only three (17.6%) patients had abnormal CxR and three (17.6%) had abnormal PFTs. We conclude that (1) conventional CxR and PFT are not good modalities for evaluating inhalation injury in fire victims because of their low sensitivity, and (2) 99mTc-DTPA radioaerosol inhalation scintigraphy can provide an objective evaluation of inhalation injury during a fire accident and may be useful in therapeutic decision-making and disease monitoring.

PMID 9021108  Eur J Nucl Med. 1997 Feb;24(2):125-9.
著者: S H Chou, S-D Lin, H-Y Chuang, Y-J Cheng, E L Kao, M-F Huang
雑誌名: Surg Endosc. 2004 Sep;18(9):1377-9. doi: 10.1007/s00464-003-9234-2. Epub 2004 May 28.
Abstract/Text BACKGROUND: Fiber-optic bronchoscopy is widely used for the early diagnosis of inhalation injury. However, there is no current bronchoscopic classification of inhalation injury for the prediction of acute lung injury (ALI). Our goal was to devise such a classification.
METHODS: Between February 1993 and January 2002, 167 patients with highly suspicious inhalation injuries were collected. All patients received fiber-optic bronchoscopy within 24 h after their accident. In total, 108 patients were diagnosed as positive under direct inspection. The patients were divided into three groups (G(1), G(2), and G(3)) according to the depth of mucosal damage. Six patients were found to be positive by biopsy and were assigned to group Gb. Of these 114 positive cases, 27 developed ALI. Meanwhile, 53 patients were diagnosed as negative; these patients were assigned to group G(0).
RESULTS: After analysis, the following results were noted: G(0) (n = 53), two ALI (3.8%); G(1) (n = 49), two ALI (4%); G(2) (n = 46), 15 ALI (33%); G(3)(n = 13),10 ALI (77%); Gb (n = 6), no ALI. We discovered that the deeper the mucosal injuries, the higher the rate of ALI. There were no deaths related to the procedure.
CONCLUSIONS: Fiber-optic bronchoscopy is a safe and effective method for the early diagnosis of inhalation injuries. Also, it is a good predictor of ALL. We hope that in the near future, this classification will serve as a treatment guideline for the early prevention of ALI. The more severe the damage, the more alert clinicians need to be to improve the patient's chances for survival.

PMID 15164282  Surg Endosc. 2004 Sep;18(9):1377-9. doi: 10.1007/s00464・・・
著者: H G Bingham, T J Gallagher, M D Powell
雑誌名: J Trauma. 1987 Nov;27(11):1286-8. doi: 10.1097/00005373-198711000-00014.
Abstract/Text Twenty-seven burned patients who had facial burns, hoarseness, or evidence of carbonaceous sputum or had been in a smoke-filled enclosed space underwent fiberoptic bronchoscopy at the time of admission. Airway severity was indexed (grades 1-5, grade 5 being the most severe). Fifteen nonsurvivors had a bronchoscopic index of 3.2 +/- 1.6 and 12 survivors an index of 3.4 +/- 1.2 (p greater than 0.05). No patient died of respiratory complications. Bronchoscopic index correlated poorly with the level of positive end expiratory pressure required to maintain oxygenation in any patient (r = 0.50). Likewise, bronchoscopic index did not correlate with duration of intubation in any survivor (r = 0.33). Immediate bronchoscopy after burn injury neither indicates the level of respiratory support that will be required nor predicts its duration.

PMID 3682040  J Trauma. 1987 Nov;27(11):1286-8. doi: 10.1097/00005373・・・
著者: C Wittram, J B Kenny
雑誌名: Br J Radiol. 1994 Aug;67(800):751-4. doi: 10.1259/0007-1285-67-800-751.
Abstract/Text The admission chest radiographs of 29 patients admitted with acute inhalation injury and burns, who required ventilatory support, were analysed for signs of inhalation injury. Four were excluded because of a history of chronic bronchitis or cardiac failure. 13 had radiological signs of inhalation injury, which included oedema of a nodular, consolidatory and interstitial pattern, and linear opacities due to atelectasis. 12 chest radiographs were normal. Inhalation injury in burns cases often requires clinical, bronchoscopic and blood gas assessment. Although changes were noted on 13/25 chest radiographs, the admission chest radiograph is an insensitive indicator of airway and parenchymal lung damage following acute inhalation injury and burns. We draw attention to the fact that significant lung damage may be present even with a normal initial chest radiograph.

PMID 8087478  Br J Radiol. 1994 Aug;67(800):751-4. doi: 10.1259/0007-・・・
著者: Kicheol You, Hyeong-Tae Yang, Dohern Kym, Jaechul Yoon, HaejunYim, Yong-Suk Cho, Jun Hur, Wook Chun, Jong-Hyun Kim
雑誌名: Burns. 2014 Dec;40(8):1470-5. doi: 10.1016/j.burns.2014.09.015. Epub 2014 Oct 16.
Abstract/Text This study was to re-evaluate inhalation injury as a prognostic factor in burn patients and to determine the factors that should be considered when refining the definition of inhalation injury. A total of 192 burn patients (152 men, 40 women; mean age, 46.1±13.8 years) who were suspected to have an inhalation injury and underwent bronchoscopy between January 2010 and June 2012 were included in this prospective observational study. All patients underwent bronchoscopy within 24h of sustaining the burn. The bronchoscopic findings were classified as normal, mild, moderate, and severe. Mechanical ventilation was administered, when required. Age, percentage of TBSA burned, ABSI score, requirement of mechanical ventilation and PF ratio, but not inhalation injury, COHb level, and bronchoscopic grades, significantly differed between the survivors and non-survivors (p<0.05). Mechanical ventilation (adjusted odds ratio [OR]: 9.787) and severe inhalation injury on bronchoscopy (adjusted OR: 45.357) were independent predictors of mortality on multivariate logistic regression analysis. Inhalation injury diagnosed through history does not predict mortality from burns. Other components such as severity of inhalation injury determined using bronchoscopy, and administration of mechanical ventilation might help predict the morbidity and mortality of burn patients with inhalation injury and all of the factors should be considered when the definition of inhalation injury is refined.

Copyright © 2014 Elsevier Ltd and ISBI. All rights reserved.
PMID 25406889  Burns. 2014 Dec;40(8):1470-5. doi: 10.1016/j.burns.2014・・・
著者: Hitoshi Yamamura, Shinichiro Kaga, Kazuhisa Kaneda, Yasumitsu Mizobata
雑誌名: Crit Care. 2013 May 25;17(3):R95. doi: 10.1186/cc12740. Epub 2013 May 25.
Abstract/Text INTRODUCTION: Smoke-inhalation injury is a major cause of mortality in burn patients, and therefore, it is important to determine accurately the severity of such injuries in these patients. The objective of this study was to evaluate whether chest computed tomography (CT) can be used for detecting early predictors of severity and complications of smoke-inhalation injury.
METHODS: We evaluated 37 patients who had sustained smoke-inhalation injuries and had undergone chest CT within a few hours of admission to a hospital. Bronchoscopy was performed according to a standardized protocol within 12 hours of admission in all smoke-inhalation injury patients. Bronchial-wall thickness (BWT) was measured 2 cm distal from the tracheal bifurcation with CT images, and the following data were collected: total number of ventilator days, duration of intensive care unit (ICU) stay, pneumonia development, and patient outcome.
RESULTS: The mean age of the patients was 63±18 years (range, 22 to 87 years), 31 (83.8%) of the patients were men, and the mortality rate was 10.8%. The causes of death in these patients were smoke inhalation (n=1), hemorrhage (n=1), and other factors resulting in sepsis (n=2). The initial carboxyhemoglobin level was 13%±14% (range, 1% to 50%). No significant correlation was found between bronchoscopic scoring and clinical factors. However, significant correlations were noted between admission BWT and development of pneumonia (R2=0.41; P<0.0001) and total number of ventilator days (R2=0.56; P<0.0001) and ICU-stay days (R2=0.17; P=0.01). Receiver operating characteristic curve analysis showed that an admission BWT cutoff value of >3.0 mm predicted pneumonia development with a sensitivity of 79%, specificity of 96%, positive predictive value of 91%, and negative predictive value of 88%.
CONCLUSION: BWT measured by using the chest CT scans obtained within a few hours of admission was predictive of the total number of ventilator days and ICU-stay days and the development of pneumonia in patients with smoke-inhalation injuries.

PMID 23706091  Crit Care. 2013 May 25;17(3):R95. doi: 10.1186/cc12740.・・・
著者: P D Navar, J R Saffle, G D Warden
雑誌名: Am J Surg. 1985 Dec;150(6):716-20.
Abstract/Text The presence of inhalation injury has been reported to increase fluid requirements for resuscitation from burn shock after thermal injury. To evaluate the effect of inhalation injury on the magnitude of burn-induced shock, the characteristics of resuscitation of 171 patients with burns covering at least 25 percent of the total body surface area were reviewed. When inhalation injury was suspected, confirmation by xenon-133 scanning, bronchoscopy, or both was obtained. Initial fluid resuscitation was calculated according to the Parkland formula, and titration was initiated to maintain a urine output of 30 to 50 ml/hour. Fifty-one patients had inhalation injuries. Patients with inhalation injuries had a mean fluid requirement of 5.76 ml/kg per percentage of total body surface area burned and a mean sodium requirement of 0.94 mEq/kg per percentage of total body surface area burned to achieve successful resuscitation, compared with a fluid requirement of 3.98 ml/kg per percentage of total body surface area burned and a sodium requirement of 0.68 mEq/kg per percentage of total body surface area burned for the group without inhalation injury (p less than 0.05). These data confirm and quantitate that inhalation injury accompanying thermal trauma increases the magnitude of total body injury and requires increased volumes of fluid and sodium to achieve resuscitation from early burn shock.

PMID 4073365  Am J Surg. 1985 Dec;150(6):716-20.
著者: Seung Ick Cha, Chang Ho Kim, Jae Hee Lee, Jae Yong Park, Tae Hoon Jung, Won Il Choi, Seung Bum Han, Young June Jeon, Kyeong Cheol Shin, Jin Hong Chung, Kwan Ho Lee, Yeon Jae Kim, Byeong Ki Lee
雑誌名: Burns. 2007 Mar;33(2):200-8. doi: 10.1016/j.burns.2006.07.017. Epub 2006 Dec 13.
Abstract/Text Relatively few reports exist regarding isolated smoke inhalation injuries in human patients. In this study, we describe the acute manifestations and short-term evolution of respiratory injuries after isolated smoke inhalation in victims of fires. Ninety-six patients admitted as the result of a subway fire were examined for acute respiratory dysfunction with clinical outcomes. Some of the survivors suffering from less severe injuries were evaluated for changes in pulmonary function over time, with the effects of steroid treatment. In 13 patients (14%), immediate respiratory failure resulted from ventilatory insufficiency, which was induced principally by mechanical airway obstruction, and manifested as significantly lowered pH and higher PaCO2 levels than in the patients requiring no mechanical ventilation. Toilet bronchoscopy allowed for early liberation from mechanical ventilation. Along with the death of 4 patients (4%), vocal cord and tracheal stenosis were noted in 5 patients and 1 patient, respectively, among 17 patients for whom endotracheal intubation was required. Pulmonary functions improved significantly after 3 months, with no further changes being observed within the subsequent 3 months. Steroid therapy resulted in no additional improvements in the pulmonary functions of these patients. In patients with isolated smoke inhalation injuries, immediate ventilatory insufficiency resulting from mechanical airway obstruction should be watched for, and managed via toilet bronchoscopy. Vigilance is required to avoid airway complications after endotracheal intubation. The improvement of pulmonary functions progressed primarily within the first 3 months, whereas short-course steroid therapy exerted no influence on the eventual recovery of pulmonary functions in the less severe cases.

PMID 17169496  Burns. 2007 Mar;33(2):200-8. doi: 10.1016/j.burns.2006.・・・
著者: Michał Zieliński, Piotr Wróblewski, Jerzy Kozielski
雑誌名: Adv Respir Med. 2019;87(3):184-188. doi: 10.5603/ARM.2019.0029.
Abstract/Text Inhalation injury is a major cause of morbidity and mortality in patients with burns. Presence of airways injury adds to the need of fluid supplementation, increases risk of pulmonary complications. Due to many mechanisms involved in pathophysiology the treatment is complex. Among them the formation of fibrin casts inside airways constitutes a prominent element. The material residing in tracheobronchial tree causes ventilation-perfusion mismatch, complicates mechanical ventilation, provides a medium for bacterial growth. Many studies of animal models and single centre human studies investigated inhaled anticoagulation regimens employing heparin in management of inhalation injury. Simultaneously safety, especially in connection with possible bleeding risk, was the subject of research. The results suggest positive impact on treatment results, with low risk of side effects. This paper revise the available clinical data on inhaled heparin use in patients with burns.

PMID 31282560  Adv Respir Med. 2019;87(3):184-188. doi: 10.5603/ARM.20・・・
著者: Kaitlin A McGinn, Katie Weigartz, Alicia Lintner, Michael J Scalese, Steven A Kahn
雑誌名: J Pharm Pract. 2019 Apr;32(2):163-166. doi: 10.1177/0897190017747143. Epub 2017 Dec 12.
Abstract/Text OBJECTIVE: Nebulized heparin has been proposed to improve pulmonary function in patients with inhalation injuries. The purpose of this study was to evaluate the impact of nebulized heparin with N-acetylcysteine (NAC) and albuterol on the duration of mechanical ventilation in burn patients.
METHODS: This is a retrospective study evaluating mechanically ventilated adult patients admitted to a regional burn center with inhalation injury. Outcomes were compared between patients who were prescribed a combination of nebulized heparin with NAC and albuterol versus similar patients who did not.
RESULTS: A total of 48 patients met inclusion criteria (heparin n = 22; nonheparin n = 26). Patients in the nonheparin group had higher percentage of total body surface area (TBSA) burned (29.00 [5.75-51.88] vs 5.25 [0.50-13.25] %TBSA; P = .009), longer duration of mechanical ventilation (6.50 [2.75-17.00] vs 3.00 [1.00-8.25] days; P = .022), and longer intensive care unit length of stay (LOS) (3.00 [3.00-28.75] vs 5.50 days [2.00-11.25]; P = .033). Upon regression, use of heparin was the only variable associated with reducing the duration of mechanical ventilation ( P = .039).
CONCLUSION: Nebulized heparin in combination with NAC and albuterol was associated with a significant reduction in the duration of mechanical ventilation.

PMID 29233052  J Pharm Pract. 2019 Apr;32(2):163-166. doi: 10.1177/089・・・
著者: B Venus, T Matsuda, J B Copiozo, M Mathru
雑誌名: Crit Care Med. 1981 Jul;9(7):519-23.
Abstract/Text Burn mortality statistics are influenced by age and degree of total surface body burn. The addition of an inhalation injury to a cutaneous burn results in a significant increase in mortality rate. Nine hundred fourteen patients with acute thermal injury were screened for positive history of burn in a closed space, facial or oropharyngeal burn, singed nasal vibrisae, carbonacious sputum, and clinical signs of upper airway involvement. On admission, 84 patients (9.2%) had more than one of the previously mentioned factors. They were prophylactically intubated and placed on optimum level of continuous positive airway pressure (CPAP) and intermittent mandatory ventilation (IMV). The mortality rate among patients without inhalation injury was 7.1%, while 54.7% of patients with inhalation injury died. Comparison of burn patients with inhalation injury to those without pulmonary involvement at the same age group and with the same percentage of burn showed significantly higher mortality rate in patients with inhalation injury. The main cause of death in the first 72 h postburn (stage 1) in patients without inhalation injury was peripheral shock (10.1%) and in patients with inhalation injury was peripheral shock (15.2%) and cardiac failure (10.8%). No pulmonary related death occurred in this stage. In 3-10 days postburn period (stage 2), burn wound sepsis (10.1%) and cardiac failure (11.8%) were the major causes of death in patients with inhalation injury. In patients with inhalation injury, pulmonary sepsis (26%) was the major cause of death in this stage. Major causes of death after 10 days postburn (stage 3) in patients without inhalation injury were pulmonary sepsis (20%) and burn wound sepsis (22%). In patients with inhalation injury, burn wound sepsis (21.7%) was the main cause of death. These data suggest that prophylactic intubation and CPAP therapy in burn patients with suspected inhalation injury prevent pulmonary related death in early stage of burn. Irrespective of presence of inhalation injury, sepsis originating from the wound or respiratory tract is the main cause of death in the late stage of burn.

PMID 7016441  Crit Care Med. 1981 Jul;9(7):519-23.
著者: Shawn Moshrefi, Clifford C Sheckter, Kimberly Shepard, Clifford Pereira, Drew J Davis, Yvonne Karanas, Danielle H Rochlin
雑誌名: J Burn Care Res. 2019 Apr 26;40(3):341-346. doi: 10.1093/jbcr/irz016.
Abstract/Text The decision to intubate acute burn patients is often based on the presence of classic clinical exam findings. However, these findings may have poor correlation with airway injury and result in unnecessary intubation. We investigated flexible fiberoptic laryngoscopy (FFL) as a means to diagnose upper airway thermal and inhalation injury and guide airway management. A retrospective chart review of all burn patients who underwent FFL from 2013 to 2017 was performed. Their charts were reviewed to determine the indications for FFL including the historical data and physical exam findings that indicated airway injury as well as patient age, TBSA, type and depth of burn injury, carboxyhemoglobin level, and clinical course. Fifty-one patients underwent FFL, with an average TBSA of 6.5% (range 0.5-38.0%) and carboxyhemoglobin level of 3.5%. Burn mechanism was flame (35.3%) or flash (51.0%), with 50% occurring in enclosed spaces. In all cases, the decision to perform FFL was based on physical exam findings meeting criteria for intubation, including facial burns, singed nasal hairs, nasal soot, voice change, throat pain or abnormal sensation, shortness of breath, carbonaceous sputum, wheezing, or stridor. Based on FFL, 9 patients (17.7%) were treated with steroids, 28 patients (54.9%) received supportive care, and 6 patients (11.8%) had repeat FFL for monitoring. One patient was intubated after repeat FFL examination. All patients who underwent FFL met traditional criteria for intubation based on exam, however 98% were monitored without issues based on FFL findings. FFL is a valuable tool that can lead to fewer intubations in acute burn patients with a stable respiratory status for whom history and physical exam suggest upper airway injury.

© American Burn Association 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
PMID 31222272  J Burn Care Res. 2019 Apr 26;40(3):341-346. doi: 10.109・・・
著者: Kazuki Matsumura, Ryo Yamamoto, Tomohiro Kamagata, Tomohiro Kurihara, Kazuhiko Sekine, Kiyotsugu Takuma, Kenichi Kase, Junichi Sasaki
雑誌名: Burns. 2020 Aug;46(5):1201-1207. doi: 10.1016/j.burns.2019.12.017. Epub 2020 Jan 22.
Abstract/Text BACKGROUND: Strategies to predict delayed airway obstruction in patients with inhalation injury have not been extensively studied. This study aimed to develop a novel scale, predicting the need for Delayed Intubation after inhalation injury (PDI) score.
METHODS: We retrospectively identified patients with inhalation injury at four tertiary care centers in Japan between 2012 and 2018. We included patients aged 15 or older and excluded those intubated within 30 min after hospital arrival. Predictors for delayed intubation were identified with univariate analyses and scored on the basis of odds ratios. The PDI score was evaluated with the area under the receiver operating characteristic (AUROC) curve and compared with other scaling systems for burn injuries.
RESULTS: Data from 158 patients were analyzed; of these patients, 18 (11.4%) were intubated during the delayed phase. Signs of respiratory distress, facial burn, and pharyngolaryngeal swelling observed on laryngoscopy, were identified as predictors for delayed intubation. The discriminatory power of the PDI (AUROC curve = 0.90; 95% confidence interval, 0.83 to 0.97; p < 0.01) was higher than that of the other scaling systems.
CONCLUSIONS: We developed a novel scale for predicting delayed intubation in inhalation injury. The score should be further validated with other population.

Copyright © 2020 Elsevier Ltd and ISBI. All rights reserved.
PMID 31982185  Burns. 2020 Aug;46(5):1201-1207. doi: 10.1016/j.burns.2・・・
著者: W G Cioffi, L W Rue, T A Graves, W F McManus, A D Mason, B A Pruitt
雑誌名: Ann Surg. 1991 Jun;213(6):575-80; discussion 580-2.
Abstract/Text Death and the incidence of pneumonia are significantly increased in burn patients with inhalation injury, despite application of conventional ventilatory support techniques. The effect of high-frequency percussive ventilation on mortality rate, incidence of pulmonary infection, and barotrauma were studied in 54 burn patients with documented inhalation injury admitted between March 1987 and September 1990 as compared to an historic cohort treated between 1980 and 1984. All patients satisfied clinical criteria for mechanical ventilation. High-frequency percussive ventilation was initiated within 24 hours of intubation. The patients' mean age and burn size were 32.2 years and 47.8%, respectively (ranges, 15 to 88 years; 0% to 90%). The mean number of ventilator days was 15.3 +/- 16.7 (range, 1 to 150 days), with 26% of patients ventilated for more than 2 weeks. Fourteen patients (25.9%) developed pneumonia compared to an historic frequency of 45.8% (p less than 0.005). Mortality rate was 18.5% (10 patients) with an expected historic number of deaths of 23 (95% confidence limits of 17 to 28 deaths). The documented improvement in survival rate and decrease in the incidence of pneumonia in patients treated with prophylactic high-frequency ventilation (HFV), as compared to a cohort of patients treated in the 7 years before the trial, indicates the importance of small airway patency in the pathogenesis of inhalation injury sequelae and supports further use and evaluation of HFV.

PMID 2039288  Ann Surg. 1991 Jun;213(6):575-80; discussion 580-2.
著者: P Reper, O Wibaux, P Van Laeke, D Vandeenen, L Duinslaeger, A Vanderkelen
雑誌名: Burns. 2002 Aug;28(5):503-8.
Abstract/Text Inhalation injury and bacterial pneumonia represent some of the most important causes of mortality in burn patients. Thirty-five severely burned patients were randomised on admission for conventional ventilation (CV; control group) versus high frequency percussive ventilation (HFPV; study group). HFPV is a ventilatory mode, introduced 10 years ago which combines the advantages of CV with some of those of high frequency ventilation. Arterial blood gases, ventilatory and hemodynamic variables were recorded for 5 days at 2h intervals. Incident complications were classically managed. A statistical analysis (Student's t-test and Wilcoxon signed rank test) demonstrated a significant higher PaO(2)/FiO(2) from days 0 to 3 in the HFPV group. No significant differences were observed for the other parameters. Our findings suggest that HFPV can improve blood oxygenation during the acute phase following inhalation injury allowing reduction of FiO(2). No significant differences were observed between groups for mortality nor incidence of infectious complications in this study.

PMID 12163294  Burns. 2002 Aug;28(5):503-8.

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