RESPIRATORY CARE

IN BURNS
Dr Yew Woon Si
Consultant Anaesthetist
Singapore General Hospital
INTRODUCTION
Challenging complications of
inhalational injury, Acute Lung
Injury, ARDS

Ranges from difficult intubations,
bronchoscopic examinations,
interpretation of ABG, ventilator
management

Multi-disciplinary approach
ACUTE MEASURES
PROPHYLACTIC INTUBATION
Suspected inhalational injury
Singed nasal hair
Facial burns
Trapped in enclosed space
Hoarseness of voice (LATE SIGN!)
Carbonaceous sputum
TBSA > 40 50%
Decreased level of consciousness
Haemodynamic instability

Adjunctive Measures
Chest Physiotherapy
Early ambulation
Early extubation if clinical condition
permits
Clearance of secretions suctioning,
coughing, therapeutic bronchoscopy

Pharmacological Adjuncts
Neb Heparin 5000U 4h
Neb 20% N-acetylcysteine 4h
Neb Salbutamol 3ml 4h
Neb Saline 3ml 4h

Neb racemic Adrenaline
MECHANICAL VENTILATION
American College of Chest Physicians
Consensus Statement
1. Choose a ventilator mode that one
is comfortable with which supports
oxygenation adequately
2. Acceptable PaO2 targeted
3. Plateau pressures < 35 cm H2O
4. Permissive hypercapnia
5. Utilization of PEEP
6. Tidal vol 8-10 ml/kg if PaO2 fails to
improve
Modes of Ventilation
Controlled Mandatory Ventilation
(CMV)
Ventilator cycles at a rate set by
operator
Cycles regardless of patients need
Patient UNABLE to trigger ventilator

Disadvantages
Poorly tolerated; poor synchrony except
in heavily sedated
Breath stacking
Synchronised Intermittent
Mandatory Ventilation (SIMV)
Most commonly used

Delivers a preset number of
ventilator-delivered breaths,
synchronised to patients own efforts
if present

May be pressure or volume
controlled


Synchronised Intermittent
Mandatory Ventilation (SIMV)
Advantages:
Better tolerated, even in awake patients
Allows patient to trigger own breaths;
maintains variable amt of respiratory
work performed by patients
Disadvantages
Excessive work of breathing if used
alone
Pressure vs Volume Control
Pressure Control
Ventilator-delivered breaths are
pressure limited.
Delivers constant pressure of air to
patient; tidal volume dependent on lung
compliance
Avoids barotrauma
Length of inspiration, pressure level and
back-up rate set by operating.
Pressure vs Volume Control
Volume Control
Tidal volume preset by operator
Airway pressures variable depending on
lung compliance
May result in barotrauma if airway
pressures unacceptably high
Pressure Support Ventilation
Designed to assist spontaneous breathing
Pressure-targeted, flow-cycled.
Patient MUST trigger each breath

ADVANTAGES
Comfortable; weaning mode
Reduces work of breathing
Can be combined with SIMV
Overcomes equipment airway resistance
ALTERNATE VENTILATION
MODES
High Frequency Percussive
Ventilation
Inverse Ratio Ventilation
Airway Pressure Release Ventilation
Extra-corporeal Membrane
Oxygenation (ECMO)

SUMMARY
1. Respiratory Care paramount in the
survival of thermally-injured
patients
2. Multi-prong approach
3. Ventilatory strategies should be one
that one is familiar with
4. Consider whether patients
conscious levels when choosing
ventilatory modes
5. Try to maintain spontaneous
ventilation if possible