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

Albright, Joslyn M. MD; Davis, Christopher S. MD, MPH; Bird, Melanie D. PhD; Ramirez, Luis BS; Kim, Hajwa MS, MA; Burnham, Ellen L. MD, MS; Gamelli, Richard L. MD, FACS; Kovacs, Elizabeth J. PhD

doi: 10.1097/CCM.0b013e3182374a67
Clinical Investigations

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. (Crit Care Med 2012; 40:–1121)

From Burn and Shock Trauma Institute (JMA, CSD, MDB, LR, RLG, EJK), Department of Surgery, Loyola University Chicago, Stritch School of Medicine, Maywood, IL; Center for Clinical and Translational Science (HK), University of Illinois at Chicago, Chicago, IL; Department of Medicine (ELB), Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver School of Medicine, Aurora, CO.

*See also p. 1345.

The authors have not disclosed any potential conflicts of interest.

Supported, in part, by the National Institutes of Health (T32 GM008750 to RLG, T32 AA013527 to EJK, R01 AA012034 to EJK, P30 AA019373 to EJK), the International Association of Fire Fighters (to JMA), the Dr. Ralph and Marian C. Falk Medical Research Trust (to EJK), and the Department of Defense W81XWH-09-1-0619.

The authors have not disclosed any potential conflicts of interest.

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© 2012 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins