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A pinboard by
Rachael Williams

Assistant Professor, Emory University School of Medicine

PINBOARD SUMMARY

Comparing outcomes in patients with inhalation injury treated with epoprostenol or nitric oxide

Introduction: Inhalation injury continues to be a significant source of morbidity and mortality. Hallmarks of inhalation injury include airway obstruction from cast formation, bronchospasm, and transvascular fluid flux. This results in decreased lung compliance, increased ventilation perfusion mismatch, and increase in dead space ventilation. The onset of respiratory failure has been seen up to 48 hours after smoke exposure. Management protocols vary by institution but include serial bronchoscopies, nebulized anticoagulants, and bronchodilators.

There have been few advances in the treatment of inhalation injury with refractory hypoxemia. Inhaled nitric oxide (iNO), an inhaled vasodilator, has been shown in small case series to improve ventilation/perfusion mismatch. Aerosolized epoprostenol also promotes pulmonary vasodilation and has anti-inflammatory properties. A single case report demonstrated improved oxygenation with use of inhaled prostaglandin during high-frequency ventilation in a patient with inhalation injury. We sought to review our experience with both vasodilators in managing refractory hypoxemia in inhalation injury. Methods This is a retrospective chart review of adult patients (n-36) admitted to the burn ICU between 1/1/2012-6/1/2016 with documented inhalation injury who underwent treatment with inhaled nitric oxide (n=18) or aerosolized epoprostenol (n=18). Results Baseline characteristics in both patient groups were similar except for larger TBSA burns in the nitric oxide group. Baseline PaO2/FiO2 ratios in both groups prior to treatment indicated moderate hypoxemia (119±54 in the epoprostenol group; 143±73 in the nitric oxide group). PaO2/FiO2 ratios increased to mild hypoxemia category in both groups, with the largest, statistically significant increase seen at the 48hr mark post initiation. Mortality rate was 55.6% in the epoprostenol group vs. 72.2% in the nitric oxide group (p=0.80). Mean duration of therapy was 11.5 days ± 9.9 (epoprostenol) and 6.3 ± 3.5 days ( nitric oxide). This represents a cost of 25,200 dollars per patient for nitric oxide therapy and 9,200 dollars per patient for epoprostenal therapy.

Conclusions Epoprostenol improved oxygentation by increasing PaO2:FiO2 ratios similar to nitric oxide while proving to be a more cost effective therapy for inhalation injury.

3 ITEMS PINNED

Safety of Nebulized Epinephrine in Smoke Inhalation Injury.

Abstract: This pilot study was conducted to profile safety of nebulized racemic epinephrine when used as a therapy for smoke inhalation injury in severely burned children. We enrolled 16 patients who were 7 to 19 years of age ([mean ± SD], 12 ± 4 years) with burns covering more than 30% of the TBSA (55 ± 17%) and smoke inhalation injury, as diagnosed by bronchoscopy at burn center admission. Patients were randomized to receive either standard of care (n = 8), which consisted of nebulized acetylcysteine, nebulized heparin, and nebulized albuterol, or to receive standard of care plus nebulized epinephrine (n = 8). Primary endpoints were death, chest pain, and adverse changes in cardiopulmonary hemodynamics (arrhythmia, arterial blood pressure, electrocardiographic [ST segment] changes, and peak inspiratory pressure). Additional endpoints included total days on ventilator, pulmonary function, and physiological cardiopulmonary measurements at ICU discharge. No adverse events were observed during or after the nebulization of epinephrine, and no deaths were reported that were attributable to the administration of nebulized epinephrine. The groups did not significantly differ with regard to age, sex, burn size, days on ventilator, pulmonary function, or cardiopulmonary fitness. Results of this pilot trial indicate epinephrine to be safe when administered to pediatric burn patients with smoke inhalation injury. Current data warrant future efficacy studies with a greater number of patients.

Pub.: 02 Jun '17, Pinned: 19 Jun '17