Respiratory care of critically ill burn patients: Mechanical ventilation and pulmonary coagulopathy

Burn patients are at high risk for lung injury and subsequent respiratory failure, often requiring mechanical ventilation (MV). Coagulopathy is frequently seen, particularly following severe burn or inhalation trauma and may result in the formation of pulmonary casts which contribute to respiratory dysfunction. While MV may be lifesaving, it could also severely harm lungs. To limit so called ‘ventilator–induced lung injury’ (VILI), ‘lung–protective’ ventilation strategies have become standard care in the nonburn intensive care unit (ICU) population. Whether lung–protective ventilation is practiced in burn patients is unknown.
Optimization of MV strategies and attenuation of pulmonary coagulopathy may shorten the duration of MV and improve the outcome of burn patients. This thesis comprises studies focusing on these two aspects of the respiratory care of burn patients.
The first part of this thesis focused on MV practices. The general aim was to assess current MV practices. To achieve this we performed a systematic review which described changes in MV practices over time and summarized the reported VILI. To gain further insight in the current ventilation practices we performed an international prospective observational cohort study, which also aimed to determine associations between ventilator settings and clinical outcomes.
The second part of this thesis focused on pulmonary coagulopathy. We aimed to determine the association between nebulized anticoagulants and outcomes of ventilated ICU–patients through an individual patient data metaanalysis and initiated a multicenter randomized controlled trial investigating feasibility, efficacy and safety of nebulized heparin versus placebo in patients with inhalation trauma.