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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 29  |  Issue : 1  |  Page : 76-81

Role of fibreoptic bronchoscopy in early diagnosis of inhalational burns in patients with facial burns


1 Department of General Surgery, MGM Medical College and Associated M.Y. Hospital, Indore, Madhya Pradesh; Department of Burns, Plastic and Maxillo-facial Surgery, Atal Bihari Vajpayee Institute of Medical Sciences and Dr RML Hospital, New Delhi, India
2 Department of Burns, Plastic and Maxillo-facial Surgery, Atal Bihari Vajpayee Institute of Medical Sciences and Dr RML Hospital, New Delhi, India
3 Department of Burns, Plastic and Maxillo-facial Surgery, Atal Bihari Vajpayee Institute of Medical Sciences and Dr RML Hospital, New Delhi; Department of Plastic Surgery, Government Medical College Haldwani, Uttarakhand, India

Date of Submission01-Mar-2021
Date of Decision03-Dec-2021
Date of Acceptance02-Jan-2022
Date of Web Publication08-Jun-2022

Correspondence Address:
Dr. Komal Tripathi
Department of Plastic Surgery, Government Medical College, Haldwani, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijb.ijb_6_21

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  Abstract 


Introduction: Inhalation burn is a major cause of mortality in burn patients. Early diagnosis of smoke inhalation injury (SII) is imperative in the management and prevention of burn injury. The gold standard modality for the diagnosis of SII is fiber-optic bronchoscopy (FOB).
Materials and Methods: This prospective, observational study included thirty patients and was conducted from November 2016 to May 2018. Patients with thermal burns sustained < 72 h with facial burns, age group 18–60 years, were included in the study.
Results: FOB was done in thirty patients. About 26.67% of patients had closed space injuries. Singeing of scalp hair/eyebrows was present in 46.67% of patients. Singeing of nasal vibrissae/mustache was present in 56.67% of patients. Eversion of eyelids and lips was present in 33.33% and 50% of patients, respectively. Hoarseness of voice, edema of tongue, and tachycardia were present in 16.67%, 50%, and 66.67% of cases, respectively. On auscultation, 26.67% patients had basal crepts. In the chest X-ray, 16.67% of patients had pulmonary edema. Forty percent of patients had arterial hypoxemia and acidosis at the time of arrival. About 56.67% of patients were proved bronchoscopically to have features of SII.
Conclusions: FOB has significant value in evaluation, prediction of prognosis, and management of SII when performed within 72 h of burns.

Keywords: Bronchoscopy, burns, smoke inhalational injury


How to cite this article:
Kanchwala N, Mohan R R, Tripathi K, Baranwal S, Jha MK, Bhattacharya S. Role of fibreoptic bronchoscopy in early diagnosis of inhalational burns in patients with facial burns. Indian J Burns 2021;29:76-81

How to cite this URL:
Kanchwala N, Mohan R R, Tripathi K, Baranwal S, Jha MK, Bhattacharya S. Role of fibreoptic bronchoscopy in early diagnosis of inhalational burns in patients with facial burns. Indian J Burns [serial online] 2021 [cited 2022 Dec 9];29:76-81. Available from: https://www.ijburns.com/text.asp?2021/29/1/76/346915




  Introduction Top


Inhalational injury is a major cause of fatality in patients suffering from burns. The presence of inhalation injury, increased age, and percentage of total body surface area (TBSA) burnt are the most significant predictors of mortality after burns.[1]

This study was done in the Indian population where no such previous study has been reported. The data regarding the magnitude of problem are not available for the Indian population. The incidence of burn inhalational injury varies from approximately 10% to 37% in patients requiring hospitalization as in other studies.[2],[3],[4]

There is a high incidence of associated mortality and morbidity. The diagnosis of inhalation injury in a burn patient is usually made on a history of being trapped in a closed space with exposure to smoke, which should be investigated further.[5]

Fiber-optic bronchoscopy can be used in all victims suspected of having inhalational injury to confirm the diagnosis of smoke inhalation injury.[6]

Burn inhalation injury can lead to local thermal injury of the respiratory tract, systemic toxicity due to agents such as carbon monoxide and cyanide, or a combination of these two.[6],[7]

Enclosed-space fires, loss of consciousness, facial burns, and large TBSA burns (>40%) should raise the suspicion of smoke inhalation injury.[8]

If diagnosed early and treated appropriately, the risk of pneumonia development may become predictable, and mechanical ventilation that may be required is facilitated.[9]

Bronchoscopic findings in patients with smoke inhalation injury (SII) include congestion, edema, mucosal ulceration, and necrosis. Chou introduced a classification to assess the severity of inhalational burns using fiber-optic bronchoscope. In this classification, the patients were divided into three groups G1, G2, G3 according to the depth of mucosal damage.[10]


  Material and Methods Top


This prospective, observational study was done in the Department of Burns and Plastic Surgery at Dr. RML Hospital, New Delhi, and was conducted from November 2016 to April 2018. Institutional Ethics Committee clearance was taken, reference no-TP (DM/Mch)(6/2016)/IEC/PGIMER/RMLH-7954/16. Cohort of thirty patients of age groups 18–60 years was included in the study.

Inclusion criteria – All the patients coming with facial burns due to thermal injury presenting within 72 h of the injury were included in the study.

Exclusion criteria – Patients with electric and chemical burns, burn injury more than 3 days old, patients with other comorbidities (chronic obstructive pulmonary disease, uncontrolled diabetes mellitus, and bleeding disorder/seizure disorder), facial burns with stridor, and hypersensitivity to local anesthetics were excluded from the study.

Materials and Methods

History of the patient was taken regarding burns in closed space, and examination was done. The percentage TBSA burn of the patients was noted. Part of face burnt, singeing of scalp hair/eyebrows, singeing of nasal vibrissae/mustache, eversion of eyelids, eversion of lips, hoarseness of voice, edema of tongue, cyanosis, carbonaceous sputum, pulse rate (bpm), and respiratory rate were evaluated.

Assessment of hemoglobin, ABG analysis, and chest X-ray were done. Bronchoscopy was done within 72 h in the patients suspected of having SII, after taking proper consent. Nebulization was done with 4% lignocaine spray. Lignocaine 10% spray was used to anesthetize oral cavity and larynx. Bronchoscope was inserted through oral/nasal route or through tracheostomy in tracheostomized patients. Bronchoscopic evaluation of respiratory tract was done, and morphology of the respiratory mucosa was noted as per Chou's classification.

Outcome of the patients was noted with respect to hospital stay (in days) and discharge from the hospital/mortality.


  Results Top


Demographics – In this study, out of the total thirty patients, 11 were females and 19 were males. The age distribution in the studied patients was as follows: [Table 1]
Table 1: Age distribution (years)

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Maximum patients were from the younger age group (n = 13, 43.33%). The least number of patients was from age group >50 years (n = 3, 10%).

History of closed space burns was found in 8 patients (26.67%), and the rest 22 patients were able to escape out.

Clinical features

Parts of face burnt in all the patients were noted. The frequency chart is as follows: [Table 2]
Table 2: Parts of face burnt

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In 14 patients (46.67% patients), the whole face was burnt. In the rest of the patients, some or the other part of the face was burnt.

The frequency of various clinical features is as follows: [Table 3]
Table 3: Clinical features

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[Figure 1]. Singeing of nasal vibrassae and moustache.
Figure 1: Singeing of nasal vibrissae and moustache

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[Figure 2]. Eversion of lips.
Figure 2: Eversion of lips

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Features of inhalational injury were present in 56.67% of patients on bronchoscopy [Table 4]. Bronchoscopic morphology.
Table 4: Bronchoscopic morphology

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[Figure 3]. G0 morphology.
Figure 3: Patient showing G0 morphology

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[Figure 4]. G 1 morphology.
Figure 4: Patient showing G1 morphology

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[Figure 5]. G2 morphology.
Figure 5: Patient showing G2 morphology

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Bronchoscopy-guided aspiration was done in four patients, in the rest, no intervention was done. Fourteen patients died, and 16 patients were discharged.

Relationship between abovementioned features with presence/absence of smoke inhalation injury, its grading, and its statistical significance

Parts of face burnt [Table 5]
Table 5: Parts of face burnt and SII

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The above chart shows that SII has no statistically significant association with part of face burnt (P = 0.241).

Parts of face burnt and grading of inhalational burns

It was observed that parts of face burnt have no statistically significant association with grading of SII (P = 0.625) [Table 6].
Table 6: Parts of face burnt and grading of inhalational burns

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Burns in closed space

SII was found to have a statistically significant association with burns in closed spaces (P = 0.004). Eight patients out of total of 17 patients with SII gave a history of entrapment in closed space [Table 7].
Table 7: Burns in closed space and inhalation injury

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In the same way, burns in the closed spaces had a statistically significant association with severity of SII (P = 0.015) [Table 8].
Table 8: Burns in closed space and morphology

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The bronchoscopic morphology and inhalational injury grading showed a statistically significant association with a P = 0.002.

Out of total of 17 patients with SII, 12 patients had tachypnea, which was statistically significant (P = 0.001). Furthermore, tachypnea had a statistically significant association with grading of SII (P = 0.001).

On auscultation, 26.67% of patients had basal crepts, rest, 73.33% patients had normal vesicular sounds, bilateral air entry was present and equal. Crepts were present as an auscultation finding in 8 out of 17 patients with SII and none of the patients without SII, thereby showing statistically significant association (P = 0.004) of crepts as a positive clinical finding in SII patients.

Crepts were present in 4 out of 11 patients with Grade 1 inhalational burns, whereas 4 out of 6 patients with Grade 2 inhalational burns had crepts. This shows that crepts had a statistically significant association with grading of SII (P = 0.006).

Chest X-ray revealed that 16.67% of total patients had pulmonary edema. Five out of 12 patients with SII had pulmonary edema which was not statistically significant (P = 0.052). In the study, 1 out of 11 patients developed pulmonary edema in Grade 1 SII patients and 4 out of 6 patients with Grade 2 SII patients, thereby showing statistical significance of pulmonary edema with increasing grade of SII. Arterial hypoxemia and acidosis on ABG analysis were found in 12 out of 17 patients with SII showing strong statistical significance (P = 0.0001).

ABG analysis showed arterial hypoxemia and acidosis in all six patients with bronchoscopic morphology G2 and in 6 out of 11 patients with bronchoscopic morphology G1. This association was statistically significant with P = 0.0001.

Outcome

Out of the total 17 patients of inhalational injury, five patients got discharged and the rest expired. This association showed strong statistical significance with P = 0.004. The association of bronchoscopic morphology and SII grading showed statistical significance with P = 0.002.


  Discussion Top


In this study, thirty maximum patients (43.33% n = 13) were from the younger age group (age <30 years). The least number was from age group >50 years (10%, n = 3). There were 11 female and 19 male patients. In 14 (46.67%) patients, the whole face was burnt. In the rest, some or the other part of the face was burnt. The part of face burnt showed no statistically significant association with either the presence or absence of inhalational injury or its grading. These findings were similar to a study by Ching et al.[11]

Out of the thirty patients studied, eight patients were trapped in a closed space during burn injury. This had a statistically significant association with inhalational burn injury and its severity. Similar results were shown by Antonio et al.[6]

The patients having G0, G1, and G2 morphology were 13, 11, and 6, respectively, which was comparable to a study of twenty patients by Bai et al.[3]

Tachypnea as a clinical feature was found to have a significant association with inhalational injury. No other studies have found such correlation. This result could be due to less number of patients studied.

On ABG analysis, arterial hypoxemia and acidosis showed a statistically significant association with inhalational injury, similar to the results of a study done by Sutton et al.[12]

On admission, chest X-ray is seldom diagnostic; but is important for baseline evaluation.[13]

Pulmonary edema on chest radiographs and crepts on auscultation showed significant association with inhalational burns and its severity. This result could be verified by the study done by Mlcak et al.[14]

Overall, the outcome that is mortality of the patients in the study had a significant association with inhalational injury and its severity.


  Conclusions Top


Fiber-optic bronchoscopy is as a simple and effective tool for the diagnosis of SII. It can also be used for prognosticating the patients of SII. The findings of bronchoscopy correlate with the clinical outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hussain A, Dunn KW. Predicting length of stay in thermal burns: a systematic review of prognostic factors. Burns 39 (2013). Available from: http://dx.doi.org/10.1016/j.burns.2013.04.026.  Back to cited text no. 1
    
2.
Agbenorku P, Agbenorku M, Bayuo J, Asare NYO. Epidemiology and outcome of suspected inhalational burn injury in a Ghanaian tertiary hospital. Burns Open, 2019;3. Available from: https://doi.org/10.1016/j.burnso.2019.02.001.  Back to cited text no. 2
    
3.
Bai C, Huang H, Yao X, Zhu S, Li B, Hang J, et al. Application of flexible bronchoscopy in inhalation lung injury. Diagn Pathol 2013;8:174.  Back to cited text no. 3
    
4.
Iyun AO, Ademola SA, Olawoye O, Michael AI, Oluwatosin OM. Comparative review of burns with inhalation injury in a tertiary hospital in a developing country. Wounds 2016;28:1-6.  Back to cited text no. 4
    
5.
Dries DJ, Endorf FW. Inhalation injury: Epidemiology, pathology, treatment strategies. Scand J Trauma Resusc Emerg Med 2013;21:31.  Back to cited text no. 5
    
6.
Walker PF, Buehner MF, Wood LA, Boyer NL, Driscoll IR, Lundy JB, et al. Diagnosis and management of inhalation injury: An updated review. Crit Care 2015;19:351.  Back to cited text no. 6
    
7.
Endorf FW, Gamelli RL. Inhalation injury, pulmonary perturbations, and fluid resuscitation. J Burn Care Res 2007;28:80-3.  Back to cited text no. 7
    
8.
Antonio AC, Castro PS, Freire LO. Smoke inhalation injury during enclosed-space fires: An update. J Braz Pneumol 2013;39:373.  Back to cited text no. 8
    
9.
Yamamura H, Kaga S, Kaneda K, Mizobata Y. Chest computed tomography performed on admission helps predict the severity of smoke-inhalation injury. Crit Care 2013;17:R95.  Back to cited text no. 9
    
10.
Chou SH, Lin SD, Chuang HY, Cheng YJ, Kao EL, Huang MF. Fiber-optic bronchoscopic classification of inhalation injury: Prediction of acute lung injury. Surg Endosc 2004;18:1377-9.  Back to cited text no. 10
    
11.
Ching JA, Shah JL, Doran CJ, Chen H, Payne WG, Smith DJ Jr. The evaluation of physical exam findings in patients assessed for suspected burn inhalation injury. J Burn Care Res 2015;36:197-202.  Back to cited text no. 11
    
12.
Sutton T, Lenk I, Conrad P, Halerz M, Mosier M. Severity of inhalation injury is predictive of alterations in gas exchange and worsened clinical outcomes. J Burn Care Res 2017;38:390-5.  Back to cited text no. 12
    
13.
Putman CE, Loke J, Matthay RA, Ravin CE. Radiographic manifestations of acute smoke inhalation. AJR Am J Roentgenol 1977;129:865-70.  Back to cited text no. 13
    
14.
Mlcak RP, Suman OE, Herndon DN. Respiratory management of inhalation injury. Burns 2007;33:2-13.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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