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. 2012 Apr;40(4):1113-21.
doi: 10.1097/CCM.0b013e3182374a67.

The acute pulmonary inflammatory response to the graded severity of smoke inhalation injury

Joslyn M Albright  1 , Christopher S Davis, Melanie D Bird, Luis Ramirez, Hajwa Kim, Ellen L Burnham, Richard L Gamelli, Elizabeth J Kovacs
Affiliations

The acute pulmonary inflammatory response to the graded severity of smoke inhalation injury

Joslyn M Albright et al. Crit Care Med. 2012 Apr.

Abstract

Objectives: To determine whether the graded severity of smoke inhalation is reflected by the acute pulmonary inflammatory response to injury.

Design: In a prospective observational study, we assessed the bronchoalveolar lavage fluid for both leukocyte differential and concentration of 28 cytokines, chemokines, and growth factors. Results were then compared to the graded severity of inhalation injury as determined by Abbreviated Injury Score criteria (0, none; 1, mild; 2, moderate; 3, severe; 4, massive).

Setting: All patients were enrolled at a single tertiary burn center.

Patients: The bronchoalveolar lavage fluid was obtained from 60 patients within 14 hrs of burn injury who underwent bronchoscopy for suspected smoke inhalation.

Interventions: None.

Measurements and main results: Those who presented with worse grades of inhalation injury had higher plasma levels of carboxyhemoglobin and enhanced airway neutrophilia. Patients with the most severe inhalation injuries also had a greater requirement for tracheostomy, longer time on the ventilator, and a prolonged stay in the intensive care unit. Of the 28 inflammatory mediators assessed in the bronchoalveolar lavage fluid, 21 were at their highest in those with the worst inhalation injury scores (grades 3 and 4), the greatest of which was interleukin-8 (92,940 pg/mL, grade 4). When compared in terms of low inhalation injury (grades 1-2) vs. high inhalation injury (grades 3-4), we found significant differences between groups for interleukin-4, interleukin-6, interleukin-9, interleukin-15, interferon-γ, granulocyte-macrophage colony-stimulating factor, and monocyte chemotactic protein-1 (p < .05 for all).

Conclusions: These data reveal that the degree of inhalation injury has basic and profound effects on burn patient morbidity, evokes complex changes of multiple alveolar inflammatory proteins, and is a determinant of the pulmonary inflammatory response to smoke inhalation. Accordingly, future investigations should consider inhalation injury to be a graded phenomenon.

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Figures

Figure 1
Figure 1
Inflammatory mediator concentrations in the BAL fluid of controls (C) and burn patients with inhalation injury graded 0–4 by bronchoscopic criteria (0 = no injury; 1 = mild injury; 2 = moderate injury; 3 = severe injury; 4 = massive injury). Statistical comparison by Kruskal-Wallace and post-hoc analysis do not include controls, which are included for visual comparison. *p < 0.05 between groups.
Figure 2
Figure 2
Inflammatory mediator concentrations in the BAL fluid of burn patients with low inhalation injury severity (Grades 1–2) vs high inhalation injury severity (Grades 3–4). Differences considered statistically significant when p < 0.05.
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