Rajaratnam Ganesh, Baldwin Alexander J
Department of Anaesthetics, Lister Hospital, East and North Hertfordshire NHS Trust, United Kingdom.
Department of Burns and Plastic Surgery, Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, United Kingdom.
Burns. 2024 Dec;50(9):107273. doi: 10.1016/j.burns.2024.09.012. Epub 2024 Sep 24.
To evaluate variations in diagnostic criteria and management recommendations for smoke inhalation injury (SII) amongst the burn networks of England, Scotland, and Wales.
A descriptive cross-sectional study examining SII guidelines provided by adult burn units and centres in England, Scotland and Wales.
All 16 adult burn units and centres responded. Fourteen (87.5 %) had guidelines. Due to sharing of guidelines, ten unique guidelines were assessed. Diagnostic criteria showed variability with no universal criterion shared amongst guidelines. Bronchoscopy was recommended by 90 % of guidelines, but the timing varied. The use of bronchoscopic scoring systems was recommended by four guidelines. Bronchoalveolar lavage (BAL) was recommended by four, with considerable variation in frequency and choice of lavage fluid. All guidelines advised at least one nebulised agent: heparin (n = 8); N-acetyl cysteine (NAC) (n = 8); or salbutamol (n = 8). All guidelines included advice on carbon monoxide poisoning; however, carboxyhaemoglobin (COHb) cut-off levels for treatment varied (5 % [n-4], 10 % [n = 3], 15 % [n = 1]). All recommended high-flow oxygen. Seven (70 %) guidelines offered guidance on cyanide poisoning. Reduced/altered consciousness was the only consistent diagnostic criterion. Five (50 %) guidelines provided intubation guidance, emphasising the role of a 'senior clinician' as the intubator. Ventilatory guidance appeared in eight guidelines, focusing on lung protective ventilation (n = 8); oxygenation goals (n = 3); and permissive hypercapnia (n = 3). Within lung-protective ventilation, advice on tidal volume (6, or 6-8 ml/kg) and plateau pressures (>30 cmH2O) were presented most commonly (n = 7).
This study has outlined the substantial variations in guidance for the management of SII. The results underscore the need for a national guideline outlining a standardised approach to the diagnosis and management of SII, within the limitations of the current evidence.
评估英格兰、苏格兰和威尔士烧伤网络中烟雾吸入性损伤（SII）的诊断标准和处理建议的差异。
一项描述性横断面研究，考察英格兰、苏格兰和威尔士成人烧伤病房和中心提供的SII指南。
所有16个成人烧伤病房和中心均作出回应。其中14个（87.5%）有指南。由于指南的共享，共评估了10份独特的指南。诊断标准存在差异，各指南之间没有共同的通用标准。90%的指南推荐进行支气管镜检查，但检查时机各不相同。4份指南推荐使用支气管镜评分系统。4份指南推荐进行支气管肺泡灌洗（BAL），灌洗频率和灌洗液的选择差异很大。所有指南均建议至少使用一种雾化药物：肝素（n = 8）；N-乙酰半胱氨酸（NAC）（n = 8）；或沙丁胺醇（n = 8）。所有指南均包含一氧化碳中毒的相关建议；然而，治疗的碳氧血红蛋白（COHb）临界值各不相同（5% [n = 4]，10% [n = 3]，15% [n = 1]）。所有指南均推荐高流量吸氧。7份（70%）指南提供了氰化物中毒的相关指导。意识减退/改变是唯一一致的诊断标准。5份（50%）指南提供了插管指导，强调“资深临床医生”作为插管者的作用。8份指南中出现了通气指导，重点是肺保护性通气（n = 8）；氧合目标（n = 3）；以及允许性高碳酸血症（n = 3）。在肺保护性通气方面，潮气量（6，或6 - 8 ml/kg）和平台压（>30 cmH2O）的建议最为常见（n = 7）。
本研究概述了SII处理指南中的显著差异。结果强调了需要制定一份国家指南，在当前证据的限制范围内，概述SII诊断和处理的标准化方法。
