From the Guidelines
Respiratory pneumonitis after thermal burns requires immediate attention and management with supplemental oxygen, mechanical ventilation if needed, and careful fluid management to prevent morbidity and mortality. The treatment approach should prioritize maintaining oxygen saturation above 94% using nasal cannula, face mask, or high-flow oxygen systems 1. For severe cases, intubation and mechanical ventilation may be necessary, with lung-protective strategies using tidal volumes of 6-8 mL/kg and PEEP of 5-10 cmH2O.
Some key considerations in managing respiratory pneumonitis after thermal burns include:
- Early recognition and intervention, as symptoms may develop hours after the initial burn injury
- Careful fluid management to prevent both dehydration and fluid overload, which can worsen pulmonary edema
- Use of bronchodilators like albuterol (2.5-5 mg nebulized every 4-6 hours) to manage bronchospasm
- Potential use of corticosteroids such as methylprednisolone (1-2 mg/kg/day) to reduce inflammation, although their use remains controversial
- Avoidance of prophylactic antibiotics unless infection is suspected
According to the most recent guidelines, patients with severe burns involving the whole face should be intubated if they meet certain criteria, such as deep circular neck burn, symptoms of airway obstruction, or very extensive burn (TBSA 40%) 1. Additionally, patients with face/neck burns who were exposed to vapors or inhaled smoke should be closely monitored due to the risk of glottis edema and respiratory distress. Fibreoptic bronchoscopy should be undertaken to identify bronchial involvement, evaluate prognosis, and investigate the presence of pneumonitis by bacterial sampling, as recommended by the UK guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults 2016 1.
From the Research
Respiratory Pneumonitis after Thermal Burns
- Respiratory pneumonitis is a significant complication of thermal burns, often caused by inhalation injury, which can lead to airway edema and obstruction, hypoxemic respiratory failure, and pneumonia 2.
- The mainstay of treatment for inhalation injury includes supportive care, such as early intubation, lung-protective or high-frequency-percussive mechanical ventilation, nebulized heparin, and aggressive pulmonary toilet 2.
- Despite these treatments, some patients may progress to severe acute respiratory distress syndrome (ARDS), for which rescue options like extracorporeal membrane oxygenation (ECMO) may be considered 2, 3.
Pathophysiology and Complications
- Inhalation injury can cause direct mucosal injury and indirect inflammation, contributing to respiratory failure in burn patients 4.
- Respiratory failure in burned patients can occur through various mechanisms, including pneumonitis and adult respiratory distress syndrome (ARDS) 5.
- Clinical and experimental studies have shown that damage to the mucosal barrier and the release of inflammatory mediators are key pathophysiological events following smoke inhalation 5.
Management and Treatment
- Emergency department management of patients with thermal burns should prioritize stabilization of airway and breathing, intravenous fluid administration, pain control, and local wound care 6.
- Referral to specialized burn care may be necessary to improve long-term outcomes, especially for patients with severe inhalation injury or those who require ECMO 2, 6.
- Mechanical ventilation settings during ECMO should be tailored to the individual patient, with consideration of the risk of ventilator-induced lung injury and the need to reduce ventilation load 3.