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Treatment
continued . . .
The
clearance of soot, mucopurulent exudate,
and sloughing mucosa is essential to avoid
progression of the lung injury. An
endotracheal tube may be necessary if
clearance of secretions is inadequate.
Ventilator assist may also be necessary if
the patient is fatiguing and if gas
exchange is worsening. Continued
readjustments in tidal volume, rate, and
positive end-expiratory pressure (PEEP)
are necessary to maintain gas exchange
while minimizing barotrauma. Sedation
(narcotic infusion) or paralysis may be
necessary if the patient’s spontaneous
ventilatory attempts further impair lung
function while on ventilator support.
Bronchodilators, particularly those
provided by aerosols, are also very
helpful, along with frequent changes in
position for postural drainage. Continuous
rotating beds are ideal for the patient
with an inhalation injury and a large body
burn where side to side patient movement
is difficult because of pain and stiffness
from tissue edema. The constant postural
drainage assists in removing airway plugs.
To be effective the movement must be at
least 45° from side to side, best
accomplished by a rotation bed.
Infection
surveillance is crucial during this early
period in order to detect a bacterial
bronchitis prior to development of a
pneumonia. Sputum smears and monitoring of
the character of the sputum are useful
early guides. Systemic antibiotics are not
given prophylactically but initiated when
a bacterial process becomes evident.
Click
the Image to Enlarge
Figure:
Rotating bed, which provides postural
drainage after major burns, especially
with smoke inhalation injury
Typical
sputum smear of a trachobronchitis on day
3-4 demonstrating neutrophils and gram
positive organisms in clusters and chains
(Begin antibiotic therapy)
Tracheal
mucosa demonstrating loss of most of the
epithelium, a high infection risk
Persistent
small airways edema and broncho-constriction
decreasing lung compliance
Do
not wait until obvious radiographic
evidence of bronchopneumonia is present
because the process, once well
established, will be difficult to reverse.
Broad-spectrum antibiotics can be used
until the specific sensitivities return
and a more tailored antibiotic regimen can
be instituted.
  
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