Taylor Fontenot, MD
Resident
Kirk Kerkorian School of Medicine at University of Nevada Las Vegas
Las Vegas, NV
Disclosure information not submitted.
Joseph Carroll, MD
General Surgery Residency Program Director
Kirk Kerkorian School of Medicine at UNLV, Department of Surgery, United States
Disclosure information not submitted.
Carmen Flores, MD
Assistant Professor
Kirk Kerkorian School of Medicine at UNLV, Department of Surgery, United States
Disclosure information not submitted.
Title: Inhalation Injury and Down Syndrome, The Need For Heightened Awareness
Case Report Body:
Introduction: Inhalation injury is well described as an independent risk factor for mortality, increasing mortality in burns by greater than 20%. Anatomic respiratory tract variants of Down Syndrome (DS) patients render them susceptible to infection and injury. Coupled with immune defects characteristic of Down Syndrome, can lead to a robust immune response to inhalation injury. In this report, we discuss the effects of smoke inhalation injury in a DS patient which merit a lower threshold for early, aggressive intervention.
Case Summary: A 23-year-old female with DS presented with smoke inhalation and partial thickness burns to the upper extremities. She developed respiratory distress 12 hours post-injury, requiring intubation and mechanical ventilation. Direct laryngoscopy demonstrated carbonaceous sputum and marked upper airway edema. Aggressive pulmonary hygiene measures were initiated: nebulized heparin, acetylcysteine, and albuterol treatments. Bronchoscopy following admission revealed minimal mucosal injury and extensive carbonaceous deposits and casts of the bronchial tree. The patient developed acute respiratory distress syndrome within 48 hours. She proceeded to the operating room for therapeutic bronchoscopy and acutely decompensated secondary to insurmountable distal airway obstruction. She succumbed to cardiopulmonary failure.
Discussion: Inhalation injury can be categorized into three types: supraglottic, subglottic, and systemic. In subglottic injuries, the main pathophysiologic change is increased bronchial blood flow, which manifests as mucosal edema, increased mucosal secretion, and eventual airway obstruction. Data exists supporting the use of bronchoscopy, nebulized heparin, acetylcysteine, and bronchodilators for subglottic injury. Our patient had several non-modifiable factors that contributed to her eventual demise. Patients with DS have smaller airways, and fewer, yet larger alveoli with reduced surface area, leaving them susceptible to mechanical stress. They exhibit significantly greater levels of pro- and anti-inflammatory cytokines that can lead to significant systemic immune response to trauma. With such non-modifiable factors, DS patients with inhalation injury warrant early consideration of definitive airway establishment, close monitoring, and aggressive pulmonary hygiene measures.