|Year : 2018 | Volume
| Issue : 1 | Page : 158-162
Diagnostic value of bronchoscopy in assessing the severity of inhalational lung injury
Shawky S Gad1, Tarek F Keshk2, Ahmed A Khames3, Sherif M Elkashty2, Athar F Abd. Elmegid Lasheen1
1 Department of General Surgery, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt
2 Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt
3 Department of Pulmonology, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt
|Date of Submission||13-Nov-2016|
|Date of Acceptance||30-Dec-2016|
|Date of Web Publication||14-Jun-2018|
Athar F Abd. Elmegid Lasheen
Department of General Surgery, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Menoufia Governorate
Source of Support: None, Conflict of Interest: None
The aim of this study was to assess the value of using flexible bronchoscopy in the evaluation and management of patients with suspected inhalational lung injury admitted in the Burn Unit, Menoufia University Hospitals, within the first 24–72 h of admission.
Inhalation injury is a major cause of morbidity and mortality in burn patients. It is one of the three most significant predictors of death after thermal injury. The incidence of respiratory failure is significant after inhalational injuries.
Patients and methods
This study was carried out on 30 patients who were admitted with inhalation injury in the Burn Unit, Department of Plastic Surgery. All patients were subjected to history taking, complete medical examination, and thorough laboratory and radiological investigations.
At the time of bronchoscopy, 12 (40%) patients were graded as G1 airway findings, 11 (36.7%) cases were graded as G2 airway findings, four (13.3%) patients were graded as G0, and three (10%) patients were graded as G3. About 26 patients had undergone bronchoalveolar lavage to remove secretions, sloughs, and carbonaceous materials until the airways became clear. On admission, 21 patients showed no pathology in their radiograph (70%), whereas nine patients showed increased bronchovascular markings and pneumonic patches. It was found that 63.6% of patients aged greater than or equal to 45 years died and 78.9% of patients aged less than 45 years survived. This shows that the mortality rate from inhalational injury increases with increasing age.
Bronchoscopy is considered the 'gold standard' for early evaluation of upper airway injury and prediction of acute lung injury.
Keywords: acute lung injury, bronchoscopy, inhalational lung injury
|How to cite this article:|
Gad SS, Keshk TF, Khames AA, Elkashty SM, Abd. Elmegid Lasheen AF. Diagnostic value of bronchoscopy in assessing the severity of inhalational lung injury. Menoufia Med J 2018;31:158-62
|How to cite this URL:|
Gad SS, Keshk TF, Khames AA, Elkashty SM, Abd. Elmegid Lasheen AF. Diagnostic value of bronchoscopy in assessing the severity of inhalational lung injury. Menoufia Med J [serial online] 2018 [cited 2019 Jun 17];31:158-62. Available from: http://www.mmj.eg.net/text.asp?2018/31/1/158/234238
| Introduction|| |
Burns are a common injury in developing countries, creating a major public health problem, and are associated with significant morbidity and mortality . Inhalational injury is a major cause of morbidity and mortality in burn patients. It is, along with age and total burn surface area, one of the three most significant predictors of death after thermal injury .
The incidence of respiratory failure is significant after inhalational injuries, with hypoxemia, pneumonia, and respiratory failure with prolonged ventilatory support and extended hospitalization being common. .
A number of parameters can be useful in evaluating inhalational injury, including bronchoscopy, PaO2/FiO2 ratio, and carboxyhemoglobin levels. Clinically significant inhalational injuries often do not manifest for three to four days after the exposure .
Complications of inhalational injury are not uncommon in patients with burns and can occur irrespective of burn injuries, and clinical manifestations are often not apparent. It can occur in patients with no body surface burn; however, its clinical manifestations are not consistent and can vary from no obvious symptoms to severe respiratory failure .
Bronchoscopic findings in patients with inhalational injury include congestion, edema, mucosal ulceration, and necrosis. When the inhaled matter contains carbon-based soot, the carbon soot will adhere to the mucosal surfaces of all visible airways .
Classification of inhalational injury by means of bronchoscopy can be important in the management of patients, despite the fact that no direct link between bronchoscopic grade and mortality has been definitively established .
| Patients and Methods|| |
Study population and selection of patients
This study was carried out on 30 patients who were admitted with inhalational injury to the Burn Unit, Department of Plastic and Reconstructive Surgery, Menoufia University Hospitals, during the period from November 2014 to March 2016.
The study protocol was approved by the Local Ethics Committee of the Menoufia University. Informed consent was obtained from the patients or the relatives before the beginning of the study.
The patients were selected randomly. Inclusion criteria were as follows: age greater than or equal to 10 years and suspected inhalational injury either by history or clinical manifestations.
Exclusion criteria were as follows: positive hepatitis C virus or hepatitis B virus results and an increased probability for bleeding tendency.
After obtaining written consent, each patient was subjected to the following:
- Full history taking from the patient or his or her relatives.
- Thorough clinical examination:
- General examination, including vital signs (blood pressure, pulse, and temperature) and level of consciousness to determine the degree of hypoxemia
- Physical examination included the following:
- Total body surface area% to detect the size of the burn
- The presence of facial and cervical burn
- The presence of carbonaceous sputum, soot in nostrils or singed nasal hairs, and burns on the tongue
- The presence of respiratory symptoms of inhalation injury: dyspnea, cough, hoarseness of voice, and wheezing
- The presence of respiratory signs of inhalational injury: tachypnea, inspiratory stridor, unstable breathing pattern or apnea, and crackles.
- Laboratory investigations were performed at the laboratory of the Menoufia University Hospitals and included the following:
- Complete blood count
- Liver function tests (albumin, aspartate aminotransferase, alanine aminotransferase, international normalized ratio, and prothrombin time)
- Kidney function tests (serum urea and creatinine)
- Arterial blood gases (ABG)
- Viral markers (HBsAg, hepatitis C virus antibodies, and HIV antibodies)
- Electrolyte level (K and Na)
- Random blood sugar
- Radiological investigations.
Chest radiography was performed on admission to serve as a baseline for subsequent radiographs. It was performed as a rule for the detection of complications of several therapeutic interventions (such as endotracheal intubation or replacement of central venous line). Moreover, it was used for follow-up of patients and detection of complications of inhalational injury (adult respiratory distress syndrome, pneumonia, atelectasis, etc.).
Bronchoscopy was performed within 24–72 h of admission in all clinically suspected inhalational injury patients.
Most patients tolerated bronchoscopy well. Monitoring continued until the effects of sedative drugs reduced and gag reflex returned.
| Results|| |
This study included 30 patients (16 male and 14 female). The patient characteristics are shown in [Table 1]. The mean age of patients admitted with inhalation injury was 37.96 ± 19.33. The incidence of inhalational injury was higher in male than in female patients and was higher in patients less than 45 (63.3%) years of age. About 66.7% of the patients were nonsmokers and 30% gave a history of chronic illness.
|Table 1: Sociodemographic characteristics and past history of the studied group (n=30)|
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All studied patients underwent bronchoscopy; 40% of the patients admitted with inhalation injury were graded as G1, 36.7% were graded as G2, 13.3% were graded as G0, and none of them was graded as G4, whereas the percentage of those exposed more to smoke inhalation was 10% and graded as G3, as shown in [Figure 1].
|Figure 1: Bronchoscopic grading of inhalation injury of the studied group.|
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Half of the patients admitted developed complications. Multiple organ failure, pneumonia, and septic shock were most reported (40, 26.7, and 20.0%, respectively), as shown in [Figure 2].
There was a significant statistical correlation between bronchoscopic grading and initial chest radiography (P = 0.01). All patients graded as G3 showed changes in their chest radiography. Chest radiography of 63.6% of G2 patients (n = 7) was free, whereas 36.4% of patients (n = 4) showed changes in their radiography, as shown in [Table 2].
|Table 2: Relationship between bronchoscopic grading and initial chest radiography among patients|
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There was a significant correlation between bronchoscopic grading and ABG analysis (P = 0.006); all patients of G0 grade had no hypoxemia, whereas all patients with G3had hypoxemia, as shown in [Table 3].
|Table 3: Relationship between bronchoscopic grading and arterial blood gases results among patients|
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As shown in [Table 4], there was a highly significant difference between grades of bronchoscopic findings and the development of complications in patients with inhalational injury (P < 0.001). All patients with G3 and 90.9% of patients with G2 grade findings developed complications. However, all patients of grade G0 passed without complications.
|Table 4: Relationship between bronchoscopic grading and the development of complications|
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There was a highly significant correlation between bronchoscopic grading and patient outcome (P < 0.001). All patients of grades G0 and G1 (84.3%, n = 16) survived, whereas 72.7% (n = 8) of patients of grade G2 and all patients of grade G3 died [Figure 3].
|Figure 3: Relationship between patient outcome and bronchoscopic gradings.|
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| Discussion|| |
In the present study, the incidence of inhalation injury was higher in patients less than 45 (63.3%) years of age. Younger patients are at a higher risk for exposure to inhalational injury compared with older ones. This is in agreement with the findings of Palmieri , but contradictory to the study conducted by Walker et al. , who reported that older patients are at an increased risk for inhalational injury because of prolonged exposure to the fire environment.
Thirty patients were proved bronchoscopically as having inhalational injury. The mean age of these patients was 37.96 ± 19.33 (range: 10–70 years): 16 (53.3%) patients were male and 14 (46.71%) patients were female. In Egypt, the mean age of the patients with inhalational injury from burn (39 patients) was 41 ± 32 (range: 9–73 years): 30 (76.9%) patients were male and nine (23.1%) patients were female .
Many patients complained of cough and dyspnea on admission (n = 13, 43.3%). Some complained of sputum with black carbon soot (n = 5, 16.7%), others came with disturbed level of consciousness (n = 7, 23.3%) due to lack of oxygen or other causes, and fewer came without any complaints (n = 2, 6.7%). This shows that clinical manifestations of inhalational injury were not consistent and can vary from no obvious symptoms to severe respiratory failure. These results are in agreement with the results of Bai et al.  and Gore et al. .
Twenty-one (70%) patients showed no abnormality in their radiographs, whereas nine patients showed increased bronchovascular markings (n = 7) and pneumonic patches (n = 2). Thus, chest radiography is not always diagnostic of the presence of inhalational injury. Similarly, Walker et al.  found that chest radiography on admission was rarely helpful in determining the presence or severity of inhalational injury, but its use is helpful as a baseline for determining future changes.
At the time of bronchoscopy, 12 (40%) patients were found to have grade G1 airway findings, 11 (36.7%) cases were found to have grade G2 airway findings, whereas four (13.3%) patients were graded as G0, and three (10%) patients were graded as G3. No patients were graded as G4. This classification of inhalational injury using bronchoscopy can be important in the management of patients. By identifying injury early, those patients with more advanced exposures can be closely observed, allowing quick clinical response to any change in their medical condition. Particularly in patients without surface burns, the lack of the findings of an early inhalational injury could result in the delay of treatment. This is in agreement with the results reported by Bai et al. .
Twenty-six patients had undergone bronchoalveolar lavage to remove secretions, sloughs, and carbonaceous material until the airways became clear. After lavage, 57.7% (n = 15) survived, whereas 42.3% (n = 11) died. The study conducted by Amin et al.  showed that, after lavage, 30 patients survived and 9 patients died with a mortality rate of 23%.
It was found that 21 (70%) patients in the studied group diagnosed as having inhalational injury by means of bronchoscopy had normal initial chest radiography, indicating that bronchoscopy can identify large airway injury. This is similar to the study by Gore et al. .
Moreover, there was a significant correlation between bronchoscopic grading and the results of ABG, wherein 18 patients with inhalational injury showed no hypoxemia in their ABG. This is similar to the finding of Gore et al. , who showed that bronchoscopy can identify airway injury even when blood gases were normal.
There were highly significant differences (P < 0.001) in PaO2/FiO2 ratios between patients who died and those who survived. PaO2/FiO2 is used mainly to assess the patient's oxygenation. This study is in agreement with the results of Hassan et al. .
All studied patients were proved bronchoscopically as having inhalational injury. Significant correlations were noted between bronchoscopic scoring and total number of ventilator days and ICU-stay (P = 0.005 and 0.01, respectively). This is in agreement with the results of Bai et al.  Similarly, in Egypt, there was a significant correlation between bronchoscopic scoring and total number of ventilator days and ICU-stay (P < 0.0001 and 0.01, respectively) . Moreover, there was a positive correlation between bronchoscopic grading and total body surface area %, indicating that the incidence of inhalational injury increases by increasing the burn size. This is in agreement with the study reported by Carr and Crowly .
All patients with high bronchoscopic grade inhalational injury (G3) and 90.9% of G2 patients developed complications, whereas all patients with low bronchoscopic grade inhalational injury (G0) and 83.3% of G1 patients did not develop complications; thus, it is considered as a good predictor for the prognosis of inhalational injury. This is in agreement with the study by Mosier et al. . However, Robert et al.  reported that high-grade and low-grade inhalational injury patients did not differ significantly in the incidence of complications.
There was a highly significant difference between the low bronchoscopic grade inhalational injury group (G0, G1, and G2) and the high-grade inhalational injury group (G3 and G4) in the incidence of mortality (P < 0.001). Bronchoscope had a role in the evaluation of the severity of inhalational injury and outcome. Endorf and Gamelli  found that patients with more severe inhalational injury on initial bronchoscopy (grades 2, 3, and 4) had worse survival rates compared with patients with lower scores (grades 0 or 1) (P = 0.03). However, Gore et al.  showed that no direct link between bronchoscopic grade and mortality has been definitively established.
Inhalational injury from burns increased mortality rate by 36.7% (n = 11). This percentage was high compared with that reported in the study by Bai et al. , who reported that inhalational injury from burns can increase mortality by 20%. There was a higher percentage (72.7%) of female patients who died, compared with that reported in the study by Kerby et al. , in which women had a 50% increased risk for death when compared with men, and the study conducted by Brusselaer et al. , in which overall mortality was 1.4% (1.6% male and 1.1% female).
There was a highly significant correlation between the development of complications in patients with inhalational injury and their outcome (P < 0.001); all patients who developed complications died (100%), indicating that inhalational injury was a major cause of morbidity and mortality in burn patients as it can trigger major complications such as respiratory failure, pneumonia, septicemia, and adult respiratory distress syndrome. This is in agreement with the studies conducted by Kimmel and Still  and Amin et al.  in Egypt.
| Conclusion|| |
From this study we can conclude that, even when the initial chest examination, chest radiography, and blood gases are normal, bronchoscopy can identify large airway injury, a precursor to respiratory complications due to inhalational injury.
An injury or a pseudomembrane that is not creating a problem for the patient at that time should be left to heal; therapeutic procedures should only be used for the more significant airways injuries or in patients with respiratory need.
The flexible bronchoscope has a great value in the diagnosis of inhalational injury without any complications and it should be incorporated into routine clinical practice.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Khan TS, Wani AH, Drazi MA, Bijli AH. Epidemiology of burn patients in a tertiary care hospital in Kashmir: a prospective study. Menouf Med J 2014; 22
Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM. Burns. In: Tintinalli J, et al.
, editors. Tintinalli emergency medicine: a comprehensive study guide
. New York: McGraw-Hill Companies; 2010. pp. 1374–1386.
Hassan Z, Wong JK, Bush J, et al.
Assessing the severity of inhalation injuries in adults. Burns 2010; 36
Masanes MJ, Legendre C, Lioret N, et al.
Using bronchoscopy and biopsy to diagnose early inhalation injury. Macroscopic and histologic findings. Chest 1995; 107
Gore MA, Joshi AR, Nagarajan G, et al.
Virtual bronchoscopy for diagnosis of inhalation injury in burnt patients. Burns 2004; 30
Marek K, Piotr W, Stanislaw S, Stefan G, Justyna G, Mariusz N, Andriessen A. Fiberoptic bronchoscopy in routine clinical practice in confirming the diagnosis and treatment of inhalation burns. Burns 2007; 33:
Palmieri T. Use of beta-agonists in inhalation injury. J Burn Care Res 2009; 30
Walker P, Buehner M, Wood L, et al.
Diagnosis and management of inhalation injury. Crit Care 2015; 19
Amin M, Shaaray H, Gad E. Role of fiberoptic bronchoscopy in management of smoke inhalation lung injury. Egypt J Chest Dis Tuberc 2015; 64
Bai C, Huang H, Yao X, Zhu S, Li B, Hang J, Zhang W, Zarogoulidis P, Gschwendtner A, Zarogoulidis K, Li Q, Simoff M. Application of flexible bronchoscopy in inhalation lung injury. Diagn Pathol J 2013; 8
Carr A, Crowly N. Prophylactic sequential bronchoscopy after inhalation injury: results from a three-year prospective randomized trial. Eur J Trauma Emerg Surg 2013; 39
Mosier MJ, Pham TN, Park DR, Simmons J, Klein MB, Gibran NS. Predictive value of bronchoscopy in assessing the severity of inhalation injury. J Burn Care Res 2012; 33
Spano S, Hanna S, Li Z, Wood D, Cartotto R. Does bronchoscopic evaluation of inhalation injury severity predict outcome?, J Burn Care Res 2016; 37
Endorf F, Gamelli R. Inhalation injury, pulmonary perturbations, and fluid resuscitation. J Burn Care Res 2007; 28
Kerby JD, McGwin G Jr, George RL, Cross JA, Chaudry IH, Rue LW III. Sex differences in mortality after burn injury, J Burn Care Res 2006; 27
Brusselaer N, Juhasz I, Erdei S, Blot R. Evaluation of mortality following severe burns injury in Hungary. Burns 2009; 35
Kimmel E, Still K. Acute lung injury, acute respiratory distress syndrome and inhalation injury: an overview. Drug Chem Toxicol 1999; 22
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]