Faculty of Medicine, Imperial College London, London, UK.
Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, Toronto, ON, Canada.
Crit Care. 2023 Nov 27;27(1):459. doi: 10.1186/s13054-023-04718-w.
Burn inhalation injury (BII) is a major cause of burn-related mortality and morbidity. Despite published practice guidelines, no consensus exists for the best strategies regarding diagnosis and management of BII. A modified DELPHI study using the RAND/UCLA (University of California, Los Angeles) Appropriateness Method (RAM) systematically analysed the opinions of an expert panel. Expert opinion was combined with available evidence to determine what constitutes appropriate and inappropriate judgement in the diagnosis and management of BII.
A 15-person multidisciplinary panel comprised anaesthetists, intensivists and plastic surgeons involved in the clinical management of major burn patients adopted a modified Delphi approach using the RAM method. They rated the appropriateness of statements describing diagnostic and management options for BII on a Likert scale. A modified final survey comprising 140 statements was completed, subdivided into history and physical examination (20), investigations (39), airway management (5), systemic toxicity (23), invasive mechanical ventilation (29) and pharmacotherapy (24). Median appropriateness ratings and the disagreement index (DI) were calculated to classify statements as appropriate, uncertain, or inappropriate.
Of 140 statements, 74 were rated as appropriate, 40 as uncertain and 26 as inappropriate. Initial intubation with ≥ 8.0 mm endotracheal tubes, lung protective ventilatory strategies, initial bronchoscopic lavage, serial bronchoscopic lavage for severe BII, nebulised heparin and salbutamol administration for moderate-severe BII and N-acetylcysteine for moderate BII were rated appropriate. Non-protective ventilatory strategies, high-frequency oscillatory ventilation, high-frequency percussive ventilation, prophylactic systemic antibiotics and corticosteroids were rated inappropriate. Experts disagreed (DI ≥ 1) on six statements, classified uncertain: the use of flexible fiberoptic bronchoscopy to guide fluid requirements (DI = 1.52), intubation with endotracheal tubes of internal diameter < 8.0 mm (DI = 1.19), use of airway pressure release ventilation modality (DI = 1.19) and nebulised 5000IU heparin, N-acetylcysteine and salbutamol for mild BII (DI = 1.52, 1.70, 1.36, respectively).
Burns experts mostly agreed on appropriate and inappropriate diagnostic and management criteria of BII as in published guidance. Uncertainty exists as to the optimal diagnosis and management of differing grades of severity of BII. Future research should investigate the accuracy of bronchoscopic grading of BII, the value of bronchial lavage in differing severity groups and the effectiveness of nebulised therapies in different severities of BII.
烧伤吸入性损伤（BII）是烧伤相关死亡和发病率的主要原因。尽管有已发表的实践指南，但在 BII 的诊断和管理方面，尚无最佳策略的共识。使用 RAND/UCLA（加利福尼亚大学洛杉矶分校）适宜性方法（RAM）的改良 Delphi 研究系统地分析了专家小组的意见。将专家意见与现有证据相结合，以确定在 BII 的诊断和管理中哪些是适当的，哪些是不适当的判断。
由参与治疗大面积烧伤患者的麻醉师、重症监护医生和整形外科医生组成的 15 人多学科小组采用改良 Delphi 方法和 RAM 方法。他们对描述 BII 诊断和管理选择的陈述进行了李克特量表评估。完成了一项包含 140 项陈述的改良最终调查，分为病史和体检（20 项）、检查（39 项）、气道管理（5 项）、全身毒性（23 项）、有创机械通气（29 项）和药物治疗（24 项）。计算适当性中位数评分和分歧指数（DI），将陈述分类为适当、不确定或不适当。
在 140 项陈述中，74 项被评为适当，40 项为不确定，26 项为不适当。初始插管使用≥8.0mm 气管内导管、肺保护性通气策略、初始支气管镜灌洗、严重 BII 的连续支气管镜灌洗、中度至重度 BII 的雾化肝素和沙丁胺醇以及中度 BII 的 N-乙酰半胱氨酸被评为适当。非保护性通气策略、高频振荡通气、高频喷射通气、预防性全身抗生素和皮质类固醇被评为不适当。专家对六个分类不确定的陈述存在分歧（DI≥1）：使用可弯曲纤维支气管镜指导液体需求（DI=1.52）、使用内径<8.0mm 的气管内导管插管（DI=1.19）、使用气道压力释放通气模式（DI=1.19）和雾化 5000IU 肝素、N-乙酰半胱氨酸和沙丁胺醇治疗轻度 BII（DI=1.52、1.70、1.36）。
烧伤专家大多同意在已发表的指南中对 BII 的适当和不适当的诊断和管理标准。在 BII 不同严重程度的最佳诊断和管理方面存在不确定性。未来的研究应调查支气管镜分级 BII 的准确性、不同严重程度组支气管灌洗的价值以及不同严重程度的 BII 中雾化治疗的效果。
