Chapter 24

### Introduction

Objectives

1. Describe the respiratory effects of surface burns and inhalation injury.

2. Discuss issues related to airway injury in patients with inhalation injury.

3. Describe the management of carbon monoxide poisoning.

4. Discuss the indications, initial ventilator settings, monitoring, and ventilator weaning for the patient with surface burns and inhalation injury.

5. Discuss various modes of ventilation that have been proposed to manage patients with burns and inhalation injury.

Respiratory complications are common in patients with burn injuries, and respiratory failure is a common cause of mortality in these patients. Pulmonary complications can occur at a number of times along the treatment course of burned patients (Table 24-1). Pulmonary complications are often associated with inhalation injury, but may occur in patients with severe surface burns who do not have inhalation injury. Mechanical ventilation is commonly necessary in these patients who develop respiratory failure.

Table 24-1Pulmonary Complications Present at Various Times in Patients With Burns and Smoke Inhalation

### Overview

#### Surface Burns

Respiratory failure commonly occurs in patients with major cutaneous burns. Such patients often have associated inhalation injury, and the presence of inhalation injury significantly increases the mortality related with cutaneous burns. However, respiratory failure and the need for mechanical ventilation may occur in the absence of inhalation injury. There are recognized interactions between smoke inhalation and cutaneous burns (Figure 24-1). Pain management is an important aspect of the care of patients with burns, and may be associated with respiratory depression. Appropriate fluid management is difficult in patients with cutaneous burns, and fluid overload with associated hypoxemia and decreased lung compliance may occur. Sepsis can also occur, resulting in respiratory failure due to acute respiratory distress syndrome (ARDS). Burn patients may be hypermetabolic, which increases the ventilation requirement and may result in respiratory failure due to fatigue.

###### Figure 24-1

Respiratory dysfunction is central to the effects of smoke inhalation and cutaneous burns.

If full thickness circumferential burns of the thorax are present, severe chest wall restriction can occur. This will typically produce respiratory failure, and can make mechanical ventilation difficult. High ventilating pressures may be required, ...

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