Changes in ventilator settings and ventilation-induced lung injury in burn patients-A systematic review

Objective: Ventilation strategies aiming at prevention of ventilator-induced lung injury (VILI), including low tidal volumes (V_T) and use of positive end-expiratory pressures (PEEP) are increasingly used in critically ill patients. It is uncertain whether ventilation practices changed in a similar way in burn patients. Our objective was to describe applied ventilator settings and their relation to development of VILI in burn patients.

Data sources: Systematic search of the literature in PubMed and EMBASE using MeSH, EMTREE terms and keywords referring to burn or inhalation injury and mechanical ventilation.

Study selection: Studies reporting ventilator settings in adult or pediatric burn or inhalation injury patients receiving mechanical ventilation during the ICU stay.

Data extraction: Two authors independently screened abstracts of identified studies for eligibility and performed data extraction.

Data synthesis: The search identified 35 eligible studies. V_T declined from 14 ml/kg in studies performed before to around 8 ml/kg predicted body weight in studies performed after 2006. Low-PEEP levels (<10 cmH₂O) were reported in 70% of studies, with no changes over time. Peak inspiratory pressure (PIP) values above 35 cmH₂O were frequently reported. Nevertheless, 75% of the studies conducted in the last decade used limited maximum airway pressures (≤35 cmH₂O) compared to 45% of studies conducted prior to 2006. Occurrence of barotrauma, reported in 45% of the studies, ranged from 0 to 29%, and was more frequent in patients ventilated with higher compared to lower airway pressures.

Conclusion: This systematic review shows noticeable trends of ventilatory management in burn patients that mirrors those in critically ill non-burn patients. Variability in available ventilator data precluded us from drawing firm conclusions on the association between ventilator settings and the occurrence of VILI in burn patients.