Future therapies

The development of new clinical therapies and ongoing laboratory investigations promise further improvement in the treatment of inhalation injury. One new therapeutic intervention involves the treatment of severe inhalation injury with aerosolized heparin. Severe injury can denude the airway and lead to the formation of bloody casts consisting of inspissated mucus and hemorrhagic plugs that can be obstructive. In this setting, aerosolized heparin 10 000 IU, administered in nebulized form every 6 h, can reduce the catastrophic complication of occluded airways and respiratory decompensation ( Cox. ..etal 1993). Pentoxifylline, another potential therapeutic agent, may improve the microcirculation through its hemorrheological and antithrombotic effects, and its inhibitory effect on cytokine release and leukocyte activation may offer relief from the hyperacute inflammatory response that follows inhalation injury. Platelet activating factor antagonists have also shown promise in animal models of inhalation injury by virtue of their ability to reduce the local and systemic responses evoked by the injury.

One of the mainstays of therapy following inhalation injury is to allow no further injury to occur. Repeated cycles of injury in the form of barotrauma or overdistension of lung units cause continued recruitment of inflammatory cells into the zone of injury and development of fibrosis through macrophage elaboration of basic fibroblast growth factor and other factors. Some investigators have evaluated intravenous CO 2 extraction as a means of decreasing the need for ventilation and its attendant high airway pressures in patients with severe physiological derangement. Another therapy that may offer relief from these repeated cycles of injury is perfluorocarbon-assisted gas exchange (PAGE). PAGE has been evaluated in many models of acute lung injury, and recently, in a porcine model of inhalation injury, transformed an inhalation injury with uniform lethality at 24 h into a survivable injury (Fitzpatrick et al. 1996).

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