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cous plugging, and increased secretions. The prevention of pneumonia involves meticulous pulmonary hygiene, use of specialized ventilator modes (such as percussive ventilation), and frequent bronchoscopy both for diagnosis and to clear debris. The use of prophylactic antibiotics is not recommended, as this practice may predispose to the development of more virulent organisms. Clinicians need to remain vigilant and monitor patients closely for the development of pneumonia. Early aggressive evaluation of pneumonia via bronchoalveolar lavage will facilitate the use of appropriate antibiotic therapy. Common organisms isolated from burn/inhalation injury patients vary widely. Infections reported include the SPACE group (Serratia, Pseudomonas aeruginosa, Acinetobacter, Citrobacter, and Enterobacter species), methicillin resistant Staphylococcus aureus (MRSA), and other (Hemophilus influenzae, Streptococcus, Klebsiella) [91].

One potential method for decreasing the incidence of pneumonia while providing definitive airway management after inhalation injury is tracheostomy. Early tracheostomy, which decreases dead space, improves laminar flow, and allows for improved pulmonary toilet, has been shown to be of benefit in children requiring greater than 10 days of intubation in several studies [92, 93]. However, a single center study in adults did not confirm these findings [94]. The use of tracheostomy is generally recommended for patients with major burn injury ( > 50% TBSA) involving the face who will require mechanical ventilation for > 10 days.

The use of steroids in inhalation injury has been controversial. Several studies performed in the 1970s and 1980s demonstrated increased infection rates in patients treated with steroids [95–97]. More recent studies have not shown any benefits to steroid administration after inhalation injury [98, 99]. As such, the use of steroids after inhalation injury is not recommended.

Nutrition after burn and inhalation injury may also contribute to patient outcomes. The early institution of enteral nutrition has been shown to decrease infection rates and improve mortality in patients with inhalation injury compared to intravenous nutrition [100]. The primary route of nutrition for patients with burn/inhalation injury should thus be enteral, and parenteral nutrition should be avoided. To date there

is little evidence that immune enhancing enteral formulas provide improvements in infectious rate or mortality in burn/inhalation injury [101].

Prognosis

Inhalation injury is one of the most important predictors of morbidity and mortality in burn patients. When present, INH-INJ increases mortality in up to 15 times [1, 2]. INH-INJ requires endotracheal intubation, which in turn increases the incidence of pneumonia.

As mentioned before, pneumonia is a common complication of INH-INJ, and increases mortality in up to 60% in these patients [2]. Patients usually recover full pulmonary function and late complications are not the rule. Complications can be secondary to the INH-INJ or to the endotracheal or tracheostomy tube. Hyper-reactive airways and altered patterns on pulmonary function (obstructive and restrictive) have been described following INH-INJ [5]. Scarring of the airway can cause stenosis and changes in the voice, requiring voice therapy and occasionally surgery.

Conclusions

The evaluation, diagnosis, and treatment of the three types of inhalation injury continue to challenge both experienced and inexperienced practitioners. Although the evaluation of each type of inhalation injury have the same foundation, there are subtle, but significant differences among the three. In addition, the various forms of inhalation injury do not occur in isolation. For example, patients with carbon monoxide toxicity will often have concomitant upper or lower airway injury, as well. Management of each of the forms of injury vary. Inhaled gas exposure requires attention to resuscitation and oxygenation, upper airway injury requires intubation until airway edema resolves, and lower airway injury may require extended periods of mechanical ventilation to maintain ventilation and oxygenation for ALI/ARDS. Finally, prognosis varies based on the extent and type of inhalation injury involved. Timely diagnosis and treatment thus remain the key to improving outcomes in patients with inhalation injury.

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