13. Desai MH, Mlcak RP, Richardson J,. et al..(J Burn Care Rehabilitation 1998;19:210-2) Shrine Crippled Children Burn Hospital, Galveston, TX, USA.

Abstract

Introduction: Smoke-inhalation injury causes a destruction of the ciliated epithelium that lines the tracheobronchial tree. Casts produced from these cells, polymorphonuclear leukocytes and mucus can cause upper-airway obstruction, contributing to pulmonary failure. We have reported that a combination of aerosolized heparin and a mucolytic agent, N-acetylcysteine, can ameliorate cast formation and reduce pulmonary failure secondary to smoke inhalation.

Method: In this study, 90 consecutive pediatric patients between 1985 and 1995 who had bronchoscopially diagnosed inhalation injury requiring mechanical ventilation were studied. Forty-three children admitted between 1985 and 1989 acted as controls. Forty-seven children admitted between 1990 and 1994 received 5,000 units of heparin and 3 ml of a 20% solution of N-acetylcysteine aerosolized every 4 hours the first 7 days after injury. All patients were extubated when they were able to meet the Hedley-White criteria and maintain a PaO2/FiO2 ratio of more than 400. The number of patients requiring reintubation for successive pulmonary failure was recorded, as was mortality.

Results: There was a significant decrease in reintubation rates, incidence of atelectasis, and in mortality for patients treated with the regimen of heparin and N-acetylcystine when compared to controls (p<0.05). Heparin/N-acetylcystine nebulization in children with massive burn injury and smoke inhalation injury results in a significant decrease in incidence of reintubation for progressive pulmonary failure and a reduction in mortality.

RP Mlcak. Shriner’s Crippled Children Hospital, Galeston TX USA.

Abstract

Introduction: Smoke inhalation injury continues to be implicated as one of the leading causes of death in patients with burn injuries. Smoke inhalation injury has a reported mortality rate of 20 to 80%. Major pathophysiology findings in these patients include deposition of fibrin cast in the airways and progressive carbon dioxide retention. Conventional therapies directed at the reduction of arterial CO2, maintenance of airway patency, and adequate oxygenation are associated with barotrauma-related complications and often are unsuccessful. We have previously shown a reduction in the incidence of reintubation for progressive pulmonary failure, a decreased incidence of atelectasis, and a reduction in mortality in pediatric patients with inhalation injury treated with aerosolized Heparin/N-acetylcystine therapy.  The purpose of this study is to present the details of our 15 year experience utilizing aerosolized heparin/N acetylcystine inhalations in the treatment of smoke inhalation injury in pediatric burns.

Methods: All medical records from 1990 through June 2005 were reviewed for the presence of inhalation injury. Three thousand six hundred and eighty four patients were admitted during this time period. Five hundred sixty-nine patients had inhalation injury diagnosed by bronchoscopy. All patients were treated with our inhalation injury protocol that consisted of aerosolized heparin/N-acetylcystine. Study variables included; demographics, burn size and mortality rate.

Results:  Five hundred sixty-nine patients were included in this study.  The mean age of patients with inhalation injury was 7 ± 5 years. There were 472 males and 97 females. The mean % TBSA burn was 50 ± 25%. The mean % third degree burn was 39 ± 30%. Seventy-six patients with inhalation injury died for an over all mortality rate of 13%.

Conclusions: Our data show a reduced mortality rate for patients with inhalation injury treated with aerosolized heparin/N-acetylcystine compared to the reported mortality rate in the literature.