Episode 10: Inhalational Injury

(upbeat music) - Welcome to TBSA, the Berm Surgery and Critical Care podcast bringing you up to date, relevant content for the treatment of critically ill-breared patients. (upbeat music) Welcome back everybody to TBSA, the Berm Surgery and Critical Care podcast. My name's Jake. - My name's Luke. I've come today to talk about inhalation injury. Pretty decent topic. We've titted up a little bit during our breathing section, during our primary survey lecture series. But like we said in that one, we're gonna be going a little bit more into pathophysiology, talking about diagnosis a little more in-depth about treatment, hearing the Isoos since we're now in the 48 hours of initial burn or cessitation. And again, kind of talk about how we do it and some take home points. And so I guess Luke, you wanna lead us off with talking about why this is a relevant thing for us in Berm Care? - Yeah, so I mean it's, one of the, we kinda talked about it last time of the things that people really care about in burn and what's so different about burn. And when we get residents and fellows and seems like everybody wants to do a recess, everybody wants to see an inhalation injury plus minus esurotomy. - Right. - And so inhalation injury, it is a big deal. But the things that we can do for it aren't crazy, it's broad. And so let's just get off on incidents and why this matters. So the incidents for inhalation injury is between 11.2 and 19.8% and all-comer burns. It is associated with increased ventilator days. I used to think that it increased your arduous risk. - But as we've discussed. - Yeah, but that may not be the case. It may not be an independent predictor for ARDS, which still seems crazy to me. It does have an increased pneumonia risk, which increased pneumonia with pneumonia plus burn does have a 60% mortality. And I think we talked about last time I'm very uncomfortable with even numbers, especially even numbers that end with zero. But this has been validated in further studies. This 60% mortality number has longer ICU length of stay. We don't like that and then increased your mortality. So the pneumonia risk, which is the thing that I think I mostly care about because of the high mortality and talking about inhalation injury. And especially not just knowing that there is an pneumonia risk, but also having ways to prevent the pneumonia is a very important part of this. And so there have been some studies, Sharani at all as well as Walker at all. That showed this increased pneumonia risk. And I think that a lot of our treatments when we start talking about our treatments are gonna be talking about how do we prevent this pneumonia? 'Cause that's sort of in the forefront of my mind when talking about inhalation injury is like, "Okay, well they have an inhalation injury. I know they have an increased mortality, which you're gonna talk about, but I know they have an increased mortality just by having an increased risk of pneumonia. How do I prevent that pneumonia? - Right, we already kind of in a fixed state of, inhalation injury positive. We can't ameliorate that, but what can we do to prevent downstream side effects from that right? - Exactly. So with that, let's talk about the mortality risk. We have long known that mortality and inhalation injury are inextricably linked. Historically, one of the ways we looked at mortality was just TBSA burn size. We would say age plus burn size gives you a predicted mortality. And this was classically described by Boe and had the Boe's who were written back in the 1960s. Had developed this no-mogram, he draw a line across the chart and that tells you a base on this age and this TBSA, this is this patient's predicted mortality. And that was valid when it was initially published, but as people manage these patients more and more and they got more clinical experience, they noticed that this inhalational injury risk was also adding to your mortality and adding a significant amount of additional mortality risk. And so that prompted publishing the revised Boe's score, which looks at age TBSA and then plus or minus inhalational injury. And if you have an inhalation injury, that adds 17 to the math of the Boe's score. And the combination of age TBSA plus 17 gives you your now new predicted risk of mortality in the no-mogram. This data is absolutely been carried far forward. If you look at a number of publications, shared in at all in 1924, looked at 1200 burn patients, single center, showed that inhalation injury increased more to 30 to 40% independent of burn size in their study. But then regression modeling actually suggested that the impact was more of 15 to 20% and kind of adds credence that 17% value that the revised Boe's score populated. Clark at all in 2006 did a 5,000 burn patient analysis from the National Burn Registry compared mortality rates with and without inhalation injury. And then the presence of inhalation injury doubled mortality in patients with large burns defined as greater than 40% TBSA. And again, they also did logistical regression analysis because that's what we do for all these patients. And they showed that the odds ratio is 2.3 for death in inhalation injury, which also correlates with on the backwards math and also correlates with a big end about a 17% increase in your TBSA or years in your Boe calculation. So again, more data continued to validate the revised Boe's score as an appropriate endpoint. Bristle Layers in 2010 also found this in a European cohort of 7,500 burn patients. Again, inhalation injury versus not and showed that adjusted Boe modeling had a plus 17 point correction which improved your accuracy for predicting mortality versus the traditional Boe score. And so for all of this, again, it just, it hammers home how significant of an additional mortality burden these patients have simply by the on-off of do you have an inhalation injury or not. And the other thing is this is not severity of inhalation injury. This is just, it's a binary thing. It doesn't matter how severe inhalation injury is, it's either you got it or you don't. And if you got it, you've bought mortality risk. - Yeah, I mean, so we are on an audio podcast. So we can't show you what the Boe's score is, you know, it's a normal gram, you should look it up. It is a, you know, it's a good thing not only for us to look at, but also something to show patients and show families of like, hey, this is what math we have. You know, I usually am like, hey, this is your mortality and this is an increase because you have an inhalation injury. And I can't, like you said, I can't un-inhalation injuries somebody. But this is what we know. Doesn't mean you're gonna treat them differently necessarily if they have a very high mortality, sort of how I bring it to patients. - And I think that's a huge clinical pearl you bring up because I can't tell you how often using real numbers has been helpful for me, for goals of care conversations to these patients. And having the Boe's score pulled up, very helpful in that to give you some real numbers and catch what this looks like. Similar to, I use the American College of Surgeons and Disquip Risk Predictor that can also show you based on type of operation you're doing with their long-term risk in comorbidities, maybe in risk of discharge to sniff and things like that. All of these tools are super helpful to kind of help guide those conversations. So the Boe's score for mortality is just, that is a huge clinical pearl for sure. - Yeah, for sure. Now, kind of segueing from incidents and kind of the background of why this is important. We should probably talk about some of the fundamental pathophysiology of inhalation injury. There's three anatomic, are three pathological states that can get injured as part of an inhalation injury. First, we wanna talk about as a direct thermal injury to the upper airways. We kind of talked about this during our breathing section before direct thermal injury is gonna be to structures above the vocal cords. That's what's gonna give you your upper airway injuries. And again, the heat, while it does typically dissipate quickly in the airways, you got your turbonets, you've got your mouth, you got your tongue, those can kind of help eliminate a lot of that heat, that direct heat. So that way by the time air reaches below your vocal cords, it's lost a lot of that kinetic energy. So it's a lot less toxic, a lot less uncommon for you to have direct thermal insults to the upper airways. Some physical exam findings, as you can see, would be things like a rapid swelling in a demon inside of the airway. People classically talk about the hot potato voice when you have direct thermal insults. Similar to if you had big peritons or abscess, you don't wanna talk or move very much 'cause stretching that mucosa causes a whole lot of discomfort. But it certainly causes it with enough ademic and cause upper airway obstruction. Classic findings in your patients are gonna have vocal cord changes, hoarseness, and they may very well have associated carbonycisputum as that those inefficiently burned elements of the actual thermal source can kind of coat their upper airways and not actually be a lower airway problem. They still have some degree of carbonycisputum. Looking at the next level down, we would say, well, okay, you must have some kind of prankimolar lower airway injury. And these, again, very uncommon to have direct thermal insult causing these problems. This tends to be caused by the downstream metabolic toxins that come from, but whatever your burning sources. these chemicals that are in the air. generated from a burning source can create, we've talked about the toxin-drones of four, but certainly you can have superoxygen species, other things that can be directly damaging to the cells that line the lower airways. These toxic substances cause direct salar injury, direct salar injury causes sloughing and shedding of the mucosa. This can go on to cause bronchorea, as the bronchorea kind of settles in the airways and all the debris settles in the airways that can dry out and eventually cause cast formation with resulting adelectasis, VQ mismatch and hypoxic respiratory failure. Again, this is not a systemic toxin-drones, but this is local cell death at the cellular level being mediated by the volatile chemicals that are coming up from the fire. It's not typically a direct thermal insult. It's very, very rare to have that. Although we'll say that direct thermal insult to the lower airways is a very devastating injury. If you've got so much heat that your upper airways can't diffuse that heat away effectively, that's a real, real significant problem and predicts a very poor clinical outcome typically. Yeah, I think of like steam burns. Yeah, like steam. You know, steam shoots out, you have a deep breath with that happening and that amount of energy is not dissipating just in your upper airway and goes all the way down to your lower airway. Yeah. Another sort of pathology, we've kind of already talked about in the disability podcast, but I think it's worth at the very least brushing up over against and that's the two major toxins that we talked about. If you go back into our disability podcast, you'll get a lot more information about these, but the two main things are your carbon dioxide and then your cyanide. And so carbon dioxide, as we know, binds hemoglobin with a much higher affinity, causes tissue hypoxia despite normal PAO2. You know, how we treat that is, you put somebody out on a hundred percent oxygen, or if you're intubating them, you crank that up to a hundred percent oxygen, you get on a knock that carbon monoxide off of this off of the hemoglobin replaced with oxygen. And then as we talked about in the disability podcast, you possibly need to go for hyperbaric therapy to further induce that, decreasing the affinity for that hemoglobin. The other one is cyanide. cyanide inhibits your mitochondrial oxidative phosphorylation. I don't know if you guys know this, but the mitochondria is the one of the cell? That's the powerhouse the cell for sure. Yeah, for sure. It causes cellular hypoxia similarly in lactic acid osythes. So patients may well, may appear well oxygenated on pulse oxymetry while remaining profoundly hypoxic at the tissue level. For just your laboratory evaluation, like we had said before, getting a cooxymetry and a carboxy hemoglobin level. Typically, your normal is around three smokers, you're up into the five seven range. Beyond that, you probably do have some level of a carbon dioxide injury. And then your lactate elevation, if you have great perfusion, but for some reason your lactate is going very high and you have no other reason why and you have all the reasons for having cyanide poisoning involved with whatever type of burn injury you have, it should raise your concern for cyanide toxicity. Totally. And like we said, ABG may show normal PAO2 and your pulse ox may look completely normal, completely unreliable and carbon dioxide poisoning. Absolutely. And so as we think about the pathophysiology leading us towards a diagnosis and having a right clinical suspicion, you know, I think Luke hit all the all the high notes for the systemic toxic drones. But there's a few things that we can have from just the EMS report that can kind of lead us down that pathway as well. So when the patient, you know, comes in or here about a transfer patient or you're getting cyanide on this patient, initially consulted, there's a few things in the history that speak more towards the likelihood of having an inhalation injury. Typically patients that have an inhalation injury are patients who can't get away from the burning source, can't get away from the smoke. So when I think about patients that can't get away from smoke, I think about people that are in close spaces. So structure fires that they can't get out of. If you're stuck in a car because you're entrapped in a vehicle and the vehicle is burning around you, all those things can certainly give you an inhalation injury because you're constantly breathing that smoke and it's constantly causing causing issues. I mean, this is why the, you know, the fire department always always tells you to get down and all fours and crawl out of your house because those that superheated air and the smoke is going to rise and be above you. And that's why you want to stay low when you're trying to get out of the, I get out of a structure fire. There's plenty of patients I've taken care of who have, who did not have any thermal injury, but they were in a structure fire and they stood up and walked out or ran out of the building. They breathed out that smoke and they went on to have an inhalation injury because of it or toxic drum because of it. So, you know, it's the same thing. If you've got, if you've got that in close space, if you can control all those, if you can keep all that smoke and all that, all that combustible material that you can't get away from, that's going to be the thing that's going to pretty, pretty supposed to be for that. Now, the converse of that, if you have somebody who has a thermal injury to the head and neck and, you know, you worry about, you know, some facial hair syncing or something, if that patient wasn't in an enclosed space, and this was from a like a flashover or they're using an accelerant to start a, start a campfire or something, those flash burns have an exceptionally low rates of potentially having an inhalation injury because again, they weren't breathing in that smoke for a prolonged period of time. The other reason why patients sometimes can't get away from the smoke is because they've altered mental status, primarily because they're unconscious. So, I've also, you know, anecdotally, I've seen patients, when I take care of these patients, it's typically in the setting of a concomitant traumatic injury. So, I'm thinking of a couple of patients that have had, we've had like a car accident and they had a TBI and were in cussed and were unconscious and they were sitting in the fire because of that or sitting in the flaming vehicle because that couldn't get out and had an inhalation injury. Secondary to that. Those are the big history findings that are going to lead you towards having a high probability of an inhalation injury. There are some physical exam findings that we classically teach and then there's the classic triad that we think about for lower airway problems. So, certainly facial burns, scenged eyebrow hairs, scenged nasal hairs, scenged facial hair, some soot on the head and neck are in and around the mouth and there's all those things can certainly lead you to worry about possibly having an inhalation injury. For me, those injuries without the proper clinical context are sometimes low yield. I've certainly taken care of patients where they have a little bit of sit in their mouth or they have one scenged eyebrow here. At a referring facility, they have been, you know, super concerned about an inhalation injury even though the patient may not have been high risk for that. Intubated the patient called me to say I've secured the air when I'm sending them to you via life flight and then they come here. We bronch them. There's no inhalation injury. We extubate them and they go home the same day. That, that, in and of itself, the facial burns, the soot around the mouth and the ears. Those may not be very specific findings for you. For me, when I see that, my questions are always, okay, the outside may have some pathology. What's the next layer in look like? You know, what does the, what are the terminates look like? What does inside of the nose look like? What does the mouth look like? Again, I'm worried about this point time for somebody having a direct thermal injury to those spots. So I want somebody to put a speculum in the patient's nose and make sure they don't have a whole lot of blisters and and and oozing coming from inside the nose. I want to look at the mouth to make sure the mouth also isn't denuded. The tongue isn't super big and painful. And then last thing I want to, that kind of addresses the upper airway stuff. Then I want to address the lower airway stuff. Do they have carbonycisputum? Are they able to bring things up? Is the, are the vulcords a dimadisk? And they have a horseness because there's actually damaged the vulcords themselves. Is there some degree of of casts and broncharia and other lower airway pathology can osculate for? I know we all don't have set the scopes all the time, but we should probably do it. We should probably use the set the scope for these patients to rule in and rule out lower airway injury. Heresy. Heresy. Find a medical student, do whatever you had to do. Get that set the scope out. And then take a good listen because if you've got andexpertory weases that really also speaks to there being a lower airway pathology. And the triad for me, on physical exam findings, carbonycisputum, vulcocord changes, plus weasing, all three of those things. I'm really thinking that this patient has a high likelihood of a lower airway problem and in a true true inhalation injury that we need to treat. Yeah, and I think the first start with that is to take their airway. We've talked about in our airway episode, Denver criteria as well as the ABA criteria. All of this were kind of assuming all these all these different these symptoms and that we're talking about right now all kind of warrant taking somebody's airway to assume that they have a inhalation injury. And please go back and listen to that. I think it's a pretty good, pretty good episode. You know, one of the one of the guys was pretty smart on there wasn't me. The other guy seemed pretty smart about what he was talking about. I don't disagree. So the so now we we assume that we have all these symptoms and they probably have an airway that's been taken. And so now we need to diagnose and grade the inhalation injury. How we do that is through bronchoscopy. Flexible bronchoscopy within the first 24 hours considered the diagnostic standard gold standard. However, you want to talk about it. And the reason why is that you can have direct visualisation of that mucusa. All the things that you were talking about going on down into the lower airways as well as in the upper airways is going to be able to be seen directly with that broncuscope. The other part that we're not really talking about that's not really involved with the broncuscope is say they take their airway at the at the point of injury and they don't have a lower airway inhalation injury. They can still have an upper airway injury and just passing that broncuscope down and never actually looking in the mouth or looking around where that tube is going down. Sometimes you can miss an upper airway injury. So I think it's worth talking about the very least because there is sometimes that if I have enough suspicion that there should be an airway injury based off all the the history that you had talked about earlier. Putting just a normal laryngeoscope down around the tube is probably worth while because if for some reason they're in a burn resuscitation and you're giving them a bunch of fluid and they had an upper airway injury this entire time, I remove that tube because I go down and there's no lower airway injury and then suddenly their airway closes off because they have an upper airway injury and it's just swelling around that tube. Now you're screwed because you're very a lot less likely to get that tube back to where it was. The other thing you you can identify so deposition you can grade the severity of the of your inhalation injury and then also you can treat so it not just doesn't just give you a diagnostic ability it also gives you the ability to therapeutic suction cleaning these these patients out and so again we're on an audio podcast here and so at some point you should look at what the the pictures of it. Let's face it half of you guys are driving right now. And so don't do that while you're driving but you should look at the the AIS scoring system for inhalation injury. So grade zero obviously means they have no injury. Grade one is a mild injury. It's minor or patchy areas of air theme could have carbonacious deposits in the proximal or distal bronchi. I'll be honest I have been you know there's sometimes with the Grade one it's a little bit harder to call because like oh is this just tube trauma from the from you know somebody being a little rampunctious with their intubating and so with that make a judgment call look at the pictures of it and say you know maybe this is a little bit of a thermal injury or not. I'm not as concerned with those and then two moderate injury you have a moderate degree of air theme you probably have carbonacious deposits you should have bronchuria and you know possibly some bronchial obstruction from that either cast or bronchuria or whatever you have that has led to this inhalation injury. Grade three is your severe inflammation you have severe severe injury you have severe inflammation with friability copious carbonacious deposits bronchuria and obstruction and then Grade four is a massive injury. I've only really seen a few of these that I could call a Grade four or a massive injury should already you know have some evidence of mucosal sloughing even though you just did your first look. Having some necrosis possibly even some endoluminal obliteration not typically you know consistent with a good outcome and so one of the questions that always kind of comes up in these patients is well how many bronchs are we doing and I think we get a little too hung up on that question and so I think it depends. So if I go in and I think there's a Grade one possibly a Grade two and doesn't look that bad you know the next day you know if we're getting some stuff up yeah maybe I'll go down for a second look. Grade three, four yeah I'm going down for a second look mostly because I'm probably going to be doing some therapeutic suction at the same time and so there's been some different papers some different studies on you know how many should we be doing and really it's what I gleaned from most of these papers is that oh it doesn't change your grading system by doing multiple bronchoscopies but to be honest that's not really why I do more than one bronchoscopy. I do my first bronchoscopy for the saying yes you have an inhalation injury or you don't. Right diagnostic. Yeah you're diagnostic and then I think my second injury or my second bronchoscopy is more just for the therapeutic portion of it. Like okay where where is this bad where can I come where can I go down into where what can I suck out what can I clean out and then honestly if I think that you know it's going to be you know I still have stuff that's not fully sloughed off and it's probably going to slough off tomorrow I'll go down for a third you know use your clinical context see the patient in front of you but at the very least for me if I go in if it's a grade two or above I'm probably going to give him a second bronchoscopy. I like it that's great and I honestly the other thing that I earlier my practice you know trying to remember off off the cuff all the AIS scores and have the picture you had that is entirely like schema driven like you just got to be like getting those reps in and seeing a lot some big you feel comfortable like making that diagnosis and there's no shame in pulling up the photos and having them while you're doing the bronchoscopy real time to take a look and say yeah this is a one yeah this is a two because you got it until you build that scheme out there's there's no shame and continued to like have the resource right in front of you to make sure you're making the right call for these patients and to be honest if I'm going to go in again anyways I kind of don't really care what the oh was it a three or is it two you know it's not changing that much for me and so if I'm going to go in any anyways just pick one you know it unless it's a slam dunk personally I mean that's just me yeah I guess we should talk about some other imaging that's involved in how relevant or well you know so chest there are other imaging we can do sure chest radiographs usually are normal especially early and really shouldn't be used to rule out imaging or rule out injury the other imaging you can get a CT usually the early ones aren't all that different but CT is probably going to show some bronchial wall thickness maybe some adelectasis but that doesn't really help me all that much and so it's it's supportive but it's definitely not diagnostic a very non-specific and so I don't you know there's some studies going on about like ultrasound for right for inhalation injury I just I don't see a scenario where bronchoscopy does not get replaced in any way shape or form totally yeah totally so now we go on to the treatment so there's no like definitive treatment right like you can't un-un-un-un inhalation injury but you know there is ways to manage it you know the you can support it it should be aggressive I think because we know just how you know how high of a patient's mortality is whenever they have pneumonia and that's really mostly what I'm thinking about is am I leaving a nitis for infection down into this patient's lungs right that's my first second third worry you know endolubial endoluminal obliteration yeah that's gonna be really really bad but that was always gonna be really really bad and you're kind of beyond where you're worried about all these other normal things but most inhalation injuries I'm like all right how do I make sure that this patient does not get a pneumonia totally and so about as critical like what can we do to get it to make Ford progress on that oh for sure yeah that's that's the other thing too so we already talked about early early airway management we already talked about you know the indications for early intubation strider, horseness you know voice changes facial burns you know enclosed space fire with a concerning exam and then a lot of times people are just intubated because they're about to transport and they don't want them crashing in whatever transport that they're doing right which I fully understand so I think aggressive pulmonary hygiene is going to be central to your management here and so like I said before scheduled bronx for suctioning especially in like severe or moderate you assume that you are going to start sloughing off a lot of your inner airway mucusa and so getting that out is going to be paramount for you because you don't want to have nice of infection held around frequent suctioning if you can do it without having to go down with a bronch and you know risk increase sedation and you know you know opening up that circuit that was previously closed and possibly causing some hypoxia that's great if you're able to get quite a bit out what just with frequent deep suctioning and then you're going to talk about some of the other inhaled therapies but then just like chest physiotherapy can you get things moving can you get the patient moving you know all of those things are going to be able to mobilize the this sloughing mucusa and all this friable tissue down in there you got to get that out yeah and like you're saying hallmark of treating these patients really is leveraging nebulizing therapy you know there's a lot of like many things in critical care and many things in burn care there's things we do with limited data there's a lot we do with limited and so you know with that we're going to kind of walk through a little bit of what the different nebulized treatments that are typically used in practice and what evidence is there to support it. You know, first line thing I think a lot of people think about when they're doing inhaled nebulizers is a bit agonists. We use it in CWD, we use it in asthma, maybe this can like help us deacrease some air flow resistance and improve some of our compliance. Strickly and inhalational injury, no evidence supports that just putting on beta agonists is going to help ameliorate your inhalation injury. No evidence to say that you're going to have, you know, better less time on vents or shorter ICU length to stay or mortality benefit or anything else like that. So, you know, while there may be some marginal benefit in conjunction with other therapies, in and of itself beta agonists, there's no evidence support that they are going to help out by themselves. If you're going to read a lot about beta agonists that are inhaled, you're going to might read a lot about sheep. Yeah, so many sheep studies about this very topic. And that's, honestly, so much of our data is like just based off a lot of the animal model work. The next thing we think about, at least for, in a non, for intensivist that maybe don't have a whole lot of experience working in the burn ICU, initial cystine and nebulilized hypertoxial inter-both use is another way to kind of break up plugs and snot and break up cast formation. And both of these agents kind of work in that space. You know, a NAC is going to help you break down some of fiber and casts. Again, using inter-sidial cystine, there's no data that shows that it is going to be in and of itself, again, beneficial in the burn population. A nebulized hypertoxialine also by itself, limited data to suggest there's any benefit there. But again, the idea behind it is that both of these agents are going to soften up the debris that's inside your lungs and allow it to be cleared faster. The one that there is some data behind and is used uniquely in burn centers, I find, is inhaled heparin. Using a Macintor at all, did a large retrospective single-center case-and-trol study. Relatively large, I should say. Back in 2017, to look at what the true benefit is, a nebulized heparin, from mechanically ventilated adults, they get started on this within 48 hours of presentation after confirming an inhalation injury. They were using nebulized heparin at 10,000 units every four hours for seven days. And they were only discerning patients if they were extubated or not. And then they also would alternate the nebulized heparin agent with albuterol as a short-acting betaagonist and a mucolytic. What they found was using this protocol of altrating a buterolytic plus nebulized heparin, they found that in the heparin group, they had reduced ventilator days. Seven ventilator days versus 14.5 days. There was no difference in mortality and there was also no incidence in bleeding complications which some people worry about that this raw mucus of service may have some extra bloody fluid that can come out of there and have bleeding issues from it. But that wasn't supported in their analysis. And so many burn centers will have nebulized heparin as another agent that they'll use as part of their pulmonary toilet package. The last thing some people talk about is inhaled nitrous oxide. Really again, Sheridan did a review of this several years ago that showed that there was limited evidence available specifically in the inhalation injury population to show that there was a benefit in inhaled nitrous. The three low quality studies that looked at in their view had an end of 29. So 29 patients was all that made up this three study, you know, large review article. So given the small power to the use of inhaled nitrous oxide and inhalation injuries, in my practice there's no role for inhaled nitrous for these patients. I don't know, look what are your thoughts on inhaled nitrous? I mean, it's very similar to the ARDS data. It only improves that one number, right? Just that one number increases your oxygen, which honestly is not usually the biggest problem in these patients. Yeah, yeah, you're going to get increased hypoiric acid. You've had some sort of a lung injury, but usually they're not that hard to oxygenate. And recruit sometimes too. Yeah. And so I just don't think that that I mean, I'll have in the back of my mind, I guess, but I don't see a scenario where I'm going to be pulling out that giant green tank anytime soon. That expensive giant green tank. Exactly. Exactly. And so as we think about our global approach clinically to how we approach these patients within a hallucinolundry, I think it's kind of tie things up in a bow. We should just kind of walk through like our general approach for like, what are we, how are we going to take this patient? So I'll leave it to you, Luke. So if you got a patient who comes in, they've got concern for an inhalation injury, they get intubated downstairs in the yard, they come upstairs, you're in the room, you're getting ready to your bronch, you put it down there, you got an inhalation injury, what do you do and to manage these patients going forward? Yeah. So I don't think, you know, they're on the vent, they're intubated. I don't much care what mode they're on from a ventilatory standpoint. Actually these people aren't having, they're not at a point yet where they're, you know, having horrible lung injury that I have to intervene on with the ventilator and switching the ventilator around a lot. If I do think that they have a possibly carbon dioxide poisoning, obviously I'm going to put it at 100%. Beyond that, I'm going to say, okay, we now have our TBSA. We now have our inhalation injury, I'm going to look at the bow score, realize what their true mortality is. Possibly talk to the family about that, but what I'm doing for the actual patient in that time, I am going to add Hepperen, 10,000 units Q4. I will ping pong that with a beta agonist, also Q4, Q6. They don't have to be at the same time, I usually like to have them staggered. And then I'm very likely to go down the next day with the bronch and look again and see if things look better, worse, the same. Possibly clean some stuff out the next day, hopefully completely clear the amount if I can. And make the determination if I'm going to go in the next day. If they do have a ton of stuff that I think are increasing my peak pressures, that they're starting to get any sort of obstruction, yeah, I'm probably going to try some deep suctioning just without a bronch. And then if that's not helping, I'll probably add some hypertonic saline. I usually don't schedule the hypertonic saline, I usually react with hypertonic saline. And then if that is happening, I'm going down again and cleaning out again. But beyond that, this is somewhat simple, just, you know, supportive care, right, mostly. But that's mostly what I'm doing for these patients. What about you? Honestly, I think we are 99% the same for the management of these patients. And I agree, get them intubated, exclude a toxic drum going on. And then once you get the bronch down there and see how severe these airway injuries, I tend to have my hampers going every four. I like a short activate agnus linked to hypertonic saline, just as a way to kind of break things up as a meucolytic. The one thing is, you know, the hypertonic saline has a chance, just like anestheticist needs to cause a reactive bronchospasm when you administer it. So you need to have that beta agnus linked to your hypertonic saline given them simultaneously. Every four hours is easy because you're already doing the heprin every four. So doing that every two can kind of help. And also, I think that, you know, having the rest of your therapist in every two hours, doing some suctioning, mobilizing things is helpful in the first 24 to 40 hours kind of decrease your secretion burden and start to get some of that gunk out of there. I, as far as the ventilator goes, you know, I, you guys know me, I love APRV. I think the, in the inhalation injury population, there's, I think there's benefit to using APRV to also kind of help break things up and bring things up with that, that significant recruitment, de-recruitment mechanism that we talked about. So just like Luke was saying, I don't necessarily schedule a day to bronch a, bronchoscopic intervention, no matter what all comers all the time. I'm selective like you are about who's going to get that second, that second, that second look. And certainly if they're severe inhalation injury, I'm probably doing a re-look. But the other thing also is, if you're in a volume control mode and you're like you're saying, having peak pressure problems and you're having issues delivering that volume, you know, that's a patient I'm probably thinking about more aggressive, non-invasive interventions as well as frequent suctioning and stuff, as well as possibly loading up for a repeat bronch. If I'm doing a pressure control mode or APRV or something again, if I'm having low volume problems, then I would also think about for that patient potentially, trying to get him cleared out and thinking more about that patient needs to be selected into the, I need to severely bronch this patient potentially category. Yeah, and you kind of mentioned it before, I guess I didn't really drive it home. We need to excavate these patients as soon as they meet excavation criteria. Absolutely. You know, one of the greatest risks for a ventilator associated with pneumonia is being on a ventilator. So, that's not the case. not helping you out. And so all of these things, if I think I can, if I go down and I don't think they're going to obstruct because they don't have a huge inhalation injury, I'm not waiting for all these other things. Oh, absolutely. So to, to, to, to extubate a patient. Yeah. Exhibition should be the ultimate goal here. To decrease, to, to help with your ultimate, ultimate goal of reducing the moment. Right. Not hurting them anymore now. Yeah. And so with that, let's just kind of a quick review of some big take home points. Um, just going to, you know, tennis court this back and forth. Um, inhalation injury has a high incence and burn, right? 10 to 20% all commerce and has an increased pneumonia risk, as well as an increased mortality risk associated with it. Yeah. And bronchoscopy is the gold standard for diagnosis and treatment of the inhalation injury. And again, pneumonia prevention is paramount given its additional mortality that's associated with that in this population. Yeah. And then sort of lastly, there's no real treatment, but there's plenty of management strategies. And that is going to focus mostly on your pulmonary hygiene, frequent suctioning, repeat broncs and maybe less therapies. Absolutely. Well, I think that wraps up inhalation injury. Anything else to add? I don't think so. I think most people thought that was going to be more complicated than it actually is. Supportive care. It's 100% what I thought when I came into the world. Totally. Totally. Well, everybody, thanks for listening. As always, give us a like, a subscribe, tell a friend about the podcast, really appreciate that. And if you guys have any ideas for future podcast episodes, we're available at TBSA pod on Instagram and TBSA [email protected]. Anyways, thanks for listening guys. I'm Jake. I'm Luke. And that wraps us up for today. Thank you guys. 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