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ORIGINAL ARTICLE
Year : 2017  |  Volume : 30  |  Issue : 1  |  Page : 234-240

Pulmonary complications for predicting mortality among major burn victims


1 Department of Chest, Faculty of Medicine, Menoufia University, Egypt
2 Department of Plastic Surgery, Faculty of Medicine, Menoufia University, Egypt
3 Department of Pulmonary Medicine, Chest Hospital, Shebin El-Kom, Egypt

Date of Submission12-Apr-2016
Date of Acceptance26-Jun-2016
Date of Web Publication25-Jul-2017

Correspondence Address:
Noha B Abd El-Azeem
Department of Pulmonary Medicine, Chest Hospital, Shebin El-Kom
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.211488

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  Abstract 


Objective
The aim of this study was to assess the incidence of early and late pulmonary complications among major burn victims and to study their effects on patient's outcome.
Background
Respiratory complications associated with burn injury are responsible for significant morbidity and mortality.
Patients and methods
Forty-two patients with major burn with no past history of pulmonary diseases were enrolled in the study. All patients were subjected to medical history taking, general, local (respiratory and burn), and upper airway examination, laboratory investigations, plain chest radiograph, and serial arterial blood gases analysis (initially after admission and then after 48 and 72 h).
Results
Pulmonary complications developed in 29 of 42 (69%) burned patients. Eleven of 42 (26.2%) patients died; 10 (90.9%) of them died due to pulmonary complications and one (9.1%) patient died due to wound sepsis. Acute respiratory distress syndrome, inhalational injury, pneumonia, acute bronchitis, lung contusion, and hemothorax were early phase (within 48 h of admission) pulmonary complications, whereas pneumonia, lung collapse, and pulmonary embolism were late phase (after 48 h of admission) pulmonary complications. Lower serum albumin and more deep burn were independent risk factors for pulmonary complications, and pulmonary complications, decreased prothrombin time concentration, and lower serum albumin were independent risk factors for mortality in patients with major burns.
Conclusion
Lower serum albumin and more deep burns were independent risk factors for pulmonary complications, and pulmonary complications, decreased prothrombin time concentration, and lower serum albumin were independent risk factors for mortality in burned patients.

Keywords: arterial blood gases, major burn, mortality and radiological findings, pulmonary complications


How to cite this article:
Mansour OF, Megahed MA, El-Wahsh RA, El-Helbawy RH, Abd El-Azeem NB. Pulmonary complications for predicting mortality among major burn victims. Menoufia Med J 2017;30:234-40

How to cite this URL:
Mansour OF, Megahed MA, El-Wahsh RA, El-Helbawy RH, Abd El-Azeem NB. Pulmonary complications for predicting mortality among major burn victims. Menoufia Med J [serial online] 2017 [cited 2019 Apr 19];30:234-40. Available from: http://www.mmj.eg.net/text.asp?2017/30/1/234/211488




  Introduction Top


Burn is a type of injury to the flesh or skin caused by heat, electricity, chemicals, friction, or radiation [1]. The most significant complications in the early phase after burn ( first 48 h) are acute upper respiratory obstruction from edema of the glottis, which occurs within few hours after burning, necessitating urgent tracheostomy. Inhalational injury to the tracheobronchial tree is often caused by irritation and noxious products of combustion than by heat. Acute respiratory distress syndrome (ARDS) is also considered an acute burn respiratory complication. Furthermore, pneumonia and atelectasis are common among critically ill burned patients [2].

Long-term complications include reactive airway dysfunction syndrome and irreversible airway obstruction from bronchiolitis obliterans, chronic bronchitis, and bronchiectasis. Bronchiectasis may develop after more than 10 years from inhalation injury [3].


  Aim Top


The aim of this study was to assess the incidence of early and late pulmonary complications among major burn victims and to study their effect on the outcome of patients.


  Patients and Methods Top


This prospective study included 42 burned patients with major burn covering more than 20% of total body surface area (TBSA) in adults and more than 10% in children [4] admitted in the Burn Unit in Menoufia University Hospitals. An ethical research approval was obtained from hospital's ethics committee, and informed consent was obtained from the patients.

After exclusion of pulmonary diseases (e.g., bronchial asthma, chronic obstructive pulmonary disease, etc.), all patients in the study were subjected to the following:

  • Medical history taking
  • General examination
  • Local examination (respiratory and burn examination)
  • Upper airway examination to assess inhalational injury
  • Laboratory investigations:

    • Complete blood count
    • Biochemistry profile, including liver function tests [alanine aminotransferase, aspartate aminotransferase, serum albumin, prothrombin time nitrogen (BUN) and creatinine level], and electrolyte testing (sodium, potassium, chloride, and calcium).


  • Imaging studies: Plain chest radiographs were obtained for all patients using Siemens X-ray Machine 300MA (Siemens Healthcare, Erlangen, Germany).
  • Serial arterial blood gas analysis: arterial blood gases analysis was performed serially: initially after admission and then after 48 h and after 72 h using RAPID Point 500 Blood Gas Systems leverage proven Siemens technology (Siemens).
  • Pulmonary complications were recorded if they occurred to patients during their hospital stay and were categorized into early (within 48 h of admission) or late (after 48 h of admission).


Statistical analysis

The data were collected, tabulated, and analyzed using SPSS (version 20; SPSS Inc., Chicago, Illinois, USA).

Two types of statistics were performed:

  • Descriptive statistics [e.g., percentage, mean (X), and SD]
  • Analytic statistics, which included the following tests:

    • χ2-Test: it was used to study the association between two qualitative variables
    • Fisher's exact test: it is a statistical significance test used in the analysis of 2 × 2° contingency tables when at least 25% of cells has expected number less than 5
    • t-Test: it is a test of significance used for comparison between two groups normally distributed having quantitative variables
    • Mann–Whitney U-test: it is a nonparametric test of significance used for comparison between two groups not normally distributed having quantitative variables
    • Paired t-test: it is a test of significance for comparison between two pairs of measurements of normally distributed quantitative data
    • Wilcoxon's signed-rank test: it is a test of significance for comparison between two pairs of measurements of not normally distributed quantitative data
    • The binary logistic model: it is used to predict a binary response based on one or more predictor variables (features – i.e., it is used in estimating the parameters of a qualitative response model)
    • Odds ratio (OR): it is a measure of association between an exposure and an outcome. It is a way to quantify how strongly the presence or absence of property A is associated with the presence or absence of property B in a given population
    • Confidence interval: hypothesis tests for the OR are not used to determine statistical significance of the association. Instead, confidence intervals of OR are constructed and used to determine whether or not the association is statistically significant.


A P value of less than 0.05 was considered statistically significant.


  Results Top


Inhalational injury, pneumonia, ARDS, hemothorax, and bronchitis were early pulmonary complications, whereas pulmonary embolism, pneumonia, and lung collapse were late complications [Table 1].
Table 1 The incidence of early and late pulmonary complications among the studied burned patients

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Twenty-nine of 42 patients passed into pulmonary complications. Eleven of them died due to pulmonary complications and one patient died due to wound sepsis [Table 2].
Table 2 Pulmonary complications and fate among the studied burned patients

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Radiological abnormalities were significantly increased in patients with pulmonary complications. Among the 29 patients who passed into pulmonary complications, 22 (75.6%) patients had radiological abnormalities and seven (24.2%) patients had normal radiographic findings [Table 3].
Table 3 Pulmonary complications and radiological findings among the studied burned patients

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There were significantly higher levels of pH, partial pressure of arterial oxygen (PaO2), the arterial oxygen saturation (SaO2), and base deficit in patients without pulmonary complications, whereas partial pressure of arterial carbon dioxide (PaCO2) was significantly lower in the same group after 48 h of burn. There were significantly higher levels of pH, PaO2, SaO2, bicarbonate level (HCO3), and base deficit in patients without pulmonary complications, whereas PaCO2 was significantly lower in the same group after 72 h of burn [Table 4].
Table 4 Pulmonary complications in relation to arterial blood gases (results after 48 and 72 h of burn)

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Burn depth and serum albumin were independent risk factors for pulmonary complications (P < 0.05; [Table 5]).
Table 5 Binary logistic regression analysis for independent risk factors of pulmonary complications

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Platelet count, PT, and serum albumin were significantly lower in the dead group, and BUN and creatinine were significantly higher in the same group (P < 0.05; [Table 6]).
Table 6 Fate among patients in relation to laboratory investigations of the studied group

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All 11 patients who died had radiological abnormalities. Only 11 (32.2%) patients survived despite having radiological abnormalities [Table 7].
Table 7 Fate among patients in relation to radiological findings

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pH, PaO2, SaO2, HCO3, base deficit, and anion gap were significantly lower among nonsurviving patients, whereas PaCO2 was significantly high among the same patients after 48 and 72 h of burn [Table 8].
Table 8 Fate among patients in relation to arterial blood gas results after 48 and 72 h

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Burn percent, PT, and pulmonary complications were independent risk factors for mortality in patients with major burn [Table 9].
Table 9 Stepwise logistic regression analysis for independent risk factors for mortality among burned patients

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  Discussion Top


The airway and lung complications of burns are directly responsible for significant morbidity and mortality [5]. In this study, pulmonary complications occurred in 69% of burned patients. The early complications were ARDS, bronchitis, pneumonia, hemothorax, and inhalational injury, whereas the late pulmonary complications were pneumonia, lung collapse, and pulmonary embolism. The early complications may be explained by that the products of combustion of various common substances are very toxic to the airways and alveoli. Initially, mucosal cilia are paralyzed and cease to clear the airways from debris. Upper airway obstruction secondary to inflamed mucosa or plugs of soot and mucus may occur. Bronchospasm may be triggered by irritating chemicals. A loss of surfactant has been reported as a consequence of thermal injury [6].

The occurrence of late pulmonary complications may be a part of multiple organ dysfunction syndrome (MODS). MODS exists in a continuum with the systemic inflammatory response syndrome, which affects most patients with a severe burn, with or without infection [7]. The risk for MODS increases with burn wounds more than 20% TBSA, increasing age, male sex, sepsis, hypoperfusion, and under-resuscitation. Most patients with MODS have an inability to attenuate the inflammatory response to injury. In general, the burn wound and the lungs are the most likely sites for an infection in the severely burned patient who subsequently develops MODS [8]. The release of endotoxins and/or exotoxins from an infective process initiates a cascade of inflammatory mediators that leads to organ damage and ultimately organ failure.

In the present study, radiological abnormalities were significantly increased in patients with pulmonary complications and patients who died, as 22 (75.6%) patients who had radiological abnormalities passed into pulmonary complications and all 11 (100%) patients who died had radiological abnormalities.

In a study by Cömert et al. [9] in Turkey, 29 patients were hospitalized in the ICU of a burn center. They were diagnosed with inhalation burn; the radiological abnormalities were found in 41.3 and 65.5% of patients on the first and fifth days of hospitalization, respectively. Among the patients who died, 79.1% showed radiological abnormalities and 50% had ARDS on the fifth day of hospitalization.

In the current work, patients with pulmonary complications had hypoxemia, lower oxygen saturation, and lower base deficit after 48 and 72 h of burn. Burned patients who died had respiratory acidosis, hypercapnia after 48 h of burn, hypoxemia, lower oxygen saturation, low bicarbonate level initially, lower anion gap, and base deficit after 48 and 72 h of burn. Hypoxemia and low oxygen saturation in patients with pulmonary complications and nonsurviving patients might be due to hypoventilation as PaCO2 was increased or might be due to venous to arterial shunt as oxygen tension and saturation did not rise significantly after administration of oxygen.

The low anion gap in nonsurviving patients could be explained by hypoalbuminemia as the albumin is a negatively charged protein and its loss from the serum results in the retention of other negatively charged ions such as chloride and bicarbonate. Andel et al. [10] found that plasma base deficit and plasma lactate were both very reliable predictors of outcome in burn patients during the first 24 h after injury. When the plasma base deficit returned to a normal range within 24 h, mortality was reduced.

In this study, patients with pulmonary complications and patients who died had significantly lower serum albumin compared with other burned patients. Hypoalbuminemia was an independent risk factor for the development of pulmonary complications, as hypoalbuminemia increased the risk for pulmonary complications four times. Because the most important function of albumin is to maintain an oncotic pressure of at least 80% of the normal level, its reduction could induce complications that predispose patients to malnutrition, the loss of immune responses, and an increased risk for infection. This result matched the result of the study by Joaquín et al. [11] in Birmingham and Cordova, in which there was an association between higher morbidity and lower serum albumin level. In a cross-sectional study, Aguayo-Becerra et al. [12] reported a mortality rate of less than 10% in severely burned patients (2/23) in whom hypoalbuminemia was frequently observed, demonstrating a significant association between the extent of the burn and the serum albumin level. However, these authors found no relationship between the level of this protein and hospital stay, complication rate, or mortality.

In the current work, an overall burned patient mortality percentage during the period of the study was 26.2% (11/42).

Mgahed et al. [13] in their study on 281 burned patients found that the mortality rate was 23.13%. However, Renz and Sherman [14] found that the mortality rate was 8.5% among 844 burned patients admitted in the Grady Memorial Hospital Burn Unit between 1987 and 1990, as one-half of burns was less than 10% TBSA, which explained the lower mortality compared with that of the present study in which the average burn size was 33.50 ± 31.71%.

In the present study we found that BUN and creatinine were significantly higher among the nonsurviving patients, as BUN was 30.64 ± 20.84 and creatinine was 3.31 ± 4.79 in the nonsurviving group. This could be explained by the occurrence of rhabdomyolysis or may be renal failure. In agreement with this, a study was conducted in the Burn Unit in Mansoura University Hospital and included 40 patients with moderate-to-severe thermal burn injury, second to third degree with more than 20% of TBSA. They found that acute renal failure was a well-known complication of severe burn and was an important factor that could increase mortality [15].

This study found that platelet count and PT were significantly lower in the nonsurviving group. This could be due to the occurrence of septicemia and disseminated intravascular coagulopathy.

A study was carried out in the Burn Unit at Indira Gandhi Government Medical College, Nagpur, on 598 patients admitted in the burn ward. The platelet count was studied. In nonsurvivors, declining trend in platelet count was observed with the development and progression of septicemia. Thus, this declining platelet count could be correlated to bad prognosis of patients [16]. Similar findings were observed in another study by Pavic and Milevoj [17]. They observed progressive decrease in platelet count on subsequent postburn days in nonsurvivors.


  Conclusion Top


Respiratory complications associated with burn injury are responsible for significant morbidity and mortality. ARDS, inhalational injury, pneumonia, acute bronchitis, lung contusion, and hemothorax were early phase pulmonary complications, whereas pneumonia, lung collapse, and pulmonary embolism were late phase pulmonary complications. Lower serum albumin and more deep burn were independent risk factors for pulmonary complications, whereas pulmonary complications, decreased PT concentration, and lower serum albumin were independent risk factors for mortality among the studied patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Herndon D. Prevention of burn injuries. In: Barrow RE, Linares HA, Cole M, et al., editors Total burn care. 4th ed. Edinburgh: Saunders; 2012. 746.  Back to cited text no. 1
    
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Hettiaratchy S, Papini R. Initial management of a major burn. BMJ, 2004; 328:1555–1557.  Back to cited text no. 4
    
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7.
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Jeschke L, Kamolz LP, Sjöberg F, Wolf SE., Handbook of burns volume 1. Acute burn care; 2012. Springer-Verlag GmbH, Vienna, Austria. p. 77–94.  Back to cited text no. 8
    
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Cömert SS, Acar H, Doğan C, Cağlayan B, Fidan A. Clinical, radiological and bronchoscopic evaluation of inhalation injury cases treated at a burn center. Ulus Travma Acil Cerrahi Derg 2012; 18:111–117.  Back to cited text no. 9
    
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Andel D, Kamolz LP, Roka J, Schramm W, Zimpfer M, Frey M, Andel H. Base deficit and lactate: early predictors of morbidity and mortality in patients with burns. Burns 2007; 33:973–978.  Back to cited text no. 10
    
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Joaquín PG, de Haro-Padilla J, Rioja LF, DeRosier LC, de la Torre JI. Serum albumin levels in burn people are associated to the total body surface burned and the length of hospital stay but not to the initiation of the oral/enteral nutrition. Int J Burns Trauma 2013; 3:159–163.  Back to cited text no. 11
    
12.
Aguayo-Becerra OA, Torres-Garibay C, Macías-Amezcua MD, Fuentes-Orozco C, Chávez-Tostado Mde G, Andalón-Dueñas E, et al. Serum albumin level as a risk factor for mortality in burn patients. Clinics (Sao Paulo) 2013; 68:940–945.  Back to cited text no. 12
    
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Mgahed M, El-Helbawy R, Omar A, El-Meselhy H, Abd El-Halim R. Early detection of pneumonia as a risk factor for mortality in burn patients in Menoufiya University Hospitals, Egypt. Ann Burns Fire Disasters 2013; 26:126–135.  Back to cited text no. 13
    
14.
Renz BM, Sherman R. The burn unit experience at Grady Memorial Hospital: 844 cases. J Burn Care Rehabil 1992; 13:426–436.  Back to cited text no. 14
    
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Gajbhiye AS, Meshram MM, Kathod AP. Platelet count as aprognostic indicator in burn septicemia. Indian J Surg 2013; 75:444–448.  Back to cited text no. 16
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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