Phẫu Thuật Bỏng: Tiếp Cận Và Phương Pháp Điều Trị Từ Trung Quốc (Chinese Burn Surgery)

240
Table 9.36 Comparison of fi bronectin (FN)-positive rates in wound tissue x
s n
±
=
(
)
,
6
Group
Time after surgery
1st week
2nd week
4th week
6th week
8th week
NH
33.23 ± 0.88
33.00 ± 2.38
36.76 ± 2.88
31.43 ± 2.06
17.93 ± 1.66
FSGT
19.48 ± 2.00 #,*,Ⴃ
20.86 ± 1.34 #,*,Ⴃ
18.65 ± 2.24 #,*,Ⴃ
18.03 ± 0.77 #,*
5.86 ± 0.66 #,*
TSGT
25.66 ± 1.71 #
29.18 ± 1.28 #
26.59 ± 2.61 #
24.55 ± 1.72 #
8.59 ± 1.09 #
CT
22.06 ± 1.43 #,*
23.70 ± 1.41 #,*
21.94 ± 2.24 #,*
19.27 ± 1.28 #,*
6.10 ± 0.41 #,*
NH natural healing, FSGT full skin graft transplantation, TSGT thin skin graft transplantation, CT composite transplantation (thin skin graft +
dermal substitute)
# p < 0.01 compared with NH; * p < 0.01 compared with TSGT; Ⴃ p < 0.01 compared with CT
Table 9.37 Comparison of integrin α2-positive rates in wound tissue x
s n
±
=
(
)
,
6
Group
Time after surgery
1st week
2nd week
4th week
6th week
8th week
NH
22.15 ± 2.04
26.96 ± 3.18
16.69 ± 3.26
7.94 ± 1.26
4.89 ± 0.69
FSGT
14.40 ± 1.62 #,*,Ⴃ
16.78 ± 3.08 #,*,Ⴃ
7.76 ± 1.06 #,*
5.11 ± 0.43 #,*
3.49 ± 0.99
TSGT
19.45 ± 1.22 #
23.12 ± 1.51 #
11.72 ± 1.56 #
6.48 ± 0.56 #
4.35 ± 0.63
CT
17.26 ± 1.38 #,*
19.97 ± 2.04 #,*
8.18 ± 1.07 #,*
5.69 ± 0.66 #
3.95 ± 0.68
NH natural healing, FSGT full skin graft transplantation, TSGT thin skin graft transplantation, CT composite transplantation (thin skin graft +
dermal substitute)
# p < 0.01 compared with NH; * p < 0.01 compared with TSGT; Ⴃ p < 0.01 compared with CT
Table 9.38 Comparison of integrin β1-positive rates in wound tissue x
s n
±
=
(
)
,
6
Group
Time after surgery
1st week
2nd week
4th week
6th week
8th week
NH
25.25 ± 1.13
34.35 ± 2.96
40.68 ± 3.23
10.56 ± 1.08
8.12 ± 1.35
FSGT
17.61 ± 1.59 #,*,Ⴃ
18.71 ± 1.07 #,*,Ⴃ
13.16 ± 1.44 #,*,Ⴃ
5.89 ± 0.44 #,*,Ⴃ
4.31 ± 0.36 #,*,Ⴃ
TSGT
20.57 ± 2.17 #
26.51 ± 2.61 #
20.28 ± 1.94 #
9.04 ± 0.98 #
6.46 ± 0.36 #
CT
21.72 ± 1.17 #
21.64 ± 1.46 #,*
17.96 ± 1.15 #,*
7.05 ± 0.79 #,*
5.20 ± 0.98 #
NH natural healing, FSGT full skin graft transplantation, TSGT thin skin graft transplantation, CT composite transplantation (thin skin graft +
dermal substitute)
# p < 0.01 compared with NH; ** p < 0.01 compared with TSGT; Ⴃ p < 0.01 compared with CT
Table 9.39 Comparison of TGF-β1-positive rates in wound tissue x
s n
±
=
(
)
,
6
Group
Time after surgery
1st week
2nd week
4th week
6th week
8th week
NH
24.09 ± 0.96
36.83 ± 2.63
28.24 ± 1.62
24.23 ± 2.43
23.29 ± 2.11
FSGT
18.27 ± 1.18 #
15.79 ± 0.80 #, *
16.74 ± 1.13 #, * ,Ⴃ
13.22 ± 1.89 #, * ,Ⴃ
10.67 ± 0.93 #, * Ⴃ
TSGT
18.88 ± 2.13 #
19.12 ± 1.93 #
22.66 ± 1.33 #
19.72 ± 1.44 #
16.79 ± 0.85 #
CT
18.31 ± 1.62 #
16.41 ± 1.88 #, *
18.66 ± 0.79 #, *
14.94 ± 1.11 #, *
14.39 ± 0.99 #, *
NH natural healing, FSGT full skin graft transplantation, TSGT thin skin graft transplantation, CT composite transplantation (thin skin graft +
dermal substitute)
# p < 0.01 compared with NH; * p < 0.01 compared with TSGT; Ⴃp < 0.01 compared with CT
9.3.1.3 Effect of 3D Structure and Components
on Myofi broblast Differentiation
First, we investigated the infl uence of 3D structure on fi bro-
blasts [ 110 ]. Decalcifi ed bone collagen and sponge were
employed and transplanted subcutaneously into rats, and
samples were obtained at the 1st week and 2nd week and
were then subjected to histological observation.
We found that outside the material of decalcifi ed bone
collagen and sponge, the morphology of fi broblasts was
spindle-shaped and the collagen arrangement was parallel to
9 Burn Wound Healing

241
Table 9.40 The expression of type III collagen and type III collagen mRNA x
s n
±
=
(
)
,
9
Index
Group
Time after surgery
1st week
2nd week
3rd week
4th week
Type III collagen
CT
65.89 ± 5.25
58.27 ± 8.36
52.02 ± 4.85
51.83 ± 5.49
TSGT
66.35 ± 3.24
68.23 ± 5.60*
68.28 ± 4.49*
65.64 ± 6.92*
Type III collagen mRNA
CT
13.63 ± 3.40
17.34 ± 4.89
14.16 ± 3.32
5.29 ± 1.07
TSGT
24.40 ± 3.02
24.74 ± 1.87*
22.54 ± 1.65*
19.71 ± 4.16*
TSGT thin skin graft transplantation, CT composite transplantation (thin skin graft + dermal substitute)
* p < 0.05 compared with CT
Table 9.41 Comparison of CD34 expression in wound tissue
Group
Time after surgery
1st week
2nd week
3rd week
4th week
CT
4.0 ± 0.7
4.3 ± 0.9*
3.5 ± 0.5*
3.1 ± 1.13*
TSGT
5.3 ± 2.0
5.4 ± 0.8
4.9 ± 1.72
5.6 ± 2.3
TSGT thin skin graft transplantation, CT composite transplantation (thin skin graft + dermal substitute)
* p < 0.05 compared with TSGT
Table 9.42 Comparison of TGF-β1, TβRI, II, and Smad3 protein expression x
s n
±
=
(
)
,
10
Index
Group
Time after grafting
1st week
2nd week
3rd week
4th week
TGF-β1
CT
13.08 ± 4.65
12.36 ± 1.51
11.18 ± 1.88
9.03 ± 1.89
TSGT
19.24 ± 4.59*
14.91 ± 4.17*
13.66 ± 1.58*
11.46 ± 2.37*
TβRI
CT
6.87 ± 2.60
4.30 ± 2.19
2.92 ± 1.21
2.22 ± 0.68
TSGT
10.62 ± 3.95*
6.21 ± 2.09*
4.22 ± 0.86*
3.51 ± 0.74*
TβRII
CT
4.34 ± 1.95
3.51 ± 0.88
2.76 ± 1.04
2.32 ± 0.49
TSGT
6.81 ± 1.20*
5.23 ± 0.86*
3.99 ± 0.58*
2.93 ± 0.64*
Smad3
CT
14.59 ± 4.22
11.36 ± 4.06
10.12 ± 2.02
6.32 ± 1.56
TSGT
23.38 ± 4.00*
16.54 ± 1.99*
13.39 ± 2.03*
9.60 ± 3.07*
TSGT thin skin graft transplantation, CT composite transplantation (thin skin graft + dermal substitute)
* p < 0.05 compared with CT
Table 9.43 Comparison of p53 expression in wound tissue x
s n
±
=
(
)
,
9
Group
Time after surgery
1st week
2nd week
3rd week
4th week
CT
19.87 ± 3.67
30.57 ± 10.90*
27.08 ± 7.12*
22.85 ± 5.19*
TSGT
16.04 ± 3.67
18.60 ± 2.74
19.30 ± 3.02
18.16 ± 1.51
TSGT thin skin graft transplantation, CT composite transplantation (thin skin graft + dermal substitute)
* p < 0.05 compared with TSGT
Table 9.44 Comparison of apoptotic rates in wound tissue x
s n
±
=
(
)
,
9
Group
Time after surgery
1st week
2nd week
3rd week
4th week
CT
15.90 ± 6.88
15.40 ± 2.61
23.54 ± 2.48*
34.02 ± 7.20*
TSGT
10.98 ± 2.34
13.36 ± 2.52
19.12 ± 3.44
4.61 ± 2.29
TSGT thin skin graft transplantation, CT composite transplantation (thin skin graft + dermal substitute)
* p < 0.05 compared with TSGT
9.3 The Defect of Dermal Template in Wounds Contributes to Scar Formation

242
the material surface (Fig. 9.7a, c ), which was similar to that
in granulation tissue. Whereas inside the material, fi broblasts
had migrated into the 3D structure, and exhibited polygonal
stellate and collagen arranged in multi-directions (Fig. 9.7b, d ),
which was similar to that in normal skin.
Outside both materials, there was no 3D structure or
formed granulation tissue, while inside the material, the
fi broblast shape and collagen arrangement exhibited a differ-
ent style, which indicates that the 3D structure may exert an
impact on fi broblast biology.
We then employed 2D and 3D culture systems to study
the effects of the structure and components on α-SMA
expression of fi broblast. We found that [ 111 ] myofi broblasts
could be induced by 3D-soluble matrix and the 2D culture
system contained fi bronectin, laminin, or collagen individu-
ally, but the new 3D culture system which had the 3D struc-
ture could barely induce myofi broblast differentiation
(Fig. 9.8 ). When the new 3D compact matrix was compressed
by pressure (the structure was damaged), the myofi broblast
differentiation could also be induced.
Previous studies demonstrated that the new 3D matrix is
more suitable for cell physiology than 2D culture systems in
terms of structure and mechanics [ 112 , 113 ]. Thus, the new
3D culture matrix could barely induce myofi broblast forma-
tion, while the damaged 3D structure could induce it.
9.3.1.4 3D Structure Is a “Template” to Direct
Cell Biology
In our experiments, 3D structure collagens with a diameter
of 500, 200, or 1,000 μm were transplanted subcutaneously
into rats. Samples were obtained three times per week and
the fi broblast biology was examined. The PCNA expression
in the 500-μm material reached a maximum at the second
week, which was higher than those of the 200- and 1,000-μm
materials. From the third week on, PCNA expression in the
500-μm material dropped rapidly and the level was close to
a
b
c
d
Fig. 9.7 The effect of 3D structure on fi broblasts and on collagen arrangement (HE ×400). ( a , c ) Areas with fi brous covering outside decalcifi ed
bone collagen and sponge respectively; ( b , d ) areas inside decalcifi ed bone collagen and sponge respectively

9 Burn Wound Healing

243
a
b
c
d
e
f
Fig. 9.8 Myofi broblast induction on various culture matrices through
fl uorescein isothiocyanate (FITC; ×200). ( a ) New 3D matrix; ( b ) new 3D
compact matrix; ( c ) new 3D soluble matrix; ( d ) fi bronectin (FN) matrix;
( e ) laminin (LN) matrix; ( f ) collagen matrix. Myofi broblasts could be
induced by FN, LN, and collagen in the 2D system and the 3D soluble
matrix, while the new 3D matrix could not induce myofi broblasts

9.3 The Defect of Dermal Template in Wounds Contributes to Scar Formation

244
those in the 200- and 1,000-μm materials. In contrast, the
apoptosis level in the 500-μm material was lower than those
in the 200- and 1,000-μm materials for the fi rst 2 weeks, but
higher than the latter two materials in the third week
(Tables 9.45 and 9.46 ). The result indicated that the 3D col-
lagen structure could regulate cell biology and depended on
the diameter of the structure [ 110 ]. The appropriate diameter
of the 3D structure was more like a “template” that helps to
induce the physiological cell cycle, including cell prolifera-
tion and cell apoptosis.
The in vitro experiments further confi rmed the above result
[ 111 ]. On the new 3D matrix culture system, the cell adhesion
rate was higher than that on the 2D culture system after cell
seeding (Fig. 9.9 ), and there was no difference among 2D cul-
ture systems with different components. In addition, the time
required for the cell to form a spindle shape was quicker on the
new 3D matrix than that on the 2D culture system (Fig. 9.10 ).
All these results indicated that the appropriate structure
was just like a “template” that directs cellular function
toward a shorter life cycle including adhesion, proliferation,
and apoptosis.
9.3.1.5 The Integrity and Continuity of the 3D
Structure Are Critical for the
“Template Effect”
We used the 3D biomaterials that had been cut into small
pieces and transplanted subcutaneously into the dorsal skin
of rats, with the intact structures serving as controls. Samples
were collected 1–3 weeks postoperatively. Histological
observation revealed that the granulation tissue formed in the
group without an intact structure, whereas less granulation
tissue formed in the group with an intact structure (Fig. 9.11 )
[ 110 ]. Hence, the integrity and continuity of the 3D structure
is crucial for the execution of its “template effect.”
9.3.2
Summary
Dermal tissue defects in the wound can result in scar forma-
tion, but when the wound is transplanted with dermal substi-
tute with a 3D structure, the scar formation was reduced.
Further studies revealed that the 3D structure with an
appropriate diameter has a “template” effect on cell biology
that can regulate repair cell function, promote tissue remod-
eling, and improve tissue compliance. In addition, the integ-
rity and continuity of dermis tissue are essential for the
execution of the “template” effect. When the integrity and
continuity of the dermis tissue were damaged, the template
effect was also lost and caused scar formation. Therefore, the
dermal tissue defect is responsible for scar formation, and
we propose the mechanism known as the “dermal template
defect theory”.
Table 9.45 Comparison of PCNA expression x
s
n
±
=
(
)
,
4
Group
Time after surgery
1st week
2nd week
3rd week
200 μm
35.866 ± 13.74
26.287 ± 7.58
21.377 ± 6.68
500 μm
48.227 ± 9.61
58.186 ± 3.49**
15.676 ± 15.47
1,000 μm
32.623 ± 7.07
31.653 ± 7.56
19.703 ± 16.03
** p < 0.01 compared with 200 μm, and 1,000 μm
Table 9.46 Comparison of apoptotic rates among different collagen membrane structures x
s n
±
=
(
)
,
4
Group
Time after surgery
1st week
2nd week
3rd week
200 μm
38.962 ± 10.16
37.011 ± 5.00
39.964 ± 3.32
500 μm
11.185 ± 3.48**
17.556 ± 3.80 #
53.576 ± 3.39 #
1,000 μm
26.767 ± 6.69*
29.783 ± 11.36
38.654 ± 8.41
* p < 0.05 comparing 1,000 μm with 200 and 500 μm respectively; ** p < 0.01 compared with 200 μm; # p < 0.05 compared with 200 μm
0
Matrix
1
2
3
4
5
6
7
Attachment rate au.
3D
FN
CO
NON
∗
∗
∗
Fig. 9.9 Comparison of the fi broblast adhesion rate at 10 min on dif-
ferent matrices. 3D new 3D matrix, FN FN matrix, CO collagen matrix,
NONE culture without matrix. *Signifi cant difference compared with
the 3D group ( p < 0.01)

9 Burn Wound Healing

245
a
b
c
d
e
f
Fig. 9.10 Morphological change in cells on various matrices for 5 h,
shown by DiL staining of life cells (×200). ( a ) New 3D matrix; ( b ) new
3D compact matrix; ( c ) new 3D soluble matrix; ( d ) LN matrix; ( e ) col-
lagen matrix; ( f ) FN matrix. The morphology of fi broblasts on the new
3D matrix was long and spindle-shaped, which was the normal shape of
fi broblasts. The cells did not resume their normal shape on the new 3D
compact matrix, the new 3D soluble matrix, LN matrix, collagen
matrix, and the FN matrix

9.3 The Defect of Dermal Template in Wounds Contributes to Scar Formation

246
References
1. Lin YZ. Basic problem of modern surgery. Shanghai: Shanghai
Science & Technology Press; 2000. p. 325–51.
2. Wang ZG. Wound healing & tissue repair. Jinan: Shandong
Science & Technology Press; 1998. p. 6–28.
3. Lu SL. Advances in wound healing mechanism and techniques.
Beijing: University of Science and Technology of China Press;
2003. p. 60–85.
4. Xu W Sh, Le JF. Wound healing in burns. Wuhan: Hubei Science
& Technology Press; 2000. p. 10–21.
5. Williams WG, Phillips LG. Pathophysiology of the burn wound.
In: Herndon DN, editor. Total burn care. New York: Saunders;
2002. p. 63–70.
6. Muller MJ, Gilpin DA, Herndon DN. Modulation of wound heal-
ing and the postburn response. In: Herndon DN, editor. Total burn
care. New York: Saunders; 2002. p. 223–36.
7. Jackson D. Diagnosis of the depth of burning. Br J Surg. 1953;
40:588.
8. Hinshaw RJ. Early changes in the depth of burns. Arch Surg.
1963;87:131.
9. McMillen MA. Common pathways of endothelial-leukocyte inter-
action in shock, ischemia, and reperfusion. Am J Surg. 1993;166:557.
10. Davis SC. Early debridement of second-degree burn wounds
enhances the rate of epithelization-an animal model to evaluate
burn wounds therapies. J Burn Care Rehabil. 1996;17:558.
11. Still JM. Primary excision if the burn wound. Clin Plast Surg.
2000;27:23.
12. Wang SJ. Therapeutic study on the early progressive injury in burn
wounds. Foreign Med Sci Orthop. 1998;19(2):84–8.
13. Zhang Y, et al. The effects of heparinoids on deep partial-thickness
burn wound healing III rats. Chin J Plast Surg Burns. 1998;14:100.
14. Sun Z, et al. Primary research on the deepening mechanism of
early burn wound. Shanghai Second Med Univ. 1997;17(Suppl):37.
15. Fang P-y, et al. The changes of fi brinolysis in plasma and wounds
in rats infl icted with deep partial thickness burns. Chin J Plast
Surg Burns. 1997;13:259.
16. Ding R. Changes in several components of plasminogen-plasmin
system after thermal injury in rats with partial thickness burns.
Shanghai Second Med Univ. 1997;3:34.
17. Wang Shijun, et al. Shanghai Second Medical University. 1998
Master’s degree thesis.
18. Lu SL, Jin SW, He L, et al. Observation of IL-8 content in deep\
partial thickness burn wounds. Acta Univ Med Secondae
Shanghai. 1998;18(4):336–7.
19. Lu SL, Jin SW, Ding CN, et al. The effect of tangential excision on
the release of local growth factors and wound healing in the deep-
partial thickness burn. Acta Univ Med Secondae Shanghai.
1997;17(suppl):23–6.
20. Shu-Liang Lu, et al. The effect of tangential excision on the
release of local growth factors and wound healing in the deep-
partial
thickness
burn.
Shanghai
Second
Med
Univ.
1997;17(Suppl):23.
21. Fang P-y, et al. Therapeutics of batroxobin on the deepening of
deep second—degree burn wounds. Shanghai Second Med Univ.
1998;18:186.
22. Wu XW. Review of hyperbaric oxygen treatment in thermal burns.
Foreign Med Sci Orthop. 1995;16(3):87–8.
23. Singer AJ, Clark RAF. Cutaneous wound healing. N Engl J Med.
1999;341:738–46.
24. Jeffcoate WJ, Harding KG. Diabetic foot ulcers. Lancet.
2003;361:1545–51.
25. Adler AI, Boyko EJ, Ahroni JH, Smith DG. Lower-extremity
amputation in diabetes. The independent effects of peripheral vas-
cular disease, sensory neuropathy, and foot ulcers. Diabetes Care.
1999;22:1029–35.
26. Ferguson MW, Herrick SE, Spencer MJ, et al. The histology of
diabetic foot ulcers. Diabet Med. 1996;13:30–3.
1 week after surgery
2 weeks after surgery
3 weeks after surgery
a
b
Fig. 9.11 Effect of tissue integrity and continuity on tissue repair (HE ×200). ( a ) Intact tissue structure; ( b ) tissue structure in pieces. Compared
with group A, massive cell and nascent collagen could be seen in group B

9 Burn Wound Healing

247
27. Delamaire M, Maugendre D, Moreno M, et al. Impaired leukocyte
functions in diabetic patients. Diabet Med. 1997;14:29–34.
28. Wysocki J, Wierusz-Wysocka B, Wykretowicz A, et al. The infl u-
ence of thymus extracts on the chemotaxis of polymorphonuclear
neutrophils (PMN) from patients with insulin-dependent diabetes
mellitus (IDD). Thymus. 1992;20:63–7.
29. Brown DL, Kane CD, Chernausek SD, Greenhalgh DG.
Differential expression and localization of insulin-like growth fac-
tors I and II in cutaneous wounds of diabetic and non-diabetic
mice. Am J Pathol. 1997;151:715–24.
30. Bitar MS. Insulin and glucocorticoid-dependent suppression of
the IGF-I system in diabetic wounds. Surgery. 2000;127:687–95.
31. Blakytny R, Jude EB, Gibson JM, Boulton AJM, Ferguson MWJ.
Lack of insulin-like growth factor I (IGF I) in the basal keratino-
cyte layer of diabetic skin and diabetic foot ulcers. J Pathol.
2000;190:589–94.
32. Jude EB, Blakytny R, Bulmer J, Boulton AJ, Ferguson MW.
Transforming growth factor-1, -2, -3 and receptor type I and II in
diabetic foot ulcers. Diabet Med. 2002;19:440–7.
33. Goldman R. Growth factors and chronic wound healing: past,
present, and future. Adv Skin Wound Care. 2004;17:24–35.
34. Castronuovo Jr JJ, Ghobrial I, Giusti AM, et al. Effects of chronic
wound fl uid on the structure and biological activity of becaplermin
(rhPDGF-BB) and becaplermin gel. Am J Surg. 1998;176:61S–7.
35. Doxey DL, Ng MC, Dill RE, Iacopino AM. Platelet-derived growth
factor levels in wounds of diabetic rats. Life Sci. 1995;57:1111–23.
36. Graiani G, Emanueli C, Desortes E, et al. Nerve growth factor
promotes reparative angiogenesis and inhibits endothelial apopto-
sis in cutaneous wounds of type 1 diabetic mice. Diabetologia.
2004;47:1047–54.
37. Bonini S, Rasi G, Bracci-Laudiero ML, Procoli A, Aloe L. Nerve
growth factor: neurotrophin or cytokine? Int Arch Allergy
Immunol. 2003;131:80–4.
38. Di Marco E, Mathor M, Bondanza S, et al. Nerve growth factor
binds to normal human keratinocytes through high- and low-affi n-
ity receptors and stimulates their growth by a novel autocrine
loop. J Biol Chem. 1993;268:22838–46.
39. Riaz S, Malcangio M, Miller M, Tomlinson DR. A vitamin D3
derivative (CB1093) induces nerve growth factor and prevents
neurotrophic defi cits in streptozotocin-diabetic rats. Diabetologia.
1999;42:1308–13.
40. Yiangou Y, Facer P, Sinicropi DV, et al. Molecular forms of NGF
in human and rat neuropathic tissues: decreased NGF precursor-
like immunoreactivity in human diabetic skin. J Peripher Nerv
Syst. 2002;7:190–7.
41. Werner S, Breeden M, Hubner G, Greenhalgh DG, Longaker MT.
Induction of keratinocyte growth factor expression is reduced and
delayed during wound healing in the genetically diabetic mouse.
J Invest Dermatol. 1994;103:469–73.
42. Gibran NS, Jang YC, Isik FF, Greenhalgh DG, Muffl ey LA,
Underwood RA, et al. Diminished neuropeptide levels contribute
to impaired cutaneous healing response associated with diabetes
mellitus. J Surg Res. 2002;108:122–8.
43. Antezana MA, Sullivan SR, Usui ML, et al. Neutral endopepti-
dase activity is increased in the skin of subjects with diabetic
ulcers. J Invest Dermatol. 2002;119:1400–4.
44. Spenny ML, Muangman P, Sullivan SR, et al. Neutral endopepti-
dase inhibition in diabetic wound repair. Wound Repair Regen.
2002;10:295–301.
45. Armstrong DG, Jude EB. The role of matrix metalloproteinases in
wound healing. J Am Podiatr Med Assoc. 2002;92:12–8.
46. Lobmann R, Ambrosch A, Schultz G, et al. Expression of matrix-
metalloproteinases and their inhibitors in the wounds of diabetic
and non-diabetic patients. Diabetologia. 2002;45:1011–6.
47. Rechardt O, Elomaa O, Vaalamo M, et al. Stromelysin-2 is upreg-
ulated during normal wound repair and is induced by cytokines.
J Invest Dermatol. 2000;115:778–87.
48. Wall SJ, Sampson MJ, Levell N, Murphy G. Elevated matrix
metalloproteinase-2 and -3 production from human dermal fi bro-
blasts. Br J Dermatol. 2003;149:13–6.
49. Terasaki K, Kanzaki T, Aoki T, Iwata K, Saiki I. Effects of recom-
binant human tissue inhibitor of metalloproteinases-2 (rh-TIMP-2)
on the migration of epidermal keratinocytes in vitro and wound
healing in vivo. J Dermatol. 2003;30:165–72.
50. Fischer C, Gilbertson-Beadling S, Powers EA, Petzold G,
Poorman R, Mitchell MA. Interstitial collagenase is required for
angiogenesis in vitro. Dev Biol. 1994;162:499–510.
51. Canturk NZ, Vural B, Esen N, et al. Effects of granulocyte-macro-
phage colony-stimulating factor on incisional wound healing in an
experimental diabetic rat model. Endocr Res. 1999;25:105–16.
52. Rayfi eld EJ, Ault MJ, Keusch GT, et al. Infection and diabetes: the
case for glucose control. Am J Med. 1982;72:439–50.
53. Lerman OZ, Galiano RD, Armour M, Levine JP, Gurtner GC.
Cellular dysfunction in the diabetic fi broblast. Am J Pathol.
2003;162:303–12.
54. Kilanczyk E, Bryszewska M. The effect of melatonin on antioxi-
dant enzymes in human diabetic skin fi broblasts. Cell Mol Biol
Lett. 2003;8:333–6.
55. Thorpe SR, Baynes JW. Maillard reaction products in tissue proteins:
new products and new perspectives. Amino Acids. 2003;25:275–81.
56. Bonnefont-Rousselot D. Glucose and reactive oxygen species.
Curr Opin Clin Nutr Metab Care. 2002;5:561–8.
57. Mudge BP, Harris C, Gilmont RR, Adamson BS, Rees RS. Role of
glutathione redox dysfunction in diabetic wounds. Wound Repair
Regen. 2002;10:52–8.
58. Rasik AM, Shukla A. Antioxidant status in delayed healing type
of wounds. Int J Exp Pathol. 2000;81:257–63.
59. Reichner JS, Meszaros AJ, Louis CA, et al. Molecular and meta-
bolic evidence for the restricted expression of inducible nitric
oxide synthase in healing wounds. Am J Pathol. 1999;154:
1097–104.
60. Lee RH, Efron D, Tantry U, Barbul A. Nitric oxide in the healing
wound: a time-course study. J Surg Res. 2001;101:104–8.
61. Shi HP, Efron DT, Most D, Barbul A. The role of iNOS in wound
healing. Surgery. 2001;130:225–9.
62. Witte MB, Thornton FJ, Tantry U, Barbul A. L-Arginine supplemen-
tation enhances diabetic wound healing: involvement of nitric oxide
synthase and arginase pathways. Metabolism. 2002;51:1269–73.
63. Brem H, Jacobs T, Vileikyte L, et al. Wound-healing protocols for
diabetic foot and pressure ulcers. Surg Technol Int. 2003;11:85–92.
64. Teixeira AS, Andrade SP. Glucose-induced inhibition of angio-
genesis in the rat sponge granuloma is prevented by aminoguani-
dine. Life Sci. 1999;64:655–62.
65. Griffi oen AW, Molema G. Angiogenesis: potentials for pharmaco-
logic intervention in the treatment of cancer, cardiovascular dis-
ease and chronic infl ammation. Pharmacol Rev. 2000;52:237–68.
66. Blakytny R, Jude E. The molecular biology of chronic wounds
and delayed healing in diabetes. Diabet Med. 2006;23:594–608.
67. Medina A, Scott PG, Ghahary A, et al. Pathophysiology of chronic
nonhealing wounds. J Burn Care Rehabil. 2005;26(4):306–19.
68. Kim KE, Cho CH, Kim HZ, et al. In vivo actions of angiopoietins on
quiescent and remodeling blood and lymphatic vessels in mouse air-
ways and skin. Arterioscler Thromb Vasc Biol. 2007;27(3):564–70.
69. Falanga V. Wound healing and its impairment in the diabetic foot.
Lancet. 2005;366:1736–43.
70. Martin A, Komada MR, Sane DC. Abnormal angiogenesis in dia-
betes mellitus. Med Res Rev. 2003;23(2):117–45.
71. Lin WD, Lu SL, Qing C, et al. The expression of VEGF and bFGF
in the wounds of diabetic and non-diabetic rats with deep burns.
Natl Med J China. 2003;83(19):1702–4.
72. Lu SL, Qiao L, Xie T, et al. Effects of the cutaneous and blood
contents of glucose on wound healing in diabetic rats with super-
fi cial partial thickness scalding. Natl Med J China. 2005;85(27):
1899–902.
References

248
73. Lu SL, Qing C, Xie T, et al. Research on olfactory mechanism of
the cutaneous “underlying disorder” in diabetic rats. Chin J
Trauma. 2004;20(8):468–73.
74. Lu SL, Xie T, Dong JY, et al. Study on impaired wound healing in
diabetes: the pathophysiological characteristics in epidermis.
Infect Infl amm Repair. 2004;51:16–8.
75. Varani J, Perone P, Merfert MG, et al. All-trans retinoic acid
improves structure and function of diabetic rat skin in organ cul-
ture. Diabetes. 2002;51(12):3510–6.
76. Niu YW, Xie T, Ge K, et al. Cell proliferation and apoptosis in
diabetic dermal tissue. J Shanghai Jiao Tong Univ (Med Sci).
2007;27(4):376–9.
77. Tian M, Qing C, Niu YW, et al. Effects of advanced glycation end-
products on skin keratinocytes by NF-κB activation. Chin J
Trauma. 2006;22(10):779–82.
78. Xie T, Lu SL. Experimental study on the proliferative events of
keratinocytes in diabetic skin. Acta Univ Medicinalis Secondae
Shanghai. 2005;25(6):541–5.
79. Qiao L, Lu SL, Dong JY, et al. Effects of high glucose conditions
on expression of VEGF and vascularization in superfi cial II burn
wound. J Shanghai Jiao Tong Univ (Med Sci). 2006;26(8):860–4.
80. Yang YM, Lu SL, Dong JY, et al. Expression of EGF receptors in
the wounds of diabetic rats with superfi cial partial thickness scald-
ing. Chin J Burns. 2003;19(4):243.
81. Ge K, Lu SL, Qing C, et al. A study on aminoguanidine improving
wound healing of diabetic burn. Chin J Trauma. 2004;20(8):
463–7.
82. Wang MJ, Lu SL, Qing C, et al. Effects of different courses of dis-
ease on the biological behavior of dermal fi broblasts in diabetic rats.
Acta Univ Medicinalis Secondae Shanghai. 2005;25(5):459–66.
83. Niu YW, Lu SL, Xie T, et al. The behavior of fi broblast in skin
with deep partial thickness scalding. Acad J Shanghai Jiao Tong
Univ. 2006;26(1):63–5.
84. Wang MJ, Qing C, Liao Zh J, et al. The biological characteristics
of dermal fi broblasts of the diabetic rats with deep-partial thick-
ness scald. Chin J Burns. 2006;22(1):63–5.
85. Ge K, Lu SL, Qing C. Research progress in delayed angiogenesis
in refractory diabetic wound. Chin J Trauma. 2003;19(10):637–9.
86. Ge K, Lu SL, Qing C, et al. The infl uence of L-arginine on angiogen-
esis in burn wounds in diabetic rats. Chin J Burns. 2004;20(4):210–3.
87. Michael B. Biochemistry and molecular cell biology of diabetic
complications. Nature. 2001;414:813–20.
88. Maisonpierre PC, Suri C, Jones PF, et al. Angiopoietin-2, a natural
antagonist for Tie-2 that disrupt in vivo angiogenesis. Science.
1997;277:55–60.
89. Xie T, Lu SL, Niu YW, et al. Study on the proliferation of epider-
mal cells of wound edge in deep partial thickness scald injury in
rat. Chin J Burns. 2005;21(2):128–32.
90. Lin WD, Lu SL, Qing C, et al. Proliferation-inhibiting effect of
advanced glycation end products modifi ed human serum albumin
to vascular endothelial cell ECV304. Natl Med J China. 2003;
83(7):572–6.
91. Wang RX, Lin Y, Zhang LM, et al. Effect of growth factor on
impaired diabetic wound healing. J Guangxi Med Univ. 2004;
21(1):5–7.
92. Niu YW, Lu SL, Qing C, et al. Change of active matrix metallo-
proteinase-2 and tissue inhibitor of metalioproteinase-2 in wounds
of diabetic and nondiabetic burned mice. Acta Univ Medicinalis
Secondae Shanghai. 2004;24(3):181–4.
93. Twigg SM, Chen MM, Joly AH, et al. Advanced glycosylation
end products up-regulate connective tissue growth factor (insulin-
like growth factor-binding protein-related protein 2) in human
fi broblasts: a potential mechanism for expansion of extracellular
matrix in diabetes mellitus. Endocrinology. 2001;142(5):1760–9.
94. Dong JY, Yoshihiro T, Qing C, et al. Effect of a radical scavenger
(MCI 186) on glucose induced apoptosis of cultured human der-
mal microvascular endothelial cells(HDMEC). Chin J Diab. 2005;
13(3):234–5.
95. Wang MJ, Lu SL, Sheng Zh Y, et al. Effects of high concentrations
of glucose on the biological behavior of dermal fi broblast in
diabetic rats. Chin J Diab. 2006;14(2):137–41.
96. Dong J, Takami Y, Tanaka H, et al. Protective effects of a free radi-
cal scavenger, MCI-186, on high-glucose-induced dysfunction of
human dermal microvascular endothelial cells. Wound Repair
Regen. 2004;12(6):607–12.
97. Niu YW, Lu SL, Qing C, et al. Effect of extracellular matrix glyca-
tion on dermal fi broblast. Acta Univ Medicinalis Secondae
Shanghai. 2004;24(9):697–700.
98. Niu YW, Lu SL. Receptor for advanced glycation end products
and wound healing. Infect Infl amm Repair. 2005;6(4):230–3.
99. Dong W, Lu SL. The experimental studies on impaired wound
healing in diabetes: the effect of advanced glycation end products
(AGEs) on the biological behavior of neutrophils. Master’s thesis,
Shanghai Second Medical University, 2005.
100. Ge K, Lu SL. Role and mechanisms of aminoguanidine on dia-
betic wound healing. PhD’s thesis, Shanghai Jiaotong University
of Medicine. 2006.
101. Su HT, Li ZY, Lu SL, et al. The clinical study of the relationship
between the defect of different thickness dermal tissues and the
proliferative scar formation. Chin J Trauma. 2005;21(7):517–9.
102. Liu YK, Lu SL, Qing C, et al. The effects of tissue mechanical
compliance on the biological behaviors of fi broblasts during
wound healing. Master’s thesis of the Second Medical University,
2003.
103. Liu YK, Lu SL, Qing C, et al. Effects of dermal template on bio-
logic behaviors of fi broblasts during wound healing. Chinese
Journal of Reparative and Reconstructive Surgery. 2005;
19(1):10–4.
104. Xiang J, Hu Q Sh, Qing C, et al. The Dynamic Histological
Observations of composite transplantation. J Shanghai Second
Med Univ. 2003;23(6):492–4.
105. Zhang J, Xiang J, Wang Zh Y, et al. The effect of dermal regenera-
tion template on wound collagen synthesis. J Shanghai Second
Med Univ. 2003;23(5):393–5.
106. Xiang J, Qing C, Liao Zh J, et al. Effect of dermal regeneration
template on myofi broblasts and cell apoptosis during wound heal-
ing. Chin J Trauma. 2004;20(2):85–8.
107. Wang XQ, Xiang J, Qing C, et al. The angiogenesis effect after
application of dermal template on wound. Chin J Clin Rehabil.
2003;7(23):3194–5.
108. Xiang J, Wang XQ, Qing C, et al. The infl uence of dermal tem-
plate on the expressions of signal transduction protein Smad 3 and
transforming growth factor β1 and its receptor during wound heal-
ing process in patients with deep burns. Chin J Burns. 2005;
21(1):52–4.
109. Wang XQ, Su HT, Xiang J, et al. The infl uence of dermal template
on the p53 gene expression and apoptosis during wound repairing
in burn patients. Chin J Burns. 2004;20(6):351–3.
110. Mao Zh G, Lu SL, Qing C, et al. The effect of three-dimensional
structure on the biological behaviors of fi broblasts. Master’s thesis
of the Second Medical University, 2005.
111. Zhang F Sh, Lu SL Qing C, et al. Induction of myofi broblast and
its signal transduction – the mechanism of scar formation.
Doctoral thesis of the Second Medical University, 2006.
112. Liu YK, Lu SL. The effect of mechanics on the myofi broblast dif-
ferentiation. Chin J Trauma. 2002;18(11):703–4.
113. Edna C, Roumen P, Daron RS, et al. Taking cell-matrix adhesions
to the third dimension. Science. 2001;23(294):1710.
9 Burn Wound Healing

249
Z. Yang, Chinese Burn Surgery, DOI 10.1007/978-94-017-8575-4_10,
© Springer Science+Business Media Dordrecht and People’s Medical Publishing House 2015
10.1
Role of Growth Factors in Cutaneous
Wound Healing
The well-orchestrated, complex series of events resulting in
the repair of cutaneous wounds are, at least in part, regulated
by polypeptide growth factors. Many engineered growth fac-
tors, including recombinant human epidermal growth factor
(rhEGF), basic fi broblast growth factor (bFGF), and platelet-
derived growth factor (PDGF), etc., have been produced and
used in clinic during the past few years. After screening the
results from different centers, some results are found to be
encouraging, while some discouraging. Although the inter-
pretation of these results depends on the angle of views of
whether the cup is half full or half empty, it may also depend
on different criteria, different wounds, and even different
aims. In this article, the successful experiences or failure les-
sons about growth factors and cutaneous wound healing are
summarized. Based on these experiences and lessons, we
give our comments about the concerns raised by people, such
as whether growth factors altered clinical practice in the past,
whether the growth factor treatment has solved all problems
involved in wound healing, whether there is a need for exog-
enous application of growth factors in acute or chronic
wounds, whether it is safe to use growth factors to promote
wound healing, whether perfect wound healing can be
achieved in those wounds treated with growth factors, and
so on.
Wound healing is a dynamic biological process, consist-
ing of a complex interaction of cellular and biochemical
events. Several growth factors have been identifi ed as regu-
latory polypeptides coordinating the healing process.
Growth factors participate in the regulation of cell prolifera-
tion, differentiation, and organ growth. In the past 10 years,
many growth factors, including rhEGF, bFGF, and PDGF,
have been produced and approved by the US Food and Drug
Administration (FDA) and the State Food and Drug
Administration of China. In the United States, the PDGF is
limited to use only in diabetic foot ulcer, although other
indications are being explored. In China, rhEGF and bFGF
have been approved for use in acute skin wounds and
chronic ulcers. Up to now, increasing data show that topical
application of single growth factor is effective in accelerat-
ing acute or chronic wound healing, although some results
are discouraging [ 1 – 5 ]. The average wound healing time in
acute skin wounds can be shortened from 1 to 4 days when
locally treated with growth factors. Also, those wounds
called “hard to heal” diabetic foot ulcers or pressure scores
show signifi cant improvement in the “healing rate” and the
“time to heal” compared with cohort controls [ 6 – 9 ]. Based
on these data, people might raise the question of whether the
growth factor treatment has solved all problems involved in
wound healing. The answer is negative; this is just the
beginning, not the end. It is necessary to look back what we
have done in the past on the one hand and to look forward to
what we shall do in the future on the other hand. Thus, it is
our suggestion that the following concerns be clarifi ed or
borne in mind in order to use rationally these growth factors
in the future.
bFGF
Basic fi broblast growth factor
rhEGF
Recombinant human epidermal growth factor
PDGF
Platelet-derived growth factor
FDA
Food and Drug Administration
rbFGF
Recombinant bovine basic fi broblast growth factor
ECM
Extracellular matrix
PDWHF
Platelet-derived wound healing formula
NaCMC
Sodium carboxymethyl cellulose
TGF
Transforming growth factor
KGF
Keratinocyte growth factor
GM-CSF
Granulocyte-macrophage colony-stimulating factor
MMP
Matrix metalloproteinases
TIMP
Tissue inhibitors of metalloproteinases
MSCs
Mesenchymal stem cells
Growth Factors and Stem Cells
for Wound Repair and Tissue
Regeneration
Xiaobing Fu
10

250
10.1.1 Exogenous Application of Growth
Factors in Acute or Chronic Wounds
In order to answer this concern, it is necessary to understand
the role of endogenous growth factors and their gene expres-
sion in tissue development, growth, repair, and changes after
wounding. It has been found that the messenger RNA for the
protein may be present in some wounds, but the protein may
be defi cient, trapped, or quickly destroyed. Our previous
study showed that acute ischemia and reperfusion reduced
the expression of the protein of endogenous bFGF and its
genes in skeletal muscle [ 10 , 11 ]. Bennett and Schultz have
postulated that repeated trauma and infection increase the
presence of proinfl ammatory cytokines and the level of
matrix metalloproteinases (MMP), decrease the tissue inhib-
itors of metalloproteinases (TIMP), and decrease the level of
growth factors. In some chronic wounds, the amount of
PDGF, bFGF, EGF, or transforming growth factor β (TGF-β)
was shown to be markedly decreased when compared with
acute wounds. The quantity and quality of cytokines and pro-
teases and their inhibitors were quite different in both acute
and chronic ulcers [ 12 – 14 ]. Landau et al. found the presence
of fi broblast growth factor inhibitory factors, which possess
heparin-like activity, in wound fl uid of chronic skin ulcers
and their ability to modulate fi broblast growth factor recep-
tor activity throughout the process of wound healing. These
factors may signifi cantly contribute to chronicity [ 15 ].
However, some studies also showed that venous stasis ulcers
were not absolutely defi cient in growth factors, but the cyto-
kines appeared to be trapped within the fi brin cuffs surround-
ing capillaries [ 16 , 17 ]. Finally, skin fi broblasts from patients
with diabetes mellitus display abnormalities in cell prolifera-
tion. The use of exogenous growth factors on diabetic
wounds has been found to stimulate fi broblast proliferation
and facilitate wound healing [ 18 ]. The results suggest that
exogenous growth factors are necessary for tissue repair.
They may act as an inducer for endogenous growth factors
and their genes expression or as a stimulator for tissue repair
cells in accelerating acute and chronic ulcer healing.
10.1.2 Growth Factors Will Alter Clinical
Practice in the Future
The increasing data show that topical application of single
growth factor is effective in accelerating acute or chronic
wound healing, although some results are discouraging. In
the United States, rhEGF was fi rst applied to split-thickness
graft donor sites in burn wounds, and the wounds treated
with rhEGF showed acceleration of healing by 1–2.5 days
[ 1 ]. Another randomized, placebo-controlled trial of the use
of recombinant bovine basic fi broblast growth factor (rbFGF)
for second-degree burns in 600 patients was carried out in
China. All wounds treated with rbFGF had earlier granula-
tion tissue formation and epidermal regeneration than those
in the placebo control group. Superfi cial and deep second-
degree burns treated with rbFGF healed in a mean of 9.9 (SD
2.5) days and 17.0 (4.6) days, respectively, compared with
12.4 (SD 2.7) and 21.2 (4.9) days. No adverse effects were
seen locally or systemically. In this study, the gold standard
of histological diagnosis to evaluate depth and healing qual-
ity was used [ 2 , 3 ]. Up to now, although only a few reports
concerning the effects of rhEGF and bFGF in acute wound
healing have been published (Table 10.1 ), the limited data
still suggest that the topical application of the abovemen-
tioned growth factors will hasten healing of acute wounds
and wound healing time is shortened by 1–4 days.
In contrast, the wound healing in chronic ulcers is more
complicated compared with healing of acute wounds, and
several growth factors have been confi rmed to accelerate
healing in these wounds (Table 10.2 ). PDGF and its relative
proteins are the fi rst approved proteins for promoting healing
Table 10.1 Typical clinical trials of engineered growth factors and their application in acute cutaneous wound healing
Authors
Reported time and
journal
Study design
Kind of
wounds
Number
of patients
Applied growth
factor
Treatment methods
Effi cacy
Follow-up
Brown
et al.
N Eng J Med .
1989;321:76–79
Prospective,
randomized,
double blind
Skin graft
donor sites
12
Silver
sulfadiazine
cream containing
0.5 ml/cm 2
Effective
1 year
EGF, 10 μg/ml
Twice daily
Cohen
et al.
Plast Reconstr
Surg .
1995;96:251–254
Signal center,
prospective,
randomized,
double blind
“Mini” donor
sites
17
Silver
sulfadiazine
cream containing
EGF
The cream was
applied to a
thickness of
approximately 1/16,
twice daily
Not
effective
6–8 months
10 μg/ml
Fu et al. Lancet . 1998;352;
1661–1664
Multicenter,
prospective,
randomized,
double blind
Superfi cial
and deep
second-
degree burns
600
Normal saline
containing
rbFGF
2,400 AU/ml
150 AU/cm 2 , once
daily
Effective
1.5 year
AU active unit
10 Growth Factors and Stem Cells for Wound Repair and Tissue Regeneration

251
Table 10.2 Typical clinical trials of engineered growth factors and their application in accelerating chronic cutaneous wound healing
Authors
Reported time
and journal
Study design
Kind of wounds
Number of
patients
Applied growth factor
Treatment methods
Effi cacy
Follow-up
Knighton et al. Ann Surg .
1986;204:
322–330
Prospective, open
label, crossover
Diabetic foot,
traumatic ulcers,
decubitus ulcers, etc.
49
10 ml aliquot containing
PDWHF; 10 ml were used
for 1 week
A thin layer of the PDWHF
salve was applied to the entire
surface of wound
Effective
No
Once daily
Knighton et al. Surg Gynecol
Obst . 1990;
170: 56–60
Prospective,
randomized, blind
Diabetic ulcers,
peripheral vascular
disease, venous stasis,
vasculitis
32
10 ml aliquot containing
PDWHF; 10 ml were used
for 1 week
A thin layer of the PDWHF
salve was applied to the entire
surface of wound
Effective
No
Once daily
Robson et al.
Lancet . 1992;
339: 23–25
Randomized, double
blind, placebo
controlled
Chronic pressure
ulcers
20
rPDGF-BB
0.01 μg/cm 2
Effective
5 months
1 μg/ml
0.1 μg/cm 2
10 μg/ml
1.0 μg/cm 2
100 μg/ml
Robson et al.
Ann Surg . 1992;
216(4):
401–408
Randomized, blind,
placebo controlled
Chronic pressure
ulcers (grades III/IV)
50
bFGF
0.01 ml/cm 2
Effective
100 μg/mL
500 μg/mL
1,000 μg/mL
Pierce et al.
Am J Path .
1994; 145:
1399–1410
Multicenter,
prospective,
randomized, double
blind
Chronic pressure
ulcers
20
rPDGF 100 μg/mL(1 μg/cm 2 ),
300 μg/mL (3 μg/cm 2 )
100 μg/mL(1 μg/cm 2 ), once daily
Effective
300 μg/mL
(3 μg/cm 2 )
Once daily
Mustoe et al.
Arch Surg .
1994; 129 :
213–219
Prospective,
randomized, double
blind
Deep pressure ulcers
41
rPDGF
100 μg/mL(10 μl/cm 2 ),
Effective
5 months
100 μg/mL(1 μg/cm 2 ),
300 μg/mL (3 μg/cm 2 )
Once daily
300 μg/mL (10 μl/cm 2 )
Once daily
Wieman et al.
Am J Surg .
1998; 176
(Suppl 2A):
74S–79S
Four multicenter,
randomized,
placebo- controlled,
parallel group studies
Diabetic ulcers
922
rPDGF
30 μg/g becaplermin gel
Effective in
studies 1, 2,
and 3. Not
effective in
study 4
3 months
30 μg/g becaplermin gel
100 μg/g becaplermin gel
100 μg/g becaplermin gel
Once daily
Rees et al.
Wound Rep Reg .
1999; 7:
141–147
Phase II randomized,
double blind, placebo
controlled
Pressure ulcers
124
rPDGF
100 μg/g
Effective
100 μg/g
Twice daily
300 μg/g
300 μg/g
Twice daily
Fu et al.
Chin Med J
(Engl). 2002;
115(3):
331–335
Prospective, open
label crossover
Traumatic ulcers,
pressure sore, diabetic
ulcers, radiation
chronic ulcers
28
rbFGF
150 AU/cm 2
Effective
Once daily
AU active unit
10.1 Role of Growth Factors in Cutaneous Wound Healing

252
of diabetic foot and other chronic non-healing ulcers. In
1986, Knighton et al. reported their successful treatment of
chronic ulcers with autologous platelet-derived wound heal-
ing formula (PDWHF). In his study, 49 patients with 95
chronic wounds were treated with the PDWHF, resulting in a
mean time of 100 % healing of only 10.6 weeks. It was nota-
ble that all of these wounds had received conventional wound
care for an average of 198 weeks without healing before
PDWHF application. After then, a similar study by this
group was carried out in 1990 in 32 patients, and the results
were satisfactory [ 4 , 5 ].
In another phase II follow-up multicenter trial of 45
patients with decubitus ulcers, Mustoe et al. again reported
that topical application of rhPDGF-BB accelerated the rate
of wound closure. They found that those ulcers receiving
100 μg/dl decreased by 71 % in volume over 28 days, and
those treated with 300 μg/dl decreased by 60 % in volume. In
contrast, those wounds treated with placebo had only 17 %
decrease in ulcer volume [ 6 ]. The result of this study chal-
lenged the concept that a higher dosage of growth factors in
wound area might induce wound healing more rapidly. It
implied that only a certain dose of growth factors would be
needed to facilitate wound healing. BFGF is another growth
factor used in clinical trial to treat chronic ulcers. Robson
et al. carried out randomized, blinded, placebo-controlled
human trials of bFGF for pressure sore. Three different con-
centrations of bFGF in fi ve dosing schedules were tested for
safety. No toxicity, signifi cant serum absorption, and anti-
body formation were detected. The slopes of the regression
curves of volume decrease with initial pressure sore volume
demonstrated a greater healing effect in the bFGF-treated
patients. Histologically, tissue sections of bFGF-treated
wounds demonstrated an increase in number of fi broblasts
and capillaries. Treatment with bFGF achieved more than
70 % wound closure [ 7 ]. In China, Fu et al. evaluated the
safety and effi cacy of topical application of rbFGF on the
healing of chronic cutaneous wounds. Twenty-eight patients
with 33 chronic cutaneous wounds that resulted from trauma,
diabetes mellitus, pressure sore, and radiation injuries were
enrolled in this prospective, open-label crossover trial. Prior
to treatment with rbFGF, all wounds failed to heal with con-
ventional therapies within 4 weeks. All wounds were locally
treated with rbFGF in a dose of 150 AU/cm [ 2 ], once daily.
It was found that healing of all chronic wounds was expe-
dited. During the study, 18 wounds completely healed up
within 2 weeks, four healed up within 3 weeks, and another
eight completely healed up within 4 weeks (Fig. 10.1 ). Only
three wounds failed to heal within 4 weeks but healed up 30,
40, and 42 days after treatment with rbFGF. Thus, compared
with conventional therapies, the effective rate of rbFGF
treatment within 4 weeks was 90.9 %. Histological examina-
tion showed that capillary sprouts were more abundant and
that fi broblasts were differentiated in wounds treated with
rbFGF. No adverse side effects related to basic fi broblast
growth factor were observed. The results further confi rmed
that rbFGF could be used to accelerate healing in chronic
wounds [ 8 , 9 ].
Of course, there are still some different results in clinical
trials. In an experiment utilizing split-thickness skin graft
donor sites bilaterally on the buttocks of healthy volunteers,
Cohen et al. found that there was no difference in wound
healing time between rhEGF and placebo control groups
[ 19 ]. Another clinical trial of bFGF for diabetic neurotrophic
was discouraging because only three out of the nine (33 %)
bFGF-treated wounds healed compared with fi ve of eight
ulcers that healed completely in the placebo group [ 20 ]. With
the analysis of these results, the authors concluded that the
differences in patients’ condition, sparse application time,
and small dose of growth factor may affect the results.
10.1.3 Delivery System for the Growth Factors
in Local Wound Healing
The initial trials were performed with growth factors in a
liquid vehicle, such as saline with heparin. Later, sodium
carboxymethyl cellulose (NaCMC) gel and silver sulfadia-
zine cream were used as the vehicles. Many clinicians are
concerned whether the growth factor protein might be
destroyed when they are used in wounds, especially in
chronic wounds because of the existing enzymes. There are
a few experiments demonstrating the changes in activity of
exogenous growth factors in wounds. According to our expe-
rience, local application of growth factors in saline or gels is
safe, simple, and effective in practice and there is no neces-
sity to change. Based on the facts of a few studies, in which
growth factors have been shown to be effi cacious but their
effect has been shown to be less dramatic as predicted and as
observed in animal studies, some authors hypothesize that
adenovirus transfected with EGF, PDGF-BB, TGF-β, and
other growth factors may produce large quantities of these
growth factors within the wound bed and dramatically
enhance wound healing. Simply stated, people plan to insure
the delivery of the growth factors by using gene therapy tech-
niques so that cells locally involved in the wound healing
process will temporarily increase their production of EGF,
PDGF-BB, or TGF-β. To date, although phase I trial about
gene transfer has been conducted, there is yet no approved
wound healing gene transfer technique to be used in human
clinical trial. The gene therapy is one of the potential modali-
ties to promote wound healing, especially for chronic ulcers,
but it may be very diffi cult to popularize in clinic before it is
proved to be a safe, simple, and effective way at present [ 21 ,
22 ]. The wound healing is a very complicated process, and
different growth factors virtually emerge at different times in
the healing process to serve specifi c purposes. In the future,
10 Growth Factors and Stem Cells for Wound Repair and Tissue Regeneration

253
the best result might be derived by using more than one
growth factor given individually specifi c for different stages
of wound healing.
10.1.4 The Safety of Using Growth Factors
to Promote Wound Healing
As mitogenic proteins, growth factors participate in the regu-
lation of normal cell proliferation and differentiation and
organ growth. They could also exert their effects on tumor
cells. Numerous studies suggest that alteration in the expres-
sion of FGF, EGF, and other growth factors may contribute
to deregulation of growth of neoplastic cells, such as MCF
breast cancer cells, ovarian cancer cells, and prostate cancer
cells [ 23 ] (Table 10.3 ).
Also, an overexpression of these growth factors in cere-
brospinal fl uid and urine can be found in patients with a wide
spectrum of cancers [ 32 – 34 ]. Because of the extensive distri-
bution and multiple functions of growth factors and their
receptors, the side effects or toxic effects are of concern as
they are present in high concentrations in the local wounds.
Abnormal cell transformation may become permanent in the
regenerated tissues after application of growth factors.
Another concern is the possible effect of growth factor, espe-
cially bFGF, in producing hypertrophic scar formation.
However, it is comforting to learn that histological assess-
ment of regenerated tissues from animal experiments or
biopsy samples from patients in clinical trials and also fol-
lowed- up results have shown no evidence of metaplasia, and
none of the patients develop hypertrophic scar or malignant
changes after use of growth factors. Finally, the concentra-
tions of growth factors used in local applications are many
times higher than those found normally in tissues and blood.
People may worry whether such high concentration of
growth factors could be absorbed into the blood to impair
liver and renal functions. The data from Robson’s study and
our laboratory showed that there is no signifi cant systemic
absorption, and we found no evidence of impairment of liver
and renal function after EGF treatment [ 7 , 35 ]. Although
a
b
c
d
Fig. 10.1 Wound healing in chronic wounds was accelerated with
engineered growth factors. A young lady with the chronic radiation
ulcer in chest 10 years. During this time, she was treated with surgical
operation, traditional medicine, skin autografting, etc., but failed to heal
( a ). After topical management with bFGF for 42 days, the wounds were
healed ( b ). Another 20-year-old man with pressure sore for 3 months.
The ulcers were fi rst treated with skin fl ap, debridement, and wound
care but failed to heal ( c ). After 22 days of treatment with bFGF, the
ulcers were healed ( d ) [ 8 ]

10.1 Role of Growth Factors in Cutaneous Wound Healing

254
there are no side effects observed at present, it is necessary to
bear in mind that the biological effects of this treatment do,
however, require further elucidation.
10.1.5 Problems of Growth Factors
Application Involved in Wound Healing
Although the results from many clinical trials are encourag-
ing, it is necessary to bear in mind that some other wound
management methods, including wound bed preparation, tra-
ditional surgical managements such as debridement (auto-
lytic debridement, surgical and sharp debridement, enzymatic
debridement, and mechanical debridement), and topical anti-
microbial therapy, are still necessary for successful wound
healing [ 36 ]. The removal of devitalized tissues and necrotic
materials (such as soft tissue, bone fascia, muscle, and liga-
ment) is mandatory, not only to improve the local host
defense but also to produce a more active wound milieu, as
well as to release tissue cytokines and growth factors.
Although systemic antibiotics are not necessary to reduce
the local bacterial burden in wounds, topical antimicrobials
are sometimes appropriate to decrease the bacterial burden in
chronic wounds with active but localized infection [ 37 ]. It
has been confi rmed that a large population of bacteria may
impair every process of wound healing process, and bacteria
may produce proteases capable of degrading growth factors.
Thus, it is very hard for a wound to heal with heavy bacterial
loads and existence of damaged tissues. Clinical trials of
exogenous application of polypeptide growth factors in
chronic wounds have not fulfi lled the high expectations
derived from results of experimental studies. There is no
convincing evidence that growth factors may substitute for
good wound care and effi cient surgical approaches to wound
closure. The ultimate goal of treatment of chronic ulcerations
remains to be reconstitution of durable skin coverage with-
out unstable scarring. Therefore, optimization of current
methods of wound therapy, including reconstructive vascular
and plastic surgery and adequate metabolic and wound con-
trol, should be employed before any adjuvant growth factor
therapy is attempted.
10.1.6 Effect of Wound Healing in Those
Wounds Treated with Growth Factors
In reviewing the previous study, it is found that almost all
wounds treated with or without growth factors heal with
scarring. There are no sweat glands, sebaceous glands, and
hair follicles in regenerated scar tissues, which frequently
cause cosmetic and functional impairment in patients who
survive extensive deep thermal injury. With the considerable
advances in elucidating the molecular basis of skin develop-
ment and wound repair, attempts at developing new therapies
to reestablish sweat glands through epidermal stem cells or
mesenchymal stem cells (MSCs) have been made. In the past
decade, there have been signifi cant advances in the identifi -
cation of molecules that stimulate cell proliferation and dif-
ferentiation, particularly in mesenchymal tissues. These
studies have indicated that growth factors, cytokines, and
components of the extracellular matrix (ECM) are required
for proliferation and differentiation of some stem and pro-
genitor cells, including mature epidermal cells and MSCs.
These growth factors may serve as autocrine or paracrine
modulators of epidermal functions, including the regulation
of epidermal stem cell divisions. Based on the developing
relationship between skin stem cells and skin appendages,
such as hair follicles and sweat glands, it is our fi rm belief
that with brilliant accomplishment in biological sciences in
the past decade, our goal of restitution of skin functions
through skin stem cells should not be far beyond our reach
[ 38 – 46 ].
Table 10.3 Expression characteristics of growth factors in some
tumorlike tissues and their possible relationship with human carcinoma
development
EGF, TGF, and EGF-R
EGF-R signaling pathway is overexpressed and/or activated in
human breast tumors and about 40 % of breast cancer tissue with
positive expression of EGF. Strong synergistic effects of the
proto-oncogene c-myc and TGF-α in inducing mammary tumors.
Upregulation of EGF-R has been identifi ed as an early event in
head and neck carcinogenesis. Increased EGF levels is associated
with the invasive ability of prostate cancer, breast cancer, ovary
cancer, bladder cancer, and lung cancer [ 24 , 25 ]
FGFs
FGFs may contribute to neoplastic cell growth in an autocrine
manner, such as MCF-7 breast cancer cell and prostate stromal
cell; bFGF values were elevated in sera from patients with
non-small cell lung cancer; bFGF was reported to promote ovarian
cancer cell growth and metastases [ 26 , 27 ]
IGF
IGF-R is overexpressed in breast tumors as well as in breast
cancer cell lines. IGFs exert mainly paracrine effects on breast
cancer. There is a possible relationship between IGF expression
and prostate cancer development and bone metastasis. The
expression of IGF is correlated with colorectal cancer
development and progression. The IGF system is also involved in
the modulation of both small cell lung cancer and non-small cell
lung cancer [SCLC and N-SCLC)] [ 28 , 29 ]
PDGF
The mitogenic activity of PDGF on breast cancer cell lines and
the presence of the PDGF receptor in these tissues were found; the
positive expression of PDGF gene in human lung cancer cell lines
is associated with its poor prognosis; PDGF may be involved in
ovarian cancer development [ 30 , 31 ]
10 Growth Factors and Stem Cells for Wound Repair and Tissue Regeneration

255
10.1.7 Healing Events Require a Growth
Factor to Become Clinically Important
As one of the agents to accelerating wound healing, the roles
of growth factors in shortening wound healing time from 1 to
4 days in acute wounds or completely healing chronic
wounds have been confi rmed [ 17 , 47 – 49 ]. As we have men-
tioned in previous study, the events of wound healing are
regulated by growth factors, cytokines, and components of
the extracellular matrix (ECM). The process of acute wound
healing differs little from one kind of tissue to another and is
generally independent of the type of injury. Although differ-
ent elements of the wound healing process proceed in a con-
tinuous and integrated manner, it is still convenient to divide
the whole process into three overlapping phases, e.g.,
infl ammatory phase, proliferative phase, and maturation
phase (Fig. 10.2a, b ), and several natural components for
descriptive purpose. In contrast, chronic ulcers are character-
ized by defective remodeling of the extracellular matrix
(ECM), a failure to reepithelialization, and prolonged infl am-
mation (Fig. 10.2c, d ). For deep chronic wounds, such as bed
sores and diabetic foot ulcers, healing demands a complexity
of angiogenesis, deposition of extracellular matrix, contrac-
tion, and epithelialization. Thus, the wound healing process
for such wounds is more complicated compared with healing
of acute wounds. All wound healing processes require
growth factors to orchestrate tissue regeneration and epithe-
lialization. Although in some wounds, such as partial-thick-
ness skin wounds and superfi cial second-degree burns,
healing is achieved almost entirely by epithelialization,
growth factors may play some roles in the processes of heal-
ing. Although wound healing time in growth factor-treated
wounds is shorten to only 1–4 days, the clinical signifi cance
of these results is visible. For donor areas, wounds can be
a
b
c
d
Fig. 10.2 The process of acute wound healing differs little from one
kind of tissue to another and is generally independent of the type of
injury. Although different elements of the wound healing process pro-
ceed in a continuous and integrated manner, it is still convenient to
divide the whole process into three overlapping phases, e.g., infl amma-
tory phase, proliferative phase, and maturation phase. The typical acute
wounds may include surgical wound ( a ) and burn injury ( b ). However,
the chronic ulcers are characterized by defective remodeling of the
extracellular matrix (ECM), a failure to reepithelialization, and pro-
longed infl ammation. The typical chronic ulcers may include the dia-
betic ulcer ( c ) and venous ulcer ( d )

10.1 Role of Growth Factors in Cutaneous Wound Healing

256
closed rapidly and the patient’s own skin soon becomes
available for harvest and autograft. All of these will be ben-
efi cial to reduce the hospitalization and accelerate earlier
return to function.
10.1.8 Great Needs to Be Done to Include
Growth Factors in Clinical Practice
Compared with the traditional medicines and other chemical
medicines, the history of gene drugs is very short. From the
1980s up to now, only 20 years is involved. Thus, much work
about growth factors and tissue repair should be done within
the next 5 or 10 years. First, it is our duty to evaluate their
effects in accelerating acute or chronic wound healing based
on the evidences based medicine. After screening the results
from different centers, some results are found to be encour-
aging, while some discouraging. Although the interpretation
of these results depends on the angle of views of whether the
cup is half full or half empty [ 50 ], it may depend on different
criteria, different wounds, and even different aims. Five
years ago, Robson et al. emphasized their expectation that
growth factors, cytokines, and other biological agents would
be used more specifi cally in the future by targeting growth
factor therapy at those specifi c components or processes that
a given wound was to heal [ 50 ]. Since fi ve years has passed
now, it is deemed to be necessary to look back and rejudge
the effi cacy and safety of these growth factors as reported
from different centers in order to use them more rationally in
the future. Second, it is necessary to clarify their best indica-
tions and the most effective dosages for different wounds in
clinical practice. To date, the most effective dosages of rhP-
DGF- BB, bFGF, and EGF for acute or chronic wounds have
been defi ned; however, with their application in different
wounds and people, even in different conditions, their best
indications and the most effective dosages should be rede-
fi ned. Third, people should pay much attention to their pos-
sible side effects and long-time effects. As we have mentioned
previously, the history of growth factors and their application
in tissue repair is very short and people worry about their
potential side effects, such as abnormal cell transformation,
tumor induction, and hypertrophic scar formation, etc. Thus,
it is necessary to bear in mind these worries, and long-time
follow-up and carefully clinical observation should be done.
Fourth, the other therapy applications of these growth fac-
tors, such as for heart vascular diseases, Parkinson’s disease,
and cosmetic fi eld, should be explored. Five other new
growth factors and their application in wound repair and
regeneration should be studied, such as transforming growth
factor β3 (TGF-β3), keratinocyte growth factor (KGF-2),
fi broblast growth factor-10, and recombinant human
granulocyte- macrophage colony- stimulating factor (rhuGM-
CSF). Preliminary studies indicated that these growth factors
had effects in reduction in pressure ulcer area and volume in
all treated wounds [ 51 , 52 ].
10.2
Role of Stem Cells in Skin Wound
Repair and Regeneration
Repair of damaged dermal tissue is accomplished by
dynamic cell-cell and cell-matrix interactions involving acti-
vation of resident cells as well as cells that migrate into the
lesion. Immediately after injury there is a hemostatic
response that activates platelets. Platelets release TGF-β and
PDGF, which begin the recruitment of infl ammatory cells
and activate several resident dermal cell types. The most
notable early infl ammatory response is the infi ltration of
neutrophils. These are necessary to control infection and
begin clearing the damaged tissue but are not critical to the
healing process. Wound healing begins a few days later with
the infi ltration of monocyte/macrophages at the site. These
cells release a number of cytokines, synthesize extracellular
matrix (ECM), and serve as a source of stem cells. The ECM
becomes vascularized by angiogenesis and forms granula-
tion tissue. Neovascularization is accomplished using both
resident endothelial cells and circulating progenitor cells
from the blood. Scar formation proceeds with the activation,
migration, and proliferation of fi broblasts and the formation
of a three-dimensional scaffold of ECM. A blood-derived
monocyte/stem cell may be the major contributor to early
matrix synthesis. These blood-derived stem cells are able to
produce a wide variety of proinfl ammatory cytokines (IL-1β,
TNF-α, MIP-1α, MIP-1β, PDGF-A, and TGF-β), which
make major contributions to the healing process. Contraction
of the wound is driven by activation and differentiation of
mesenchymal cells into myofi broblasts that are able to draw
the edges of the damaged tissue over the defi cit. Migration of
viable keratinocytes within the wound and from the edges of
it stimulated by type I and type IV collagen, fi bronectin, and
vitronectin, as well as serum factors, is responsible for the
reepithelialization of the surface. The cells include both the
basal stem cells of the epidermis and the transit-amplifying
cells. If epidermal stem cells are lost, migrating stem cells
from surviving hair follicles are able to supply epidermal
cells.
Among the main sources of cells that might be used for
repair and regeneration of injured tissues are embryonic stem
cells (ESCs) and adult stem cells. ESCs have great capacity
for self-renewal and plasticity, but their use is limited by sci-
entifi c, political, and ethical considerations. The use of adult
stem cells, especially mesenchymal stem cells (MSCs), is
not burdened by many of these problems. MSCs can be iso-
lated from bone marrow and other tissues such as adipose
tissue, nerve tissue, umbilical cord blood, and dermis [ 53 –
57 ]. Although most studies have found that MSCs can con-
10 Growth Factors and Stem Cells for Wound Repair and Tissue Regeneration

257
tribute to skin reconstitution in cutaneous wounds, the
complete regeneration of injured skin is still a long way off
[ 58 – 60 ]. Understanding the mechanisms that underlie nor-
mal wound repair is of profound medical importance,
because many disease states include elements of non-healing
or poorly healing lesions. Given the role of MSCs in wound
repair of developmental systems and their emerging use as
therapeutic agents, we propose that MSCs may be a critical,
manipulable component of wound repair in humans.
Understanding the role of MSCs within the tissue where a
wound occurs will be quite valuable. Additionally, several
studies are also investigating other possible sources of stem
cells such as adipose tissue or hair that might be easier to
obtain.
10.2.1 The Benefi ts of MSCs in Skin Wound
Healing and Regeneration
Animal transplantation studies have shown that MSCs are
able to differentiate into cells of the residing tissue, repair
damaged tissue due to trauma or disease, and partially restore
normal function [ 58 , 59 , 61 ]. MSCs not only participate in
the regeneration of tissues of mesenchymal lineages, such as
intervertebral disc cartilage [ 62 ], bone [ 63 ], cardiomyocytes
[ 64 ], and articular cartilage at knee joints [ 65 ], but they also
appear to differentiate into tissue cells derived from other
embryonic layers, including the skin [ 59 ] and lung [ 66 ].
These experiments demonstrate the plasticity of MSCs and
their potential usefulness in complex tissue repair and regen-
eration, as well as in cell therapy. In addition, neither autolo-
gous nor allogeneic MSCs induce immunoreactivity in the
host on local transplantation or systemic administration [ 67 ,
68 ]. Thus, these cells represent an important building block
for cell therapy, wound repair, regenerative medicine, and
tissue engineering [ 69 ].
Increasing evidence has shown that MSCs participate in
the regeneration of skin in cutaneous wounds [ 59 , 67 , 70 ,
71 ]. Transplanting autologous and allogeneic MSCs on the
surface of deep burn wounds in rats decreased infl ammatory
cell infi ltration into the wound and accelerated the formation
of new vessels and granulation tissue. The regeneration pro-
cess was most active after transplantation of autologous
cells, and transplanted cells remained viable on the surface
and deep in the regenerating tissue throughout the observa-
tion period [ 72 ]. The cells produced bioactive substances
that seemed to have accelerated the regeneration process
after wounding. Mansilla et al. [ 67 ] created a full-thickness
skin defect in mice and used human MSCs (hMSCs) to
accelerate the wound healing. All skin wounds healed with-
out a scar or retraction at a median time of 14 days after
wounding. Deng et al. [ 71 ] transplanted CM-DiI fl uorescence-
labeled Fik-1+ bone marrow MSCs (BM-MSCs) of BALB/c
mice (H-2Kd, white) into lethally irradiated C57BL/6 mice
(H-2 KB, black). Using fl uorescence tracing, Y chromosome-
specifi c PCR, and Southern blot analysis, the authors found
the donor cells migrating to and taking up residency in the
skin of recipient mice, which later grew white hairs. RT-PCR
confi rmed the skin tissue within the white hair regions
largely composed of donor-derived H-2Kd cells. Thus,
MSCs appear to respond to wound healing signals and con-
tribute to skin wound repair and regeneration.
MSCs have been examined in skin repair and regenera-
tion after various acute and chronic skin injuries, such as
acute incisional and excisional wounds, diabetic skin ulcers,
radiation burns, and thermal burns [ 60 , 70 , 73 ]. However,
most research has investigated their contribution to repair
after skin incision and excision wounding. In one study of
chronic diabetic foot ulcers that involved 29-day treatment
with an autologous biograft composed of autologous skin
fi broblasts on biodegradable collagen membrane combined
with autologous MSCs applied directly to the wound and
injected into the edges of the wound on days 1, 7, and 17,
wound size was decreased and vascularity of the dermis and
dermal thickness of the wound were increased [ 73 ]. In a case
report of severe buttock radiation burn that described treat-
ment combining physical techniques, surgery, and autolo-
gous BM-MSC therapy, clinical evolution (radiation pain
and healing progression) during the 11-month follow-up was
favorable, with no recurrence of radiation infl ammatory
waves seen on radiography [ 60 ]. Autologous BM-MSCs
have played an important role in promoting tissue regenera-
tion after radiation injury [ 60 ].
The potential of MSCs to differentiate into skin tissue
cells has been described. Sasaki et al. injected bone
BM-MSCs into wounds in mice and showed that MSCs
transdifferentiated into keratin 14-positive cells, as well as
keratinocytes, endothelial cells, and pericytes in vivo [ 59 , 70 ,
74 – 76 ]. The authors also reported that several chemokine
receptors, especially CCR7, enhanced MSC migration [ 59 ].
Wu et al. [ 70 ], in an excisional wound splinting model in
diabetic mice, examined the benefi t of injecting allogeneic
BM-MSCs around the wound and applying them to the
wound bed and reported the following results: the MSCs
expressed the keratinocyte-specifi c protein keratin and
formed glandular structures, and wounds showed accelerated
closure and high levels of vascular endothelial growth factor
(VEGF) and angiopoietin-1; these results suggested that
BM-MSCs promoted wound healing through a direct contri-
bution and release of preangiogenic factors. We have cocul-
tured BrdU-labeled adult human BM-MSCs and heat-shocked
confl uent adult human-derived sweat gland cells (SGCs)
in vitro and intravenously injected the allogeneic BrdU-
labeled BM-MSCs into full-thickness skin wounds in rats
in vivo. In vitro immunohistochemical double-staining
showed the BrdU-labeled BM-MSCs were incorporated into
10.2 Role of Stem Cells in Skin Wound Repair and Regeneration

258
SGC layers, and some BrdU-labeled MSCs were positive for
the SGC markers CK19 and CEA [ 76 ]. The in vivo results
showed labeled MSCs in hair follicles, sebaceous glands,
blood vessels, and dermis in full-thickness wounds [ 76 ].
After wound healing, some labeled MSCs returned to the
bone marrow, whereas others were retained in the dermis
[ 76 ]. In another study, we found that in vitro expanded and
purifi ed BM-MSCs took on phenotypes of vascular endothe-
lial cells or epidermal cells after culture in media supple-
mented with VEGF and EGF, respectively. In another study,
after culture in media supplemented with VEGF and EGF
in vitro, minipig BM-MSCs expressed factor VII-related
antigen and cytokeratin, markers of vascular endothelial
cells and epidermal cells, respectively. As well, in vivo auto-
grafting experiments showed that BrdU-labeled minipig
BM-MSCs could convert into the phenotypes of vascular
endothelial cells in granulation tissue, sebaceous duct cells,
and epidermal cells in regenerated skin. We evaluated wound
healing quality in minipigs by measuring the percentage
reepithelialization, the amount of new epithelium covering
the wound bed, and the amount of granulation tissue and
extracellular matrix fi lling the wound bed; speed of reepithe-
lialization was signifi cantly enhanced, as were the morpho-
logic features with increased number of epidermal ridges and
increased thickness of regenerated epidermis. The number
and arrangement of microvascularities, fi broblasts, and col-
lagen were enhanced with autologous BM-MSCs treatment
[ 77 ]. All these fi ndings strongly demonstrate that adult
MSCs can contribute to the healing of injured skin append-
ages and might provide a cell resource for rebuilding skin
appendages.
10.2.2 Questions Remaining in the Use
of MSCs for Skin Wound Healing
and Regeneration
Despite signifi cant progress in evaluating the wound healing
benefi t of MSCs transplantation, many questions remain to be
answered. First, whether the mechanism of MSCs in wound
repairs is due to transdifferentiation or cell fusion remains
unclear [ 59 , 70 , 78 ]. Although much research has supported
the view that the phenotype transition of MSCs in the wounds
is due to transdifferentiation [ 59 , 79 ], cell fusion may be the
other mechanism. Data from the preliminary studies are not
suffi cient to show whether skin appendages, including seba-
ceous glands and sweat glands regenerated by MSCs, are
functional. More research is needed to determine whether
MSC-derived cells possess functions similar to those of their
original tissues. To date, candidate signaling pathways that
may be involved in transdifferentiation of MSCs have not
been completely identifi ed. The isolation of adult stem cells
with suffi cient purity and quantity still remains diffi cult, and
defi nitive markers allowing for positive selection of adult
stem cells have not been fully revealed. Moreover, research
needs to better examine not only MSCs but also cells that
make up the niche or microenvironment that supports the sur-
vival and differentiation of stem cells. Many observations
strongly imply a critical infl uence of microenvironmental
cues in cell fate [ 80 ]. Also, because most MSCs are found to
be circulating, understanding of the mechanisms of the cells
migrating and homing to the correct tissue is likely as impor-
tant as the specifi c differentiation cues. In addition, although
current studies have shown that MSCs have the ability of site-
specifi c differentiation in response to cues provided by differ-
ent microenvironments, perfect regeneration and rebuilding
of an organ have not been achieved [ 77 ]. Finally, the plasticity
of stem cells may be a double-edged sword, and instability of
cellular phenotypes may lead to deterioration of structure
and/or function of tissues and may eventually give rise to
malignant cells.
To fully control the potential of MSCs, future studies
should aim to determine the cellular and molecular charac-
teristics of these cells for optimal identifi cation, isolation,
and expansion. As well, we need to understand the natural,
endogenous roles of MSCs in normal and abnormal tissue
functions.
10.2.3 Stem Cells in Skin Can Act
as an Alternative Source for Skin
Regeneration
Adult skin consists of epidermis, dermis, and appendages
such as hair and glands that are linked to the epidermis but
project deep into the dermal layer. Stem cell biology of the
skin has been a focus of increasing interest in current life
science. Committed stem cells with a limited differentiation
potential for regeneration and repair of epidermis have been
known for decades. Recent studies further found that adult
skin tissues contain cell populations with pluripotent charac-
teristics. Multipotent stem cells from skin with and without
hair follicles, both in epidermal and dermal tissues, can dif-
ferentiate and generate multiple cell lineages. Especially, the
hematopoietic system in epidermal and dermal tissue, like
skin, may be a local, acceptable reservoir of various adult
stem cell populations. Given their easy accessibility, such
stem cells can provide an experimental model not only for
skin biology but also for studying the epithelial- mesenchymal
cell interactions of organs other than the skin.
10 Growth Factors and Stem Cells for Wound Repair and Tissue Regeneration

259
10.2.4 Induced Stem Cells for Wound
Treatment
The realization over the past few years that mature somatic
cells can be induced to express a stem cells phenotype has
opened new avenues of research in many areas – among them
is wound healing. The understanding of these cells and how
far reversal of the differentiation of somatic cells may be con-
trolled has yet to be fully explored. The stability of the
induced pluripotent stem cells (IPS cells) and their ability to
become malignant have not yet been determined. Nonetheless,
it is possible that this approach will provide an alternative
source of autologous stem cells for the treatment of wounds.
Understanding of the cellular and biochemical processes
of wound healing has rapidly advanced over the past decade,
with many of the key mediators and events now character-
ized. With these advances, the concept that stem cells may
play an important role in contributing pools of cells to repop-
ulate damaged tissue or to play transient roles has emerged.
Although the stem cells of the epidermis have received the
most attention, studies in angiogenesis and matrix deposition
are beginning to add the stem cell to the constellation of cells
involved in these processes as well. Along with these puta-
tive roles, stem cells may well be involved in expansion of
the mesenchymal pool of cells for the reconstitution of the
collagenous dermis and scar.
References
1. Brown GL, Nanney LB, Griffen J, et al. Enhancement of wound
healing by topical treatment with epidermal growth factor. N Engl J
Med. 1989;321:76–9.
2. Fu X, Shen Z, Chen Y, et al. Randomized placebo-controlled trial of
use of topical recombinant bovine basic fi broblast growth factor for
second-degree burns. Lancet. 1998;352:1661–4.
3. Fu X, Wang Z, Sheng Z. Advances in wound healing research in
China: from antiquity to the present. Wound Rep Reg. 2001;9:2–10.
4. Knighton DR, Ciresi KF, Fiegel VD, et al. Classifi cation and treat-
ment of chronic nonhealing wounds. Successful treatment with
autologous platelet-derived wound healing formula (PDWHF).
Ann Surg. 1986;204:322–30.
5. Knighton DR, Ciresi KF, Fiegel VD, et al. Stimulation of repair in
chronic, nonhealing, cutaneous ulcers using autologous platelet-
derived wound healing formula. Surg Gyn Obs. 1990;170:56–60.
6. Mustoe TA, Cutler NR, Allman RM, et al. Phase II study to evaluate
recombinant PDGF-BB in the treatment of pressure sores. Arch
Surg. 1994;129:213–9.
7. Robson MC, Phillips LG, Lawrence WT, et al. The safety and effect
of topically applied recombinant basic fi broblast growth factor on
the healing of chronic pressure sores. Ann Surg. 1992;216:401–6;
discussion 406–8.
8. Fu X, Shen Z, Guo Z, et al. Healing of chronic cutaneous wounds
by topical treatment with basic fi broblast growth factor. Chin Med
J (Engl). 2002;115:331–5.
9. Fu X, Shen Z, Chen Y, et al. Recombinant bovine basic fi broblast
growth factor accelerates wound healing in patients with burns,
donor sites and chronic dermal ulcers. Chin Med J (Engl).
2000;113:367–71.
10. Fu X, Cuevas P, Gimenez-Gallego G, et al. Ischemia and reperfu-
sion reduces the endogenous basic fi broblast growth factor in rat
skeletal muscles. Chin Med J (Engl). 1995;108:699–703.
11. Fu X, Yang Y, Li X, et al. Ischemia and reperfusion impair the gene
expression of endogenous basic fi broblast growth factor in rat skel-
etal muscles. J Surg Res. 1998;80:88–93.
12. Trengove NJ, Bielefeldt-Ohmann H, Stacey MC. Mitogenic activ-
ity and cytokine levels in non-healing and healing chronic leg
ulcers. Wound Rep Reg. 2000;8:13–25.
13. Tarnuzzer RW, Schultz GS. Biochemical analysis of acute and
chronic wound environments. Wound Rep Reg. 1996;4:321–5.
14. Trengove NJ, Stacey MC, MacAuley S, et al. Analysis of the acute
and chronic wound environments: the role of proteases and their
inhibitors. Wound Rep Reg. 1999;7:442–52.
15. Landau Z, David M, Aviezer D, et al. Heparin-like inhibitory activ-
ity to fi broblast growth factor-2 in wound fl uid of patients with
chronic skin ulcers and its modulation during wound healing.
Wound Rep Reg. 2001;9:323–8.
16. Bennett NF, Schultz GS. Growth factors and wound healing: part
II. Role in normal and chronic wound healing. Am J Surg.
1993;166:74–81.
17. Robson MC. Exogenous growth factor application effect on human
wound healing. Prog Dermatol. 1996;30:1–7.
18. Grazul-Bilska AT, Luthra G, Reynolds LP, Abdullah KM, et al.
Effects of basic fi broblast growth factor (FGF-2) on proliferation of
human skin fi broblasts in type-II diabetes mellitus. Exp Clin
Endocrinol Diabetes. 2002;110:176–81.
19. Cohen IK, Crossland MC, Garrett A, et al. Topical application of
epidermal growth factor onto partial-thickness wounds in human
volunteers does not enhance reepithelialization. Plast Reconstr
Surg. 1995;96:251–4.
20. Feng J, Du WH, Wang J. Clinical study of various growth factors on
the improvement of impaired healing ulcers in patients with dia-
betic disease. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi.
1999;13:273–7.
21. Andree C, Swain W, Page C, et al. In vivo transfer and expression
of a human epidermal growth factor gene accelerates wound repair.
Proc Natl Acad Sci U S A. 1994;91:12188–92.
22. Margolis DJ, Crombleholme T, Herlyn M. Clinical protocol: phase-
I trial to evaluate the safety of H5.020CMV.PDGF-B for the treat-
ment of a diabetic insensate foot ulcer. Wound Rep Reg. 2000;8:
480–93.
23. Favoni RE, Cupis AD. The role of polypeptide growth factors in
human carcinomas: new targets for a novel pharmacological
approach. Pharmacol Rev. 2000;52:179–205.
24. Klijn JGM, Berns PMJ, Schmitz PIM, et al. The clinical signifi -
cance of epidermal growth factor receptor (EGF-R) in human breast
cancer. A review on 5232 patients. Endocr Rev. 1992;
13:3–17.
25. Ellerbroek SM, Hudson LG, Stack MS. Proteinase requirements of
epidermal growth factor-induced ovarian cancer cell invasion. Int J
Cancer. 1998;78:331–7.
26. Di Blasio AM, Cremonesi L, Vigano P, et al. Basic fi broblast growth
factor and its receptor messenger ribonucleic acids are expressed in
human ovarian epithelial neoplasm. Am J Obstet Gynecol.
1993;169:1517–23.
27. Russell PJ, Bennett S, Stricker P. Growth factor involvement in pro-
gression of prostate cancer. Clin Chem. 1998;44:705–23.
References

260
28. Rasmussen AA, Cullen KJ. Paracrine/autocrine regulation of breast
cancer by the insulin-like growth factors. Breast Cancer Res Tread.
1998;47:219–33.
29. Lambert S, Vivario J, Boniver J, et al. Abnormal expression and
structural modifi cation of the insulin-like growth factor-II gene in
human colorectal cancer. Int J Cancer. 1990;46:405–10.
30. Kawai T, Hiroi S, Torikata C. Expression in lung carcinomas of
platelet-derived growth factor and its receptor. Lab Invest.
1997;77:431–6.
31. Dabrow MB, Francesco MR, Mcbrearty FX, et al. The effects of
platelet-derived growth factor and receptor on normal and neoplas-
tic
human
ovarian
surface
epithelium.
Gynecol
Oncol.
1998;71:29–37.
32. Nguyen M, Watanabe H, Budson AW, et al. Elevated levels of
angiogenic peptides, basic fi broblast growth factor, in urine of
patients with a wide spectrum of cancers. J Natl Cancer Inst.
1993;86:356–61.
33. Li VW, Folkerth RD, Watanabe H, et al. Microvessel count and
cerebrospinal fl uid basic fi broblast growth factor in children with
brain tumors. Lancet. 1994;344:82–6.
34. Uckun FM, Narla RK, Zeren T, et al. In vivo toxicity, pharmacoki-
netics, and anticancer activity of Genistein linked to recombinant
human epidermal growth factor. Clin Cancer Res. 1998;4:1125–34.
35. Wang S, Zhou L, Ma Z, et al. Experimental observation on ADRs of
recombinant human epidermal growth factor (rhEGF) in healthy
and burned volunteers. Chin New Drugs J. 2000;9:34–6.
36. Jeffcoate WJ, Harding KG. Diabetic foot ulcers. Lancet.
2003;361:1545–51.
37. Schultz GS, Sibbald RG, Falanga V, et al. Wound bed preparation:
a systematic approach to wound management. Wound Rep Reg.
2003;11:S1–28.
38. Li J, Fu X, Sun X, et al. The interaction between epidermal growth
factor and matrix metalloproteinase’s induces the development of
sweat glands in human fetal skin. J Surg Res. 2002;106:258–26.
39. Slack
JMW.
Stem
cells
in
epithelial
tissues.
Science.
2000;287:1431–3.
40. Fiona M, Watt FM, Brigid LM. Out of eden: stem cell and their
niches. Science. 2000;287:1427–30.
41. Blecher SR, Kapalanga J, Lalonde D, et al. Induction of sweat
glands by epidermal growth factor in murine X-linked anhidrotic
ectodermal dysplasia. Nature (London). 1990;345:542.
42. Jones PH, Harper S, Watt FM. Stem cell patterning and fate in
human epidermis. Cell. 1995;80:83–93.
43. Tursad K, Troy TC. Epidermal cell lineage. Biochem Cell Biol.
1998;76:889–98.
44. Streuli C. Extracellular matrix remodeling and cellular differentia-
tion. Curr Opin Cell Biol. 1999;11:634.
45. Schwartz MA, Baron V. Interactions between mitogenic stimuli, or
a thousand and one connections. Curr Opin Cell Biol. 1999;11:197.
46. Brivanlou AH, Gage FH, Jaenisch R, et al. Setting standards for
human embryonic stem cells. Science. 2003;300:913–6.
47. Robson MC, Phillips LG, Thompson A, et al. Platelet derived
growth factor-BB for the treatment of chronic pressure ulcers.
Lancet. 1992;339:23–5.
48. Robson MC, Phillips LG, Thompson A, et al. Recombinant human
platelet derived growth factor-BB in the treatment of pressure
ulcers. Ann Plast Surg. 1992;129:193–20.
49. Mandracchia VJ, Sanders SM, Frerichs JA. The use of Becaplermin
(rhPDGF-BB) gel for chronic non-healing ulcers: a retrospective
analysis. Clin Podiatr Med Surg. 2001;18:189–209.
50. Robson MC, Mustoe TA, Hunt TK. The future of recombinant
growth factors in the wound healing. Am J Surg. 1998;176:80S–2.
51. Bianchi L, Ginebri A, Hagman JH, et al. Local treatment of chronic
cutaneous leg ulcers with recombinant human granulocyte-
macrophage colony-stimulating factor. J Eur Acad Dermatol
Venereol. 2002;16:595–8.
52. Hirshberg J, Coleman J, Marchant B, et al. TGF-beta3 in the treat-
ment of pressure ulcers: a preliminary report. Adv Skin Wound
Care. 2001;14:91–5.
53. Kim WS, Park BS, Sung JH, et al. Wound healing effect of adipose-
derived stem cells: a critical role of secretory factors on human der-
mal fi broblasts. J Dermatol Sci. 2007;48:15–24.
54. Dai Y, Li J, Dai G, et al. Skin epithelial cells in mice from umbilical
cord blood mesenchymal stem cells. Burns. 2007;33:418–28.
55. Perng CK, Ku HH, Chiou SH, et al. Evaluation of wound healing
effect on skin-defect nude mice by using human dermis-derived
mesenchymal stem cells. Transplant Proc. 2006;38:3086–7.
56. Shih DT, Lee DC, Chen SC, et al. Isolation and characterization of
neurogenic mesenchymal stem cells in human scalp tissue. Stem
Cells. 2005;23:1012–20.
57. Jones EA, Kinsey SE, English A, et al. Isolation and characteriza-
tion of bone marrow multipotential mesenchymal progenitor cells.
Arthritis Rheum. 2002;69:3349–60.
58. Yoshikawa T, Mitsuno H, Nonaka I, et al. Wound therapy by mar-
row mesenchymal cell transplantation. Plast Reconstr Surg.
2008;121:860–77.
59. Sasaki M, Abe R, Fujita Y, et al. Mesenchymal stem cells are
recruited into wounded skin and contribute to wound repair by
transdifferentiation into multiple skin cell type. J Immunol.
2008;180:2581–7.
60. Lataillade JJ, Doucet C, Bey E, et al. New approach to radiation
burn treatment by dosimetry-guided surgery combined with autolo-
gous mesenchymal stem cell therapy. Regen Med. 2007;2:
785–94.
61. Baksh D, Song L, Tuan RS. Adult mesenchymal stem cells: charac-
terization, differentiation, and application in cell and gene therapy.
J Cell Mol Med. 2004;8:301–16.
62. Crevensten G, Walsh AJ, Ananthakrishnan D, et al. Intervertebral
disc cell therapy for regeneration: mesenchymal stem cell implanta-
tion in rat intervertebral discs. Ann Biomed Eng. 2004;32:
430–4.
63. Arinzeh TL, Peter SJ, Archambault MP, et al. Allogeneic mesen-
chymal stem cells regenerate bone in a critical-sized canine seg-
mental defect. J Bone Joint Surg Am. 2003;85-A:1927–35.
64. Fukuda K. Molecular characterization of regenerated cardiomyo-
cytes derived from adult mesenchymal stem cells. Congenit Anom
Kyoto. 2002;42:1–9.
65. Barry FP. Mesenchymal stem cell therapy in joint disease. Novartis
Found Symp. 2003;249:86–96.
66. Ortiz LA, Gambelli F, McBride C, et al. Mesenchymal stem cell
engraftment in lung is enhanced in response to bleomycin exposure
and ameliorates its fi brotic effects. Proc Natl Acad Sci U S A.
2003;100:8407–11.
67. Mansilla E, Marin GH, Sturia M, et al. Human mesenchymal stem
cells are tolerized by mice and improve skin and spinal cord inju-
ries. Transplant Proc. 2005;37:292–4.
68. Liu H, Kemeny DM, Heng BC, et al. The immunogenicity and
immunomodulatory function of osteogenic cells differentiated from
mesenchymal stem cells. J Immunol. 2006;176:2864–71.
69. Bajada S, Mazakova I, Richardson JB, et al. Updates on stem cells
and their applications in regenerative medicine. J Tissue Eng Regen
Med. 2008;2:169–83.
70. Wu Y, Chen L, Scott PG, et al. Mesenchymal stem cells enhance
wound healing through differentiation and angiogenesis. Stem
Cells. 2007;25:2648–59.
71. Deng W, Han Q, Liao L, et al. Engrafted bone marrow-derived fl k-
(1+) mesenchymal stem cells regenerate skin tissue. Tissue Eng.
2005;11:110–9.
72. Shumakov VI, Onishchenko NA, Rasulov MF, et al. Mesenchymal
bone marrow stem cells more effectively stimulate regeneration of
deep burn wounds than embryonic fi broblasts. Bull Exp Biol Med.
2003;136:192–5.
10 Growth Factors and Stem Cells for Wound Repair and Tissue Regeneration

261
73. Vojtassák J, Danisovic L, Kubes M, et al. Autologous biograft and
mesenchymal stem cells in treatment of the diabetic foot. Neuro
Endocrinol Lett. 2006;27 Suppl 2:134–7.
74. Fu XB, Qu ZL, Sheng ZY. Potentiality of mesenchymal stem
cells in regeneration of sweat glands. J Surg Res. 2006;136:
204–8.
75. Kataoka K, Medina RJ, Kageyama T, et al. Participation of adult
mouse bone marrow cells in reconstitution of skin. Am J Pathol.
2003;163:1227–31.
76. Li HH, Fu XB, Ouyang YS, et al. Adult bone-marrow-derived mes-
enchymal stem cells contribute to wound healing of skin append-
ages. Cell Tissue Res. 2006;14:325–35.
77. Fu XB, Fang LJ, Li XK, et al. Enhanced wound-healing quality
with bone marrow mesenchymal stem cells autograft after skin
injury. Wound Rep Reg. 2006;14:325–35.
78. Spees JL, Olson SD, Ylostalo J, et al. Differentiation, cell fusion,
and nuclear fusion during ex vivo repair of epithelium by human
adult stem cells from bone marrow stroma. Proc Natl Acad Sci U S
A. 2003;100:2397–402.
79. Yamada Y, Nishimoto E, Mitsuya H, et al. In vitro transdifferentiation of
adult bone marrow Sca-1+ cKit- cells cocultured with fetal liver cells
into hepatic-like cells without fusion. Exp Hematol. 2006;34:97–106.
80. Tuan RS, Boland G, Tuli R. Adult mesenchymal stem cells and cell-
based tissue engineering. Arthritis Res Ther. 2003;5:32–45.
References

263
Z. Yang, Chinese Burn Surgery, DOI 10.1007/978-94-017-8575-4_11,
© Springer Science+Business Media Dordrecht and People’s Medical Publishing House 2015
11.1
Advance in Research
and Management of Inhalation Injury
Zongcheng Yang, Erfan Xie, and Shunzhen Qi
Inhalation injury refers to damage of the respiratory tract and
lung parenchyma caused by inhalation of heat and/or smoke.
Heat can injure the mucous membrane of respiratory tract
and lung parenchyma directly. In flame burns, besides hot
air, plenty of smoke can be inhaled. Smoke contains harmful
chemicals such as CO, CO2, NO, N2O, NO2, phosgene, alde-
hydes, cyanides, SO2, hydrogen chloride, ketone, arsenides,
and organic acids. These chemicals can enter the bronchia
and alveoli and damage the mucous membrane and/or lung
parenchyma. In flame burns, after the airways are injured by
inhaled hot air and smoke, hypoxia and carbon monoxide
poisoning can occur [1].
After the Chicago nightclub fire in 1942, respiratory dam-
age was proposed explicitly as an important factor for burn
and death [1]. However, inadequate attention was paid to
inhalation injury, and inhalation injury was rarely studied. In
1974, a clinical analysis of 181 cases of inhalation injury was
reported by scholars from the Third Military Medical
University of China. It was found that the mortality was
8.9 % in patients with inhalation injury and was 43.1 % in
those without inhalation injury (Table 11.1). Moreover, the
mortality rates of patients with mild, moderate, and severe
inhalation injury were 29.0, 66.7, and 100 %, respectively.
The report highlighted the importance of inhalation injury in
China.
In light of the importance of inhalation injury, research-
ers from the Third Military Medical University, Jiangxi
Medical College, and other institutions have conducted a
series of comprehensive clinical and experimental studies
since 1978. After 30 years of efforts, the research findings
are fruitful.
11.1.1 Highlights in Diagnosis of Inhalation
Injury
Generally, under the following circumstance, inhalation
injury should be considered: (a) flame burn that occurs in a
closed space, especially when the victim presents with con-
scious disturbances, coma, or combined blast injury; (b)
face, neck, and chest burns, particularly deep burns of the
mouth and nose; (c) nose hair scorched, lip swelling, red-
dening and blisters of the oral cavity and oropharynx, and
mucous membrane whitening; (d) irritable coughs and car-
bon dust containing sputum; (e) trachyphonia, swallowing
pain, or difficulty; and (f) dyspnea and/or wheezing.
However, these circumstances cannot confirm or rule out the
diagnosis of inhalation injury. Inhalation injury sometimes
exists in victims without face and neck burns and even with-
out body surface burns. For example, in the 2,000 Luoyang
fire, all of 309 victims died of inhalation injury without
body surface burns. It was found that 70 % victims of inha-
lation injury had facial burns and 70  % victims of facial
burns had not inhalation injury. Carbon particles in sputum
may come from the nose, and the victims may have no air-
way damage. Thus, patients suspected of inhalation injury
should be checked repeatedly and monitored continually.
Fibrobronchoscopy is a good tool to determine the extent of
mucous membrane damage to the airways. The victims of
inhalation injury may develop many complications such as
respiratory failure. Therefore, it is inadequate to diagnose
inhalation injury, and the extent and development of inhala-
tion injury must be inspected and monitored dynamically.
Inhalation Injury
Zongcheng Yang, Guohui Li
11

264
11.1.1.1  Chest X-Ray
If inhalation injury is suspected, chest X-ray should be car-
ried out every 6–12 h at the early stage and every 1–2 days at
the later stage. Because moderate to serious inhalation injury
could cause tracheospasm and mucosal swelling, as well as
luminal narrowing, X-rays may reveal tracheal abnormalities
early. Tracheal cavity narrowing becomes obvious at 2–6 h
after inhalation injury, and spheroid shadow and vessel wall
thickening may be observed in some cases.
11.1.1.2  Fibrobronchoscopic Study
Fibrobronchoscopic study could identify inhalation injury
promptly. The incidence of inhalation injury has increased
from the previously alleged 3–33 % to 50–60 % after the
application of fibrobronchoscopy. A fibrobronchoscope can
be inserted into secondary and tertiary bronchi, allowing
direct observation of mucosal injury, sputum, and secretions.
Under fibrobronchoscopy, mucosal injury is classified into
three grades: grade I, mild hyperemia of tracheal mucous
membrane; grade II, obvious mucosal hyperemia and edema,
madder red mucous membrane, with submucosal hemor-
rhage and mucosal injury; and grade III, paleness, necrosis,
and stripping mucosa, submucosal tissues, and even,
cartilage.
Fibrobronchoscopy is unable to reveal pathological
changes of small airways and pulmonary alveoli.
Nevertheless, most of the patients with serious bronchial
injury suffer from injury to small airways and pulmonary
alveoli. In particular, most patients with inflammation at the
openings of bronchi and dry and moist rales have serious
alveolar injury [2].
11.1.1.3  Respiratory Function Testing
A definite diagnose of inhalation injury should take into
account ventilatory dysfunction and abnormal oxygenation.
PaO2 and blood oxygen saturation reflect oxygen supply,
and PaCO2 reflects ventilation. Arterial blood HCO3
−, BE,
and pH are indicators for oxygen consumption by tissues.
Some patients with serious burn and inhalation injury have
cardiopulmonary dysfunction, and the ventilation/perfu-
sion ratio and pulmonary shunt should be further assessed
in them.
11.1.1.4  Clinical Manifestations
The clinical manifestations of inhalation injury usually
reflect the severity of injury and the patient’s responses to
injury, and they differ greatly among patients. Patients with
mild injury may not have symptoms, while those with severe
injury may develop acute respiratory failure. According to
the severity and extent, inhalation injury can be classified
into three grades [1]:
A. Mild inhalation injury
The pathological changes are usually found in the oral
and nasal cavities and pharynx. Most patients have facial
burns. The common symptoms and physical signs include
the presence of carbon particles in the sputum, scorched
body hair, oral blisters, oropharyngeal inflammation, a
sooty tongue or pharynx, tachypnea, and hacking coughs.
In addition, there is pain and dry sensation in the larynx.
Hoarseness is less obvious and respiratory distress is
absent. The chest is often normal upon physical examina-
tion. Congestion and swelling of mucous membrane of
nasal cavity and posterior wall of pharynx are not
unusual, and even mucosal erosion and desquamation
may be found in some cases.
B. Moderate inhalation injury
Damage involves mainly the laryngeal, pharyngeal,
and tracheal regions. Besides the clinical manifesta-
tions as described in the mild inhalation injury, there
are hoarseness and signs of upper airway obstruction.
Irritable coughs with carbonaceous sputum are com-
mon, and sometimes sloughed mucous membranes
may be coughed up. Redness and edema of the upper
airway are prominent and airway swelling may prog-
ress and ultimately lead to occlusion of the airway. The
breathing sound becomes weak and rough. A high-
pitched crowing sound can be heard during inspiration
when the upper airway is obstructed. Wheezing and
dry rales are rare, and moist rales are usually absent.
Chest X-rays usually do not show any abnormalities.
Fibrobronchoscopy may reveal edema of the supraglot-
tic area and congestion, edema, hemorrhagic spots, or
even erosion and desquamation of the tracheal mucosa.
The tracheal carina is usually normal or slightly wid-
ened due to edema.
Table 11.1  Mortalities of burn patients with and without inhalation injury
TBSA (%)
~29
30–49
50–69
70~
Total
N
%
N
%
N
%
N
%
N
%
Without inhalation
injury
94.2
0.84
179
7.8
97
25.7
95
62
1,224
8.9
With inhalation
injury
30
9.09
46
10.6
50
50
53
90.5
181
43.1
11  Inhalation Injury

265
C. Severe inhalation injury
The injury involves the bronchi, bronchioles, and even
pulmonary alveoli. Besides the clinical manifestations as
described in the mild and moderate inhalation injury, there
are widespread bronchospasm, occlusion of small airways,
and pulmonary edema. Severe respiratory distress and
­progressive hypoxemia may develop rapidly. Blood-tinged
or blood frothy sputum and sloughed mucous membrane
are commonly seen. Restlessness, confusion, stupor, or
even coma usually indicates severe hypoxia. Wheezing
and dry or moist rales can be heard all over the chest.
Fibrobronchoscopic examination reveals congestion,
edema, hemorrhage, and erosion of mucous membrane of
bronchiole. Chest X-rays can reveal pulmonary edema as
early as 2hs after injury. Xenon-133 scintiphotographic
lung scan usually provides positive findings. Blood gas
analysis indicates hypoxemia [lowered PaO2 and elevated
D (A-a) O2 and Qs/Qt]. Many patients have hypocapnia at
the early stage and hypercapnia at later stage.
Table 11.2 summarizes the main clinical manifestations
of inhalation injury.
11.1.2 Secondary Inflammatory Reaction
Is an Important Pathogenetic Factor
of Inhalation Injury
Pathological changes of inhalation injury may be primary or
secondary. Primary injury is caused by heat and smoke, and
secondary injury is principally caused by secondary inflam-
mation. In the Burn Research Institute of the Third Military
Medical University, a dog model for smoke injury to one lung
was reproduced using a double-lumen catheter [3]. In the
injured lung, lymph flow increased rapidly and obvious patho-
morphologic changes such as pulmonary edema and perivas-
cular hemorrhage, compartment thickening, and infiltration of
a great number of inflammatory cells developed. Interestingly,
the protected lung showed a similar increase in lymph flow
and similar pathomorphologic changes despite being venti-
lated with oxygen and without smoke exposure. These find-
ings suggest that the lung not exposed to smoke may be
damaged by secondary inflammatory reaction (Table 11.3).
The pathological changes in serious inhalation injury
include: (a) tracheobronchitis caused by heat and smoke,
which may lead to infection, and (b) pulmonary edema,
which may develop half an hour after severe inhalation
injury. The pathogenesis of pulmonary edema is compli-
cated, which may involve primary damage and secondary
inflammation: (c) pulmonary atelectasis and collapse result-
ing from mucous hyperemia, edema, suppuration, and des-
quamation and airway obstruction with secretions and tissue
debris. Pulmonary surfactants reduce after inhalation injury,
which contributes to pulmonary collapse.
11.1.3 Pulmonary Edema After Inhalation
Injury
Pulmonary edema is the most important pathological change
of inhalation injury; however, its characteristics and patho-
genesis are not clear yet. Researchers from the Burn Research
Institute of the Third Military Medical University have dem-
onstrated that pulmonary edema in inhalation injury is prin-
cipally caused by increase of vascular permeability.
Table 11.2  Clinical manifestations of inhalation injury
Affected sites
Symptoms
Physical signs
X-ray findings
Blood-gas analysis
Mild
Nose, mouth, pharynx
Dry sensation and pain
of pharynx
Scorched body hair, redness
of nose and pharynx
−
−
Moderate
Larynx, trachea
Hoarseness, upper
airway obstruction
Airway obstruction,
wheezing, dry rales
−
±
Serious
Bronchi, alveoli
Hypoxia
Dry and moist rales
Pulmonary edema
Hypoxemia
Table 11.3  Biochemical parameters in dogs with smoke inhalation injury to the right lung
Right lung
Left lung
Normal group (n = 5)
Injured group (n = 6)
Normal group (n = 5)
Injured group (n = 6)
TLW (ml/g)
3.31 ± 0.35
6.33 ± 1.87**
3.35 ± 0.54
5.74 ± 1.82**
MPL (μ/g)
2.48 ± 0.55
6.53 ± 0.44**
2.62 ± 0.74
6.21 ± 0.56*
PLA2 (μ/g)
34.7 ± 6.02
122 ± 26.8**
30.6 ± 6.22
97.1 ± 12.4**
PAF (ng/g)
14.8 ± 1.02
48.2 ± 5.16**
13.2 ± 0.91
46.8 ± 5.64**
MDA (nmol/mg protein)
2.85 ± 0.31
5.33 ± 0.67**
3.01 ± 0.22
4.54 ± 0.43**
* p < 0.05, ** p < 0.01, vs the normal group
11.1  Advance in Research and Management of Inhalation Injury

266
11.1.3.1  Imbalance of Fluid Exchange in Lungs
After Inhalation Injury
Fluid exchange in the lung depends on vascular permeability,
hydrostatic pressure, and colloid osmotic pressure, connec-
tive tissues, pulmonary capillary, and elasticity and surface
tension of alveolar epithelium. Owing to existing negative
pressure gradient between pulmonary alveoli and interstitial
substances outside pulmonary alveoli, the fluid is drained
into the lymphatic vessels which exist between blood vessels
and lobules, and the fluid would enter pulmonary alveoli
only if the accumulation of fluid in interstitial substances
exceeds the drainage capability of lymphatic vessels, or if
the structural and/or functional integrity of pulmonary epi-
thelium is damaged.
The Amount of Water Increases in Lungs After
Inhalation Injury
According to the dry/wet weight method adopted by the
Burn Research Institute of the Third Military Medical
University, the water content of lung was 79.06 ± 0.76 % in
normal dogs and was 79.01 ± 0.3 % in normal rats. It was
found that the water content of lung was about 84  % at
12–24 h after inhalation injury. Determination of the water
content with Pierce method also indicates that increases in
the total lung water content (TLW) and the extravascular
lung water (EVLW) at 2 h after injury are signs of acute con-
gestion in the lungs. EVLW increases at 6 h after injury indi-
cate pulmonary edema (Table 11.4).
EVLW was monitored in goats with smoke inhalation
injury [4]. It was found that the water content increased obvi-
ously 1 h after injury and reached a peak at 2 h after injury
(5.97 ± 0.63 vs 18.32 ± 3.96  ml/kg). The water content
reduced at 4 h after injury, but did not restore to normal at 6 h
after injury (Fig. 11.1).
Plasma Colloid Osmotic Pressure Reduces After
Inhalation Injury
Vessel wall is a semipermeable membrane, which allows the
passage of water and micromolecules, such as glucose,
amino acids, and inorganic ions, and macromolecules such
as proteins cannot pass through vessel wall. Osmosis is
attributed to the molecules that cannot pass through vessel
wall freely. Researchers from the Third Military Medical
University determined the normal plasma colloid osmotic
pressure to be 2.51 ± 0.74 kPa in 15 goats, and they found
that the pressure reduced at 1 h after smoke inhalation injury
and kept decreasing later on (Table 11.5).
Alveolar Epithelial Cells and Pulmonary Capillary
Endothelial Cell Are Damaged After Inhalation Injury
The integrity of alveolar epithelial cells and pulmonary cap-
illary endothelial cells is crucial for maintaining the fluid
exchange balance in the lungs. Varying degrees of damages
of alveolar epithelial cells and endothelial cells were found
upon autopsy in inhalation injury victims. Similar changes
were also found in experimental animals with inhalation
injury, including sheep, goats, dogs, rabbits, and rats. The
following pathological changes were observed in sheep with
smoke inhalation injury [5].
Transmission electron microscopy (TEM): At 2 h after
injury, interstitial edema was found in the thick area of
­alveolar septa. Neutrophils and platelets aggregated in the
Table 11.4  Water contents of lung in animals with smoke inhalation injury
Before injury
Time after injury (h)
2
6
24
EVLW
2.29 ± 0.19
2.06 ± 0.64
5.19 ± 1.68
3.99 ± 1.55
TLW
3.87 ± 0.37
4.86 ± 0.18
5.74 ± 0.94
4.86 ± 1.02
RBLW
1.57 ± 0.19
2.32 ± 0.73
0.89 ± 0.45
0.86 ± 0.65
21
18
15
12
9
6
3
0
1
2
4
6
(h)
EVLW (ml/kg)
Q1 (ml/h)
Fig. 11.1  EVLW and QL after smoke inhalation injury
Table 11.5  Plasma colloid osmotic pressure (kPa) in goats with smoke inhalation injury
Time after injury (h)
0
1
2
4
6
2.51 ± 0.74
1.76 ± 0.41
1.62 ± 0.60
1.46 ± 0.56
1.73 ± 0.09
11  Inhalation Injury

267
capillary. Endothelial cells contained an increased number of
micro-pinocytotic vesicles. Cytoplasmic swelling and large
bubbles were observed. Cell surface microvilli degenerated
and decreased, and occasionally bubbles were found. No
obvious change was found in alveolar epithelial junctions.
The thin alveolar septum was thickened.
These pathologic changes were aggravated at 6  h after
injury. Capillary endothelial junction was impaired, resulting
in the formation of intercellular gaps (Fig. 11.2). Emptying
of type II alveolar cells was activated. Type I alveolar cells
became swollen, with significant vacuolization. Thin alveo-
lar septa were thickened significantly. Basement membrane
thickening was also significant.
At 24 h after injury, the following were observed: capil-
lary endothelial cell swelling, cytoplasmic prominence, for-
mation of surface microvilli, occasionally, cell damage, and
interruption of continuity (Fig. 11.3).
Type I alveolar cells were found swollen, vacuolated, and
even necrotic. In type II alveolar cells, endoplasmic reticu-
lum expansion, lamellar body vacuolation, or emptying were
observed. Some type II alveolar cells were hyperplastic and
began to repair or replace the necrotic type I alveolar cells.
As a result of significant basement membrane thickening,
type I alveolar cells were highly swollen.
By freezing itching replica electron microscopy, in sheep,
the main alterations in intercellular junction apparatus
between pulmonary capillary endothelial cells after smoke
exposure were as follows: disruption of strands, loss of gran-
ules, and destruction of the whole junction apparatus so as to
direct communication of both sides. In addition, there were
irregular strands and appearance of free ends. In intercellular
junction apparatus between alveolar epithelial cells, there
may be disruption of strands, irregular strands, and appear-
ance of free ends.
Lymph Flow and Protein Contents Increase
in the Lung After Inhalation Injury
Chronic lung lymph fistulas were prepared in sheep before
injury [6]. The breath, heart rate, body temperature, urine,
feces, and lungs were found normal 5–7  days after the
operation. Pulmonary lymph was yellow and lymph flow
was stable. The animal was fasted for 12 h. Under intrave-
nous anesthesia with ketamine, a Swan-Ganz catheter and
central venous catheter were inserted through the right jug-
ular vein, and another catheter was placed into the aorta via
the right carotid artery. The animal was subject to smoke
inhalation injury 24 h later. Lung lymph flow increased 1 h
after injury, reached the peak at 4–6 h, and did not decline
even at 24 h after injury. The lung lymph/plasma protein
ratio (L/P TP) increased significantly 1 h after injury, began
to decline at 6 h, and was still higher than normal at 24 h
after injury. The lung lymph/plasma albumin ratio (L/PA)
increased significantly after injury, and the lung lymph/
plasma globulin ratio (L/PG) increased within the 4 h after
injury but changed insignificantly later on. The lung lymph/
plasma β-globulin ratio (L/P β) decreased after injury
(Table 11.6).
Similar results were obtained in goat models for inhala-
tion injury (Table 11.7). Lung lymph flow increased mark-
edly after injury, which indicated that pulmonary interstitial
water increased quickly after inhalation injury. Albumin and
globulin increased, indicating increased capillary permeabil-
ity. Pulmonary edema was aggravated by increased capillary
permeability after injury.
Pulmonary Vascular Permeability Increases
After Inhalation Injury
In rats with smoke inhalation injury, pulmonary vascular per-
meability increased as shown by intravenous infusion of
Fig. 11.2  Dissociation of pulmonary capillary endothelial cells (End)
after smoke inhalation injury (between the two arrows, TEM × 41880)
Fig. 11.3  Dissociation of pulmonary capillary endothelial cells (End)
and formation of cracks (a) after smoke inhalation injury (TEM × 44690)
11.1  Advance in Research and Management of Inhalation Injury

268
Evans blue (10  mg/kg) or 131I-bovine serum albumin (131I
BSA) (0.1 ml) (Tables 11.7, 11.8, and 11.9).
Pulmonary Hypertension Contributes to Pulmonary
Edema After Inhalation Injury
In animals (dogs, sheep) with simple inhalation injury or
with 30 % total body surface burn combined with inhalation
injury, the heart rate decreased immediately after injury and
then increased gradually 30  min later. Pulmonary artery
pressure (PAP), pulmonary artery wedge pressure (PAWP),
and pulmonary capillary pressure (PmV) increased signifi-
cantly 10–30 min after injury, and then decreased, and were
near to the pre-injury levels 1 h later. Pulmonary vascular
resistance (PVP) increased for more than 6 h after injury.
Cardiac output (CO), cardiac index (CI), left ventricular
work (LVW), and femoral artery pressure (FAP) decreased
after injury (Table 11.10). Pathological study indicated myo-
cardial edema, degeneration, and muscle fiber breakage after
inhalation injury [7].
Similar results were obtained from goats with smoke
inhalation injury (Table 11.11).
These data suggest that extravascular water increases
­rapidly in the lungs after severe inhalation injury. Lung
lymph flow increases as the lymph protein content increases.
Clinical symptoms and X-ray examination also indicate
­pulmonary edema. Pathological examination reveals endo-
thelial cell damage and intercellular gap widening, which
suggests that increased vascular permeability contributes to
inhalation injury. In addition, transient elevation of pulmo-
nary arterial pressure, pulmonary artery wedge pressure, and
PmV plays supplementary roles in pulmonary edema at the
early after injury stage (2–6 h).
The Liquid Transport Barrier of Alveolar
Epithelium Plays a Role in Pulmonary
Edema During Inhalation Injury
In inhalation injury, the alveolar epithelial cells are injured to
certain extent. Thus, the liquid transport of alveolar epithe-
lium may be affected. The liquid in pulmonary alveoli is
transported in two ways: (1) passive transport, which depends
on the pressure difference between pulmonary alveoli and
capillary vessels and the osmotic gradient between liquid
and blood plasma in pulmonary alveoli; (2) active transport,
which depends on sodium channels (ENaCs) and water
channels (Aquaporin AQP) on alveolar epithelial cells. Na+
enters the cell through EnaCs, and then Na+ and K+ stimulate
ATPase (NKA) to pump Na+ into the interstitium. As Na+ has
been pumped out, there is an electrochemical gradient inside
the cell, thus facilitating the passage of Na+ across the cell
membrane. During the process of Na+ transport, Cl− and
water are absorbed. In addition, Aquaporin (AQP) on alveo-
lar epithelial cells accelerates the transport of water. Active
transport plays a major role in draining the alveolar fluid.
After smoke inhalation injury, both type I and type II
alveolar epithelial cells are injured. Experiments in rats with
smoke inhalation injury indicate obvious dysfunction of
alveolar liquid transport [8, 9].
Table 11.6  Lung fluid exchange parameters after inhalation injury in sheep (n = 5)
Before injury
After injury (h)
1
2
4
6
12
QL (ml/h)
5.4 ± 2.8
15.4 ± 140.4*
13.2 ± 4.2*
17.2 ± 8.2*
25.9 ± 10.4*
28.3 ± 14.8*
L/P TP
0.61 ± 0.07
0.61 ± 0.09*
0.65 ± 0.10
0.66 ± 0.12
0.66 ± 0.12
0.62 ± 0.08
CL (ml/h)
3.3 ± 1.5
9.2 ± 4.8
8.6 ± 4.4*
10.8 ± 5.4*
16.8 ± 9.3*
17.5 ± 9.4*
PS (ml/h)
8.5 ± 2.4
23.8 ± 14.1*
24.5 ± 15.1*
32.4 ± 24.2*
49.4 ± 32.6*
46.2 ± 33.3*
COPL (kPa)
1.2 ± 0.3
1.2 ± 0.3
1.0 ± 0.4
0.9 ± 0.5
0.8 ± 0.4
0.9 ± 0.2
COPP (kPa)
1.7 ± 0.4
1.7 ± 0.4
1.6 ± 0.3
1.6 ± 0.3
1.5 ± 0.3
1.4 ± 0.2
* p < 0.05, vs before injury
Table 11.7  Lung fluid exchange parameters after inhalation injury in goats
Before injury
After injury (h)
1
2
4
6
QL (ml/h)
3.97 ± 2.60
11.80 ± 10.10
16.88 ± 5.10
16.74 ± 10.73
12.56 ± 6.67
CL (ml/h)
2.18 ± 2.14
7.95 ± 5.11
12.83 ± 7.00
11.11 ± 9.85
8.17 ± 7.45
L/P TP
0.42 ± 0.24
0.81 ± 0.28
0.94 ± 0.26
0.71 ± 0.33
0.67 ± 0.34
L/P AP
0.37 ± 0.27
0.79 ± 0.40
1.07 ± 0.40
0.93 ± 0.67
0.59 ± 0.33
Leakage pr (mg/h)
63.26 ± 19.95
220.49 ± 43.38
654.78 ± 204.78
307.62 ± 135.90
172.60 ± 66.85
Table 11.8  Evans blue content in tissues (fluorescence inten-
sity/300 mg tissue) at 24 h after injury
Group
Trachea
Lung
Control (n = 6)
26.0 + 4.72
26.08 + 3.78
Injury group (n = 6)
96.40 + 7.04
94.12 + 9.89
11  Inhalation Injury

269
A. After inhalation injury, the alveolar liquid clearance rate
(ALCR) is reduced and the pulmonary epithelial perme-
ability (PEP) increases
ALCR per unit time can be determined with Rezaiguia
method according to the change in the protein concentration
of alveolar liquid.

Vi= Vd
5 Tpi Vf = Vf
Tpi
Fr / Tpf
×
(
)
×
×
(
)


ALCR =
1 h
= Vi
Fwi
Vf
Fwf / Vi Fwi
1
m ⋅
(
)
×
×
(
)
×
(
)
−
−
(Vi and Vf refer to the initial and final total volume of alveo-
lar liquid, respectively; Vd represents 5 % of the infused pro-
tein; Fwi and Fwf indicate the initial and final water contents
in pulmonary alveoli; Tpi and Tpf refer to the initial and final
protein concentration in pulmonary alveoli.)
After smoke inhalation injury, ALCR reduces remarkably
until the end of observation (24 h) (Table 11.12).
Alveolar epithelium permeability (AEP) was also deter-
mined with Folkesson method. AEP (%) = (cpm of
125I-albumin infused through trachea  – cpm of irrigating
solution) ÷ total cpm × 100 %. After inhalation injury, AEP
increased remarkably (Table 11.13).
B. The activity of ENaCs and NKA declines on type II alve-
olar epithelial cells after smoke inhalation injury
ENaCs and NKA exist only on type II alveolar epithelial
cells. Patch clamp technique was employed to analyze the
single-channel current flow of ENaCs. When the patch clamp
voltage changes between −80 and +40, a cell-attached
method was adopted to record the inside single-channel cur-
rent flow. The channel openings are mainly the single dwell
opening and the single burst opening. The electric conduc-
tance is 4 + 0.2  Ps, and the electricity-voltage curve (I–V
curve) shows the reversal potential to be −39 mV. The activ-
ity of ENaCs can be expressed with the probability of chan-
nel opening (Po), the average opening time (t1), and the
average closing time (t2). After 6  h of smoke inhalation
injury, the average opening time (t1) of ENaCs reduces obvi-
ously, the average closing time (t2) prolongs obviously, and
Table 11.9  131I BSA content in lung tissues after inhalation injury in rats (fluorescence scintillation count/mm/g)
Control
Injury group (time after injury) (h)
1
3
6
12
24
n = 48
48
48
44
48
48
60.2 + 11.4
126.3 + 17.6
119.3 + 14.2
164.1 + 51.7
148.1 + 29.4
106.2 + 18.1
Table 11.10  Hemodynamic changes after inhalation injury in sheep (n = 5)
Before injury
After injury
1/6
1/2
1
2
4
6
12
Cardiac output
(L/min)
5.5 ± 1.6
5.7 ± 2.4
5.5 ± 2.7
5.8 ± 3.1
5.8 ± 3.2
6.2 ± 2.5
6.1 ± 1.8
5.9 ± 3.4
PAP (kPa)
14 ± 0.7
15.1 ± 1.3
14.3 ± 1.3
14.5 ± 1.2
13.5 ± 1.5
12.8 ± 1.7
12.3 ± 1.3
13.3 ± 1.6
PVP (kPa)
2.4 ± 0.4
2.5 ± 0.5
2.7 ± 0.8
2.9 ± 0.8
3.1 ± 0.5
3.5 ± 0.5
3.1 ± 0.8
3.6 ± 0.5*
PAWP (kPa)
0.8 ± 0.3
1.7 ± 0.9
1.3 ± 0.5
1.7 ± 1.2
2.0 ± 1.2
2.3 ± 1.3
1.9 ± 0.5*
2.5 ± 1.3*
PmV (kPa)
1.5 ± 0.3
2.1 ± 0.7
2.0 ± 0.9
2.3 ± 0.9
2.1 ± 0.8
2.7 ± 0.9
2.4 ± 0.4
2.9 ± 0.9*
Table 11.11  Pulmonary vascular pressure after inhalation injury in goats (kPa, n = 15)
Parameter
Before injury
After injury
5 min
30 min
1 h
2 h
4 h
6 h
PAP
1.64 ± 0.37
2.24 ± 1.09
2.32 ± 0.63
1.80 ± 0.43
1.77 ± 0.57
1.89 ± 0.52
1.91 ± 0.65
PCWP
0.55 ± 0.2
1.12 ± 0.52
0.64 ± 0.55
0.68 ± 0.47
0.60 ± 0.19
0.60 ± 0.13
PmV
1.00 ± 0.16
1.56 ± 0.52
1.16 ± 0.52
1.12 ± 0.20
0.99 ± 0.33
1.13 ± 0.37
Table 11.12  ALCR reduced after smoke inhalation injury in rats
(μl · h−1) (n = 8, x
s
±
)
Control
Injury group (time after injury, h)
2
6
12
24
338 ± 29
323 ± 21
267 ± 21**
226 ± 11
175 ± 19**
** p < 0.01, vs control
Table 11.13  AEP increased after smoke inhalation injury in rats (%)
(n = 8, x
s
±
)
Injury group (time after injury, h)
Control
2
6
12
24
6.7 ± 0.7
16.8 ± 1.1**
28.4 ± 1.4**
44.5 ± 1.6**
57.6 ± 2.2**
** p < 0.01, vs control
11.1  Advance in Research and Management of Inhalation Injury

270
the probability of channel opening (P) drops remarkably.
These changes continue until the end of observation (24 h)
(Table 11.14). This experiment showed an obvious decline in
the activity of ENaCs.
Meanwhile, the hydrolyzing activity of Na+-K+-ATPase
on type II alveolar epithelial cells declines obviously
(Table 11.15).
C. After smoke inhalation injury, the expression of ENaC
mRNA, NKA mRNA, and AQP mRNA is reduced in
alveolar epithelial cells
At 12 and 24 h after injury, the expression of α-ENaC
mRNA was reduced obviously in type II alveolar epithelial
cells. The ratio of α1-ENaC mRNA to β-actin mRNA
reduced by 26 and 41  %, respectively. The expression of
α1-NAK mRNA reduced and the ratio of α-NAK to β-actin
reduced by 35 % at 12 h after injury. The expression of AQP1
mRNA reduced (Table 11.16).
D. Inhibiting or stimulating liquid transport across alveolar
epithelium reduces pulmonary edema after injury
With the use of amiloride, a specific blocker of ENaCs, or
ouabain, a specific inhibitor of NKA, it was found that ALCR
reduced by 45.8  % and the extravascular water in lung
increased by 43.8 % after smoke inhalation injury, suggest-
ing an obvious reduction in ALCR and a remarkable increase
in EVLW. In addition, the changes became more apparent
after blocking ENaC and NKA (Table 11.17). These findings
demonstrate that the alveolar epithelial barrier against water
does relate to pulmonary edema after inhalation injury.
Cytokines and Inflammatory Cells Contribute
to Secondary Impairment Following Inhalation Injury
Heat and smoke can directly injure the airways and lung
parenchyma. Moreover, secondary inflammatory responses
play a major role in subsequent injury. Secondary responses
constitute cascade reactions. The pathogenesis of secondary
responses is complicated, which involves many cytokines,
inflammatory mediators, and activating factors. Researchers
from the Third Military Medical University and other institu-
tions have investigated the roles of dozens of these factors in
inhalation injury [10, 11].
A. Complements and histamine in inhalation injury
Complements are activated immediately after inhalation
injury. The total hemolytic activity of left heart blood and the
hemolytic activity of the alternative pathway reduced imme-
diately after steam inhalation injures in dogs, and they reached
the lowest levels in 2 h after injury. Activated complements
release C3a and C5a. The contents of anaphylactic toxins
(ATs) in left heart blood increased obviously in 1–2 h after
steam inhalation injury in dogs [12]. The contents reduced in
4 h after injury but were still higher than those in the control
group (Table 11.18). Anaphylactic toxins (ATs), mainly C3a
and C5a, increase the permeability of blood vessels, contract
Table 11.14  Changes of dynamics properties of ENaCs on type II alveolar epithelial cells after inhalation injury in rats (n = 4, x
s
±
)
Group
Dwell opening
Burst opening
P0
t1 (ms)
t2 (ms)
t1 (ms)
t2 (ms)
Control
1.46 ± 0.08
0.82 ± 0.06
0.92 ± 0.09
0.47 ± 0.05
0.32 ± 0.03
6 h after injury
1.07 ± 0.09**
1.12 ± 0.05**
0.83 ± 0.08
0.65 ± 0.05**
0.24 ± 0.02**
12 h after injury
0.86 ± 0.09**
1.21 ± 0.06**
0.69 ± 0.06**
0.87 ± 0.04**
0.19 ± 0.02**
24 h after injury
0.53 ± 0.08**
1.34 ± 0.09**
0.46 ± 0.05**
0.99 ± 0.08**
0.14 ± 0.02**
** p < 0.01, vs control
Table 11.15  Changes of hydrolyzing activity of Na+-K+-ATPase on
type II alveolar epithelial cells after inhalation injury in rats (n = 5,
x
s
±
)
Control
Injury group (time after injury, h)
6
12
24
30.4 ± 1.2
22.2 ± 2.9**
20.3 ± 1.7**
11.6 ± 1.9**
** p < 0.01 vs control
Table 11.16  Changes of relative values of α-ENaC, α1-NKA and
AQP1 mRNA expressions in type II alveolar epithelial cells after inha-
lation injury in rats (%, n = 5, x
s
±
)
Group
α1-NKA
α-ENaC
AQPI
Control
0.79 ± 0.05
0.54 ± 0.08
0.90 ± 0.05
12 h after injury
0.51 ± 0.02**
0.40 ± 0.02**
0.53 ± 0.03**
24 h after injury
0.54 ± 0.04**
0.32 ± 0.02**
0.53 ± 0.05**
** p < 0.01 vs control
Table 11.17  Effect of amiloride (A) and ouabain (B) on alveolar liq-
uid clearance rate (ALCR), total lung water (TLW), and extravascular
lung water (EVLW) ( x
s
±
)
Group n
ALCR (μl/h)
TLW (ml/g)
EVLW (ml/g)
C
7
331.5 ± 23.4
3.14 ± 0.15
2.26 ± 0.12
SI
7
179.8 ± 15.2**
3.76 ± 0.13**
4.02 ± 0.12**
A
7
156.6 ± 13.2**#
3.95 ± 0.12**#
4.17 ± 0.13**#
O
7
157.7 ± 12.4**#
3.94 ± 0.16**#
4.20 ± 0.14**#
AO
7
123.4 ± 14.8**##
4.23 ± 0.14**##
4.49 ± 0.13**##
T
7
283.3 ± 21.6**##
3.30 ± 0.13*##
2.66 ± 0.15**##
TA
7
214.6 ± 22.1**##△△
3.51 ± 0.14**##△3.09 ± 0.10**##△△
TO
7
211.1 ± 23.5**##△△
3.49 ± 0.14**##△3.08 ± 0.13**##△△
*p < 0.05; ** p < 0.01 vs C group; #p < 0.05; ##p < 0.01 vs SI group; △
p < 0.05; △△ p < 0.01 vs T group
11  Inhalation Injury

271
smooth muscles, and increase muciparous glands. In addi-
tion, they induce mast cell degranulation and release of hista-
mine. The content of histamine increased drastically in left
heart blood but remained unchanged in right heart blood 4 h
after injury [13]. The content of histamine was 5.72 ± 0.84 μg/g
in the lung 24 h after injury, which was obviously lower than
the normal content of 9.36 ± 1.26 μg/g (p < 0.05) (Tables 11.18
and 11.19). Histomorphological studies revealed degranula-
tion of mast cells. Thus, it is concluded that anaphylactic tox-
ins induce mast cell degranulation and release of histamine to
the lung blood, thus increasing the permeability of capillary
in the lung.
B. Arachidonic acid metabolites and platelet-activating fac-
tor in inhalation injury
Pulmonary capillary endothelial cells, granulocytes, and
platelets are important sites for synthesis of arachidonic acid.
In rats with smoke inhalation injury, lung tissue PLA2-1 mRNA
expression decreases, while PLA2-II mRNA and 85KD PLA2
protein expressions increase in 3 h after inhalation injury. PLA2
activity increases in lung tissue homogenates and on lung cell
membrane [14, 15]. Inhalation injury will activate PLA2 and
induce the production of arachidonic acid metabolites. In goats
with chronic lung lymph fistulas, the contents of TXA2 and
6-ketone-PGFα
increased
obviously
in
lung
tissues
(Table 11.20). TXB2 increased 5 min after inhalation injury.
6-ketone-PGFα increased 1 h after injury reached a peak in 2 h
and remained at high levels in 6 h after inhalation injury [16].
Leukotriene, a metabolite of arachidonic acid, contributes
to secondary inflammation after inhalation injury [17].
Granulocytes and pulmonary alveolar macrophages were
found to synthesize and release LTB2 in rabbits 2  h after
smoke inhalation, which lasted 72 h (Table 11.21).
Table 11.18  Changes in anaphylactic toxins (U/ml) in left heart blood after injury
Group
Normal value
Time after injury (min)
5
30
60
120
240
Normal
36.50 ± 26.12
33.60 ± 24.15
32.10 ± 17.66
41.30 ± 25.14
44.50 ± 25.41
69.20 ± 29.82
Steam inhalation
32.50 ± 23.12
34.86 ± 32.06
33.93 ± 32.64
61.34 ± 44.13*
61.14 ± 24.69*
75.75 ± 38.14
*p < 0.05, vs the normal group
Table 11.19  Changes in the content of histamine after smoke inhalation in dogs (ng/ml)
Group
Before injury
Time after injury (h)
0.5
1
2
4
6
Control (n = 7)
Arterial
Whole blood
plasma
21.5 ± 4.9
17.8 ± 4.1
18.7 ± 6.1
15.2 ± 4.2
18.1 ± 3.3
20.7 ± 5.4
18.1 ± 10.0
15.6 ± 5.4
14.8 ± 8.4
12.4 ± 3.4
9.7 ± 4.0
13.1 ± 4.7
Venous
Whole blood
plasma
19.5 ± 6.6
18.2 ± 6.2
21.3 ± 9.0
17.2 ± 7.1
16.8 ± 6.7
17.6 ± 6.3
14.4 ± 7.3
13.9 ± 6.1
11.3 ± 3.7
13.5 ± 7.5
10.5 ± 5.4
11.5 ± 5.1
Injury (n = 7)
Arterial
Whole blood
plasma
18.5 ± 7.0
22.1 ± 8.1
26.4 ± 8.3
26.1 ± 5.7
20.6 ± 6.5
20.0 ± 13.8
14.3 ± 7.1
13.9 ± 5.0
14.1 ± 7.5
12.8 ± 4.8
13.2 ± 7.2
10.3 ± 8.1
Venous
Whole blood
plasma
20.3 ± 8.2
24.8 ± 4.8
21.4 ± 8.7
23.6 ± 7.8
21.5 ± 5.3
21.3 ± 6.9
14.7 ± 6.6
15.9 ± 6.0
16.4 ± 5.8
13.7 ± 6.1
15.7 ± 6.3
15.4 ± 6.3
Table 11.20  TXB2/6-ketone PGF1α ratios
Before inhalation
injury
Time after inhalation injury
5 min
30 min
1 h
2 h
4 h
6 h
Artery
0.24 ± 0.03
0.43 ± 0.08*
0.62 ± 0.13**
0.78 ± 0.15*
0.80 ± 0.09*
0.34 ± 0.07
0.27 ± 0.03
Vein
0.28 ± 0.03
0.40 ± 0.05*
0.48 ± 0.10*
0.53 ± 0.08*
0.65 ± 0.09*
0.35 ± 0.05
0.28 ± 0.06
Lung lymph
0.29 ± 0.01
–
0.44 ± 0.08*
0.50 ± 0.08*
0.70 ± 0.20*
0.39 ± 0.09
0.42 ± 0.11
Lung tissue
0.29 ± 0.03
–
–
1.10 ± 0.59*
1.53 ± 0.90*
1.18 ± 0.13*
0.38 ± 0.10
*p < 0.05, **p < 0.01, vs before inhalation injury
Table 11.21  Release of leukotriene by granulocytes and pulmonary alveolar macrophages in rabbits with smoke inhalation injury
Time after injury (h)
0
2
6
24
48
72
Granulocytes
32.2 ± 4.5
57.1 ± 7.1
76.7 ± 14.1
62.6 ± 11.6
50.9 ± 8.6
43.3 ± 9.5
Macrophages
66.67 ± 16.24
107.27 ± 26.73
141.57 ± 50.13
74.53 ± 15.07
85.77 ± 42.27
11.1  Advance in Research and Management of Inhalation Injury

272
Platelet-activating factor (PAF) is an important lipid
mediator synthesized and released by inflammatory cells
under the action of phospholipase A2. Increasing amounts of
PAF was synthesized and released by granulocytes and pul-
monary alveolar macrophages in rabbits with smoke inhala-
tion injury, suggesting that PAF may participate in lung
injury (Table 11.22).
C. Pulmonary alveolar macrophages and granulocytes in
smoke inhalation injury
Pulmonary alveoli can be affected directly by smoke or
indirectly by obstruction with casts or by systemic release of
cytokines. A great number of particulates are deposited in the
tracheobronchial tree proximal to the alveolus, and chemical-
laden particles are deposited both in the alveolus and airways.
Pulmonary macrophages are activated by these particles, and
they scavenge foreign material through phagocytosis and sub-
sequent release of lysozymes and superoxide. Activated mac-
rophages then release cytokines, such as oxygen-­derived free
radicals, proteinases, polypeptide hormones, and lipids.
Inflammatory signals are thus introduced into the alveolus
and subsequently the pulmonary circulation.
Consistent with the inflammatory milieu of the alveolus,
there is a rapid increase in the number of neutrophils in the
capillaries. These neutrophils are primed and activated, and
they express leucocytic selectins and begin rolling, adher-
ence, and migration out of the capillary into the interstitium
or alveolus. These neutrophils further exacerbate the inflam-
matory process [18, 19].
In goats with chronic lung lymph fistulas, β-glycuronidase
increased obviously in lung lymph fluid, was two to six
times  the baseline value 2  h after smoke inhalation, and
reached the peak value in 4 h. This change is consistent with
that of the L/P ratio [20].
It was also found that activated granulocytes and pulmonary
alveolar macrophages released plenty of oxygen-­derived free
radicals, as were measured by the cytochrome C reduction
method, in rabbits with smoke inhalation injury [20] (Table 11.23).
Activated granulocytes release lysomal enzymes such as
elastase, trypsin, alkaline phosphatase, and cathepsin in
addition to glucosiduronate [21] and oxyradicals after inha-
lation injury. In rabbits suffering from smoke inhalation
injury, the elastase activity in PMNs and AMs decreases
30 min after injury and until the end of observation (24 h
after injury) (Table 11.24).
Elastase degrades elastin and collagen, and elastase
released to lung tissues would damage pulmonary intersti-
tium, alveolar wall, and vascular endothelial cell. Main
in vivo inhibitors of elastase are α1-trypsinase (α1-P1) and
α2 macroglobulin (α1-M). Antiprotease activity decreases in
rabbits suffering from smoke inhalation injury. Serum ­trypsin
inhibitory capacity (STIC) decreased quickly, and trypsin
inhibiting capacity (BTIC) in pulmonary alveolar liquid
increased obviously (Table 11.25).
11.1.3.2  Pulmonary Surfactant in Inhalation
Injury
Pulmonary surfactant (PS) is a surface-active lipoprotein
formed by type II alveolar cells, and it reduces surface
­tension, maintains the structure of alveoli, and prevents
Table 11.22  PAF synthesis and release by granulocytes in rabbits
with smoke inhalation injury (n = 6)
Time after injury (h)
0
2
6
24
16.7 ± 7.3
40.5 ± 5.8
41.9 ± 7.5
30.1 ± 7.2
Table 11.23  O−
2 release by granulocytes and pulmonary alveolar macrophages in rabbits with smoke inhalation injury (nM/10 [6] cells/15 min)
Time after injury
0
2
6
24
48
72
Granulocytes
40.81 ± 0.42
124.57 ± 30.60**
103.98 ± 25.64**
121.79 ± 40.86**
53.50 ± 15.56
38.40 ± 9.59
Pulmonary alveolar
macrophages
77.21 ± 34.20
125.57 ± 27.25*
161.71 ± 64.75
113.62 ± 30.07
59.14 ± 27.67
*p < 0.05, **p < 0.01 vs the control group
Table 11.24  Elastase (Ela) activity change
No.
PMN-Ela activity (μU/106)
AM-Ela activity (μU/106)
BALF-Ela activity (μU/mg)
Normal control
8
119.519 ± 47.343
85.973 ± 17.822
314.966 ± 66.535
Inhalation injury
30 min after injury
10
70.692 ± 28.925*
62.298 ± 17.261*
593.757 ± 206.655**
2 h
10
77.980 ± 15.489*
65.197 ± 16.771*
746.458 ± 262.220**
6 h
10
89.807 ± 31.619*
80.413 ± 24.971*
941.447 ± 328.844**
12 h
9
77.968 ± 20.470*
58.976 ± 22.882*
881.673 ± 164.453**
24 h
9
95.185 ± 22.476
71.176 ± 14.435
639.411 ± 21.734
*p < 0.05, **p < 0.01 vs the normal control
11  Inhalation Injury

273
­pulmonary collapse. In addition, PS is involved in preventing
pulmonary edema, eliminating oxyradicals, and protecting
the host respiratory system. PS consists of 85–90 % lipids
and 2 % proteins. Phospholipids (PL) account for 80–90 %
of lipids, and phosphatidyl choline (PC) accounts for 75 % of
PLs. Dipalmitoyl phosphatidylcholine (DPPC), approxi-
mately 50 % of PC, is the active ingredient for surface ten-
sion reduction. Plasma-derived proteins such as albumin and
IgG account for two thirds of the protein components, and
the other one third is surfactant-associated proteins (SP).
About 50 % of SPs are hydrophilic proteins, i.e., SP-A and
SP-D, and 1–2 % of SPs are hydrophobic proteins, i.e., SP-B
and SP-C. PS is formed in the endoplasmic reticulum of type
II alveolar cells, which is secreted into the alveolar space via
Golgi body and stored in the lamellar body (LB). There are
four morphological forms in the alveolar space, i.e., LB,
tubular myelin, monomolecular layer, and vesicles.
The secretion and activity of surfactant are significantly
reduced after inhalation injury, which is a major factor for
atelectasis.
Alteration of Pulmonary Surface Tension After
Inhalation Injury
Sixty-five to seventy-five percent of pulmonary elastic recoil
is attributable to surface tension. Surface tension is a major
counteraction against alveolar dilation. Without sufficient
tension, a moderate pressure increase could result in drastic
dilation, while excessive tension may provoke alveolar
collapse.
Direct measurement of surface tension is not possible yet,
and the content of PS in bronchoalveolar lavage fluid (BALF)
and in pulmonary tissue homogenates is usually determined.
The surface tension is estimated by the Wilhelmy surface
membrane balance method modified by researchers from the
Third Military Medical University based on the rationale as
follows: the density of surfactant increases with compression
of the surface area of fluid and decreases with expansion of
the surface area. The alteration of the surface tension is
transferred to the sensor via a metal film in the fluid, which
is recorded as a change in the electric current. Such ­membrane
balance produces three major indexes of surface tension:
(1) minimal surface tension (Tmin, mN/m), (2) maximum
surface tension (Tmax, mN/m), and (3) hysteresis loop area
(Ha, mN. min).
Another two indexes can be calculated according to the
following formulas:
Stabilityindex,SI = 2
Tmax
Tmin / Tmax +Tmin
×(
) (
)
−

The higher SI is, the higher stability would be.
Recovery index, RI = (△T ′ + Tmin)/Tmin, △T′ speci-
fies the tension when the surface area is compressed to 25 %.
RI is an index reflecting the dilation of monomolecular layer
from Tmin to Tmax. A higher score is preferred.
Surface tension of BALF and pulmonary tissue homoge-
nates in rabbits and dogs with steam or smoke inhalation
injury was tested using a micro surface tension device
(Figs. 11.4 and 11.5). The area to tension curve is continu-
ously recorded, which reflects the alteration of surface ten-
sion during compression and dilation.
The area of hysteresis loop of BALF and pulmonary tis-
sue homogenates in rabbits with steam inhalation injury
decreased obviously 6 h after injury. Although the changes
in Tmin and Tmax were not significant, the surface tension
on hysteresis loop with 70  % area compressed increased
Table 11.25  TIC changes in blood serum and BALF
No.
STIC (mg/ml)
(mg/g)
BTIC (mg/g)
Normal control
8
1.136 ± 0.114
17.705 ± 1.998
9.006 ± 1.827
Inhalation injury
30 min after injury
10
1.067 ± 0.167
14.344 ± 2.494*8
18.989 ± 2.474**
2 h
10
1.007 ± 0.132*
14.877 ± 1.514**
31.244 ± 4.116**
6 h
10
1.000 ± 0.087*
14.189 ± 1.514**
18.371 ± 3.363**
12 h
9
1.035 ± 0.066*
15.435 ± 2.168*
16.464 ± 3.794**
24 h
9
1.090 ± 0.039
18.273 ± 3.349
16.325 ± 3.958**
*p < 0.05
**p < 0.01 vs the normal control
Expansion
Compression
dyn/cm
40
20
10
20
30
50
Surface area (%)
70
100
Fig. 11.4  Area to surface tension curve of BALF in the control group
11.1  Advance in Research and Management of Inhalation Injury

274
­significantly [22] (Table 11.26). In dogs with smoke inhala-
tion injury, Tmin of pulmonary tissue homogenates
increased obviously with mild changes of Tmax.
Changes of the Component of Pulmonary Surfactant
After Inhalation Injury
After smoke inhalation injury in rats, the amount of total
phospholipids (TPL) in BALF increased rapidly, and that in
pulmonary tissue decreased gradually (Table  11.27). PC
reduced relatively, and phosphatidyl ethanolamine (PE) and
phosphatidyl serine (Phs) increased absolutely and relatively.
The steady state of Phs and PE and the gradual decrease of
PC (Table 11.28) indicate PC consumption after inhalation
injury and increases of the other components [23].
The level of SP-A in homogenates increased gradually in
2 h after smoke inhalation injury in rats, so did its percentage
Expansion
Compression
dyn/cm
40
50
60
20
10
20
30
50
Surface area (%)
70
100
Fig. 11.5  Area to surface tension curve of BALF at 6 h after smoke
inhalation
Table 11.26  Area of hysteresis loop and surface tension in rabbits with steam inhalation injury (n = 10)
Area of hysteresis loop (dyn·min)
Surface tension upon 70 % compression (dyn·min)
Homogenates
Lavage fluid
Homogenate
Lavage fluid
Control
12.5 ± 3.3
21.9 ± 2.0
21.3 ± 3.29
4.32 ± 1.74
2 h after injury
7.9 ± 1.3*
21.2 ± 3.5
24.30 ± 2.86*
6.22 ± 6.15
6 h after injury
7.0 ± 1.5*
12.7 ± 0.02*
25.33 ± 2.97*
17.82 ± 7.01**
18 h after injury
5.8 ± 1.5*
12.1 ± 2.3*
29.85 ± 3.51*
19.37 ± 5.72**
*p < 0.01, vs control group
Table 11.27  PLs in BALF after injury ( x
s
±
)
Group
PI
Phs
PE
PC
(mg/g dry lung)
(%TPL)
(mg/g dry lung) (%TPL)
(mg/g dry lung)
(%TPL)
(mg/g dry
lung)
(%TPL)
Control
0.48 ± 0.09
4.75 ± 1.07
0.32 ± 0.16
3.66 ± 1.40
0.64 ± 0.26
6.53 ± 1.78
6.72 ± 1.29
77.32 ± 4.13
2 h after
injury
0.63 ± 0.11
5.39 ± 1.42
0.56 ± 0.20
4.88 ± 1.53
1.03 ± 0.29
8.65 ± 1.83
8.18 ± 1.56
68.53 ± 4.46
6 h after
injury
1.27 ± 0.30**
7.53 ± 1.66*
1.20 ± 0.44**
7.45 ± 2.16**
1.92 ± 0.64**
11.27 ± 2.41**
9.24 ± 2.17
54.16 ± 5.55**
12 h after
injury
0.94 ± 0.26**
6.18 ± 1.31
0.88 ± 0.32**
5.32 ± 1.74
1.64 ± 0.54**
9.89 ± 2.05*
9.64 ± 2.83
57.81 ± 6.39**
24 h after
injury
0.96 ± 0.29**
6.82 ± 1.54
0.86 ± 0.25**
6.07 ± 1.79
1.37 ± 0.58
10.16 ± 2.26*
6.65 ± 1.42
50.68 ± 4.51**
Table 11.28  PLs in pulmonary tissue homogenates after smoke inhalation injury in rats ( x
s
±
)
Group
PI
Phs
PE
PC
(mg/g dry
lung)
(%TPL)
(mg/g dry
lung)
(%TPL)
(mg/g dry
lung)
(%TPL)
(mg/g dry lung)
(%TPL)
Control
4.04 ± 0.88
4.95 ± 0.96
3.26 ± 0.87
3.79 ± 1.02
4.81 ± 1.22
5.42 ± 1.31
40.95 ± 6.93
51.76 ± 4.58
2 h after injury
2.76 ± 0.75
4.68 ± 1.14
2.71 ± 1.02
4.25 ± 1.58
3.67 ± 1.19
5.74 ± 1.85
34.74 ± 5.68
47.81 ± 4.26
6 h after injury
2.82 ± 0.82
5.47 ± 1.58
2.80 ± 0.84
5.40 ± 1.61
3.47 ± 1.06
6.69 ± 2.04
30.69 ± .4.04*
47.53 ± 3.91
12 h after injury
3.63 ± 1.17
6.82 ± 2.19
3.08 ± 1.10
5.83 ± 1.90
3.92 ± 1.32
7.46 ± 2.49
26.41 ± 4.15**
44.62 ± 3.77*
24 h after injury
3.20 ± 1.04
5.63 ± 1.85
3.15 ± 1.24
5.57 ± 2.38
3.65 ± 1.28
6.44 ± 1.93
24.92 ± 4.82**
43.75 ± 3.35**
11  Inhalation Injury

275
in TPL (Table 11.29). The expression of SP-A in pulmonary
tissues decreased obviously [24, 25].
The ultrastructure of PS in the alveolar space was also
affected after smoke inhalation injury in rats. There are three
major ultrastructures of PS in the normal alveolar space
under electron microscopy, i.e., LB that is secreted by type II
alveolar cells, TM with highly organized lattice arrange-
ment, and vesicles of various sizes. Transformation of LB to
TM was observed 2  h after smoke inhalation injury. TM
destruction with lattice derangement was observed. Massive
vesicle aggregation with very few TM occurred in 12 h after
injury, and vesicles dominated in 24  h after injury. These
results indicate that after inhalation injury, the amount of sur-
factant and the amount and activity of PL and its components
is reduced in pulmonary tissues, resulting in abnormal sur-
face tension and atelectasis.
11.1.3.3  New Management Strategies
for Inhalation Injury
Advances in the care of patients with major burns have led to
a reduction in mortality and a change in the causes of death.
Inhalation injury has now become the leading cause of death
in burn patients. Smoke inhalation combined with skin burn
is fatal in 30–90 % of victims. Such high mortality results
from the traditional passive strategy of management, which
only adopts symptomatic measures, e.g., oxygen therapy for
anoxic cases, mechanical ventilation for cases with severe
hypoxemia, and tracheostomy for cases with upper airway
obstruction. It is known that some complications of inhala-
tion injury can be prevented by blocking certain pathoge-
netic links. The victims should be treated early and before
confirmation of the diagnosis of inhalation injury. The basic
goals of early treatment include maintenance of a patent air-
way, prevention of atelectasis and subsequent pneumonia,
and prompt management of pulmonary edema in an attempt
to prevent respiratory failure. The major measures are (1)
immediate 100 % oxygen therapy after injury for correction
of hypoxemia, elimination of CO, and prevention of CO poi-
soning in the site of fire; (2) establishment of an artificial
airway within 6 h after severe inhalation injury to prevent
upper airway obstruction; (3) sufficient fluid resuscitation
early after injury to prevent shock; (4) early airway lavage
for eliminating residual primary and secondary injury related
factors, reducing secondary injury, and preventing airway
infection; and (5) mechanical ventilation in case of signs of
hypoxemia emerging. Meanwhile, many new measures have
been developed to treat inhalation injury, such as preventive
and therapeutic application of surfactants, airway lavage
with the use of surfactant, high-frequency ventilation, liquid
ventilation, NO inhalation, and administration of other medi-
cations. The use of new comprehensive therapies has reduced
the mortality of inhalation injury cases significantly [26]
(Tables 11.30 and 11.31).
The chief measures for early stage inhalation injury are
introduced as follows:
Inhalation of Oxygen of High Concentrations
for 1~2 h Immediately After Severe Inhalation Injury
In light of low oxygen and high CO concentrations in air at
the site where flame inhalation injury occurs, oxygen should
be administered at the site of fire as early as possible to cor-
rect carbon monoxide poisoning and hypoxia. Inhaling pure
oxygen will shorten the half-elimination time of carbon
Table 11.29  SP-A level in BALF from rats with smoke inhalation
injury
μg/ml
%TPL
%TPL
Control
1.35 ± 0.43
1.76 ± 0.54
1.04 ± 0.28
2 h after injury
2.89 ± 0.92*
2.80 ± 0.65
0.72 ± 0.21
6 h after injury
3.58 ± 1.13**
2.35 ± 0.72
0.25 ± 0.08
12 h after injury
3.73 ± 0.96**
2.56 ± 0.50
0.20 ± 0.06
24 h after injury
3.90 ± 1.24**
3.28 ± 0.92*
0.26 ± 0.09
Table 11.30  Mortality of inhalation injury cases in different time periods in the burn wards of the Third Military Medical University
Time period
Mild
Moderate
Severe
Number
Mortality (%)
Number
Mortality (%)
Number
Mortality (%)
1958–1980
176
(34.37 %)
56
(70.0 %)
27
(100.0 %)
1981–1990
165
(11.46 %)
70
(48.78 %)
34
(55.26 %)
1991–2000
178
(6.31 %)
59
(24.28)
22
(48.27)
Table 11.31  Mortality of inhalation injury cases in different time periods in the burn wards of Jiangxi Medical College
Time period
Mild
Moderate
Severe
Number
Mortality (%)
Number
Mortality (%)
Number
Mortality (%)
1989–1991
85
3(3.5 %)
18
2(11.1 %)
36
24(66.6 %)
1992–1994
93
1(1.07 %)
12
1(8.3 %)
53
28(52.5$)
1995–1998
92
0
18
1(5.5 %)
79
34(47.0 %)
11.1  Advance in Research and Management of Inhalation Injury

276
monoxide (HbCO) from 250 min to less than 50 min. Oxygen
of high concentrations (70 % or higher) is administered via a
mask if HbCO is below 10 %. In case of severe CO poison-
ing with conscious disturbances and symptoms of pulmo-
nary failure, mechanical ventilation should be performed.
Usually, after several hours of oxygen therapy, the level of
blood COHB will restore to near normal. The concentration
of oxygen inspired must be then reduced to 40 % or lower to
maintain PaO2 at 70 mmHg.
Establishment of an Artificial Airway Within 6 h After
Moderate to Severe Inhalation Injury
Thermal injury to the airways may result in massive swelling
of the tongue, epiglottis, and/or aryepiglottic folds, as well as
airway obstruction. Airway swelling develops over hours, as
fluid resuscitation is ongoing; therefore, an initial evaluation
will not predict precisely the severity of airway obstruction
that may occur later. Airway obstruction must be foreseen,
and the respiratory status be continuously monitored to
assess the need for airway control and ventilator support. If
the history and initial examination indicate the likelihood of
significant thermal injury to the upper airway, tracheal intu-
bation for the purpose of airway protection and possible ven-
tilatory support should be considered early in the course of
resuscitation. If these measures are delayed, anatomic distor-
tion caused by massive swelling of airway will make intuba-
tion difficult. Therefore, an artificial airway should be
established 6  h before edema becomes extremely serious
[27, 28]. The indications are (1) inhalation injury in combi-
nation with deep burn in the head and neck, particularly with
a large burn area; (2) severe inhalation injury, with rapidly
developing symptoms such as hoarseness, wheezing, and
dyspnea; (3) prolonged hypoxemia necessitating mechanical
ventilation; and (4) inhalation injury accompanied by con-
scious disturbances, coma, or respiratory depression. Special
cautions should be taken for patients with deep burn in the
head and face who require transportation. Tracheal intuba-
tion
or
tracheostomy
must
be
performed
before
transportation.
Early Bronchial Lavage: Eliminating or Reducing
Primary and Secondary Damaging Factors
and Preventing Complications
Sputum aspiration and airway lavage are common and effec-
tive methods, but they are often used to clear airway secre-
tions and necrotic debris. Smoke is one direct damaging
factor in inhalation injury. Medium-sized particles in smoke
(>5  μm in diameter) are most likely to precipitate in the
upper respiratory tract. Particles (1–5 μm in diameter) are
most likely to precipitate in the lower respiratory tract.
Particles (<1 μm in diameter) can enter pulmonary alveoli.
Hot carbon particles not only burn the lung but also cause
damages for several hours to, even, several days due to the
poisonous substances surrounding hot carbon particles.
Through early lavage, the damaging residues are cleared,
thus preventing continuous damage. Early lavage can also
scavenge inflammatory mediators and cytokines, thus reduc-
ing secondary inflammation reactions [29].
One group of rats with severe inhalation injury was
infused intratracheally with 37 °C normal saline (30 ml/kg)
immediately after injury, and another group of rats with
severe inhalation injury was infused intratracheally with
37 °C normal saline (30 ml/kg) and PS (100 mg/kg). The
experimental results showed that the rats receiving early
lavage presented with mitigation in lung damage, respiratory
dysfunction, inflammation reaction and pulmonary edema,
as well as reduction of mortality. PS further mitigated these
damages and reduced mortality [29–31] (Tables 11.32,
11.33, 11.34 and 11.35).
Table 11.34  Water content of lungs in rats with inhalation injury after lung lavage
Group
TLW (ml/kg)
EVLW (ml/g)
Lung/heart index (g/g)
Lung/body index (g/g)
Control
2.79 ± 0.40
2.21 ± 0.29
2.18 ± 0.22
6.30 ± 0.73
BAL with PS
2.19 ± 0.18
1.65 ± 0.21
1.60 ± 0.19
5.48 ± 0.41
Immediate treatment
2.26 ± 0.24
1.83 ± 0.19
1.80 ± 0.21
5.69 ± 0.54
Delayed treatment
2.41 ± 0.29
1.99 ± 0.32
1.87 ± 0.23
5.85 ± 0.44
Table 11.33  Blood gas analysis of rats with inhalation injury after lung lavage
Group
PaO2 (kPa)
PaCO2 (kPa)
A-aDO2 (kPa)
pH
Control
7.44 ± 1.90
7.44 ± 1.28
3.00 ± 1.08
7.094 ± 0.159
Immediate treatment
11.07 ± 0.76
4.47 ± 0.04
1.32 ± 0.41
7.358 ± 0.105
Delayed treatment (2 h after injury)
9.88 ± 1.14
5.084 ± 1.06
1.93 ± 0.62
7.308 ± 0.095
Table 11.32  Mortality of rats with inhalation injury after lung lavage
Group
No. of rats
No. of deaths
Mortality (%)
Control
27
13
48.15
BAL with PS
19
7
26.34
Immediate treatment
29
5
26.32
Delayed treatment
21
8
38.09
11  Inhalation Injury

277
Early lung lavage is widely applied to treat inhalation
injury. For lung lavage, an artificial airway needs to be estab-
lished, a suction catheter be introduced slowly into the left or
right bronchus, and 5 ml normal saline with or without anti-
biotics be injected. A few seconds after injection, the patient
begins coughing, and he/she should immediately receive
sputum aspiration and lavage. The procedure should be
repeated in the left/right bronchus and every 4–6 h. The num-
ber of lavage treatment can be increased depending on the
tolerance level of the patient.
Early Fluid Resuscitation After Inhalation Injury
Thermal injury leads to significant fluid loss due to the dam-
age and loss of the protective keratin layer of the skin.
Multiple fluid resuscitation formulae are being used in the
world. Pulmonary capillary permeability increases after
severe inhalation injury. It is generally believed that eleva-
tion of the capillary hydrostatic pressure engendered by vig-
orous administration of fluid for resuscitation will enhance
the escape of capillary fluid and worsen oxygenation and
increase edema in the lung and chest wall. In light of pulmo-
nary edema, the volume of fluid is traditionally limited for
early fluid replacement. In the early 1980s, researchers from
the Third Military Medical University performed fluid resus-
citation in dogs with 30 % full thickness skin burn combined
with severe steam inhalation injury according to Parkland
formula. The experimental results showed that the lung water
amount was not higher in dogs subject to fluid replacement
than the ones without fluid replacement and that pathological
changes were not worsened in the lung of dogs subject to
fluid replacement (Table  11.36) [32]. The experimental
results also showed that the reduction of blood plasma vol-
ume and cardiac output after severe steam inhalation injury
was equivalent to that in dogs with 30 % skin burn. It is well
known that inadequate perfusion of lung tissues will cause
pulmonary edema because of hypoxia. In patients with
severe burns, pulmonary edema may develop immediately
after injury and long before resuscitation. Therefore, early
fluid infusion should not be restricted after inhalation injury.
Due to the large individual differences in early fluid resusci-
tation, the volume of fluid infusion should be adjusted on the
basis of a predetermined target volume. The goal of fluid
resuscitation is to guarantee adequate blood perfusion of
organs/tissues.
Mechanical Ventilation
Unlike ARDS due to other causes, severe inhalation injury
is severe primary lung damage. Pulmonary edema and
hypoxemia may occur immediately after injury, and respi-
ratory failure may develop immediately. Meanwhile, these
patents often suffer from chest constriction due to eschar,
tracheal spasm, and airway obstruction. Therefore, the use
of mechanical ventilatory support is paramount in manag-
ing patients with severe inhalation injury. However,
mechanical ventilatory support may lead to additional lung
injury when used at the extremes of pulmonary physiology,
a concept that has been termed ventilator-induced lung
injury. Successful treatment of severe inhalation injury
requires strategies that take advantage of multiple tech-
niques to provide effective mechanical ventilatory support,
while minimizing ventilator-­induced lung injury and
improving oxygenation/ventilation. Volume respirators
rather than pressure-controlled ventilators should be used
to provide respirator support. Various modalities may be
used. The ARDSnet data with protective lung ventilatory
strategies should be considered an appropriate initial venti-
latory strategy. Tidal volumes between 6 and 8  mL/kg
should be titrated with inspiratory oxygen concentration to
meet the patient’s needs with a positive end expiratory
pressure of 5–10 cm/H2O.
There are pros and cons for different methods of ventila-
tion. High-frequency ventilation uses minute tidal volumes
at very high frequencies of 300–600 breaths/min, which pro-
vides adequate oxygenation. Researchers from Jiangxi
Medical College investigated high-frequency jet ventilation
(HFJV) in the 1970s, and they manufactured HFJV respira-
tory machines in 1982 in China [33, 34]. The experimental
results and clinical results are as follows:
1. HFJV reduces the lung water content in dogs with inhala-
tion injury, adjusts fluid distribution in pulmonary inter-
stitium, and increases circulation of lung lymph.
2. HFJV adjusts the distribution of extravascular lung water.
Table 11.36  Lung water contents of dogs with 30 % 3rd degree burn
combined with severe steam inhalation injury after fluid replacement
Group
N
Right lung water
Control
7
81.26 ± 1.21
Fluid resuscitation
7
81.5 ± 1.36
Table 11.35  Biochemical factors in blood after smoke inhalation injury
Group
PLAP (μg/L)
MDA (mmol/ml)
α1-PI (μmol. min. ml)
ET (pg/ml)
Control
4.36 ± 1.16
5.97 ± 0.59
3.42 ± 0.25
10.59 ± 1.93
BAL with PS
3.27 ± 0.93
5.39 ± 0.54
3.66 ± 0.29
4.85 ± 1.06
Immediate treatment
2.84 ± 1.02
5.28 ± 0.62
4.09 ± 0.22
3.36 ± 0.97
Delayed treatment
3.76 ± 1.15
5.78 ± 0.65
3.60 ± 0.32
7.02 ± 1.84
PLAP placental alkaline phosphatase, MDA malonaldehyde, α1-PI α1 proteinase inhibitor, TNF tumor necrosis factor, ET endothelin
11.1  Advance in Research and Management of Inhalation Injury

278
3. HFJV and high-frequency two-way jet ventilation
(HFTJV) are superior to conventional mechanical venti-
lation (CMV) in terms of breathing mechanics and gas
exchange in dogs with steam inhalation injury.
A total of 148 patients with inhalation injury were treated
with HFJV in the Burn Research Institute of Jiangxi Medical
College from 1989 to 1998, and the treatment outcomes were
satisfactory. HFJV was showed to increase PaO2 effectively,
without causing retention of CO2.
Having confirmed the effectiveness of HFV for inhalation
injury, researchers from Jiangxi Medical College further
investigated the effect of high-frequency oscillatory ventila-
tion (HFOV) combined with exogenous pulmonary surfac-
tant (PS) in rabbits with steam inhalation injury [35]. The
results showed that CMV and HFOV combined with PS
increased PaO2 and reduced PA-aO2 and that HFOV increased
PaO2 more significantly than CMV did. PaO2 was higher and
the lung water content was lower in the group administered
with PS than the group not administered with PS. Histological
examination of lung tissues showed that HFOV and HFOV +
PS mitigated hemorrhage, exudation, inflammatory cell infil-
tration, and alveolar atelectasis, when compared with CMV
and CMV + PS, respectively. HFOV + PS mitigated lung
damage most apparently among these methods. It was sug-
gested that CMV, HFOV, and exogenous PS used in combi-
nation are synergistic in the treatment of inhalation injury.
Therapeutic Effect of Early Nitric Oxide (NO)
Inhalation
NO is an ultra short-acting, potent vasodilator that works by
increasing cyclic guanosine monophosphate in smooth mus-
cle. When inhaled, it goes to ventilated lung areas, selectively
dilating the capillaries that perfuse those segments, better
matching ventilation with perfusion, and reducing intrapul-
monary shunt, while reducing pulmonary hypertension.
Inhaled nitric oxide (INO) has been used as a therapeutic
agent to treat pulmonary hypertension and decrease intrapul-
monary shunt. In order to prevent secondary damages caused
by early pulmonary hypertension and hypoxia-­ischemia after
inhalation injury, researchers from the Third Military Medical
University and Shijiazhuan International Peace Hospital
investigated the use of INO in treating inhalation injury in
dogs, rabbits, and rats, as well as in patients [36–38].
(a) INO improves respiratory function and reduces damage
to lungs after inhalation injury.
•
Selective reduction of pulmonary arterial pressure
(PAP): After NO inhalation, mean PAP (mPAP), pul-
monary capillary wedge pressure (PCWP), pulmo-
nary microvascular pressure (PmvP), and peripheral
vascular resistance (PVR) decrease.
•
Improvement of pulmonary oxygenation: After NO
inhalation, PaO2, Ca-vO2, and PaO2 at 50 % SaO2 and
respiratory control index (RCI) increase, and A-aDO2
decreases significantly. Meanwhile, DO2, VO2, and
oxygen uptake rate (ERO2) increase and the content
of lactic acid in arterial blood lowers remarkably.
•
Improvement of respiratory ventilation: After NO inha-
lation, PaCO2, respiratory index (RI), alveolar dead
space rate (VD/VT), pulmonary arterial shunt rate (QS/
QT), and carbonyl hemoglobin (HbCO) reduce [38].
(b) INO improves cardiac function and reduces heart dam-
age after inhalation injury.
•
Cardiac functional improvement: After NO inhala-
tion, cardiac output (CO), stroke volume (SV), stroke
index (SI), cardiac stroke work index (CSWI), and
right ventricular stroke work index (RVSWI) increase
obviously. Meanwhile, the peak value of left ventric-
ular systolic pressure (LVSP), maximum rate of
change in left ventricular systolic pressure (±dp/
dtmax), left ventricular end-diastolic pressure
(LVEDP), and left ventricular stroke work index
(LVSWI) increases substantially,
•
Blood hypercoagulability improvement: After NO
inhalation, the number of erythrocytes (RBC), hema-
tocrit (HCT), erythrocyte aggregation index (EAI),
and low shear of blood-specific viscosity (Lηb)
reduce; whole-blood viscosity (Lηh) and plasma vis-
cosity (ηp) decrease remarkably; and the erythrocyte
rigid index (ERI) increases.
Based on the results from animal experiments, research-
ers from Shijiazhuan International Peace Hospital tested
early inhalation of NO (20 ppm) in patients with inhalation
injury and found no obvious side effects but improved oxy-
genation and reduced damage by oxyradicals. However, fur-
ther clinical trials are to be performed due to the limited
clinical cases in previous studies.
11.2
Study of the Treatment of Inhalation
Injury with High-Frequency
Ventilation
Guohui Li and Guanghua Guo
Mechanical ventilation is an important one of various methods
of treatment of inhalation injury but which may induce ventila-
tor-induce lung injury (VILI) with improper ventilatory fac-
tors. To reduce VILI, protective ventilation strategy was
promoted to treat pulmonary dysfunction, with ventilatory
parameters of tide volume (VT) 6–8 ml/kg, inspiratory plateau
pressure ≤30 cm H2O, PEEP 8–10 cm H2O, and FiO2 40–50 %.
High-frequency ventilation (HFV) is a kind of lung protective
ventilation strategy, which appeared in the late 1960s. High-
frequency jet ventilation (HFJV) was studied by Cao Yong in
our country in the 1970s, and high-­frequency jet ventilators
were appraised and produced in batch process in 1982 [1].
11  Inhalation Injury

279
The effect of treatment of inhalation injury with HFJV
was verified in animal experiment and clinical application
but poor effect of elimination of CO2. To improve the
effect of elimination of CO2, high-frequency two-way jet
ventilation (HFTJV) was studied by professor Cao Yong
and HFTJV respirators were made (Fig.  11.6). HFTJV
may increase elimination of CO2 and maintain normal
PaO2. Since 1985, experiment study and clinical applica-
tion of treatment inhalation injury with HFJV have been
carried out and payed widely attention in our country.
11.2.1 Experimental Study of Treatment
of Inhalation Injury with HFJV
11.2.1.1  Effect of HFJV on Pulmonary Water,
Distribution of Pulmonary Interstitial
Fluid, and Lympha of Right Lymphatic
Duct of Dogs with Smoke Inhalation
Injury
Pulmonary water increases because pulmonary vascular per-
meability increased after severe inhalation injury. Wu
Zhihong studied the effects of HFJV on pulmonary water
and distribution of pulmonary interstitial fluid of dogs with
smoke inhalation injury.
Effect of HFJV on Pulmonary Water and Distribution
of Pulmonary Interstitial Fluid of Dogs with Smoke
Inhalation Injury
Pulmonary water content in HFJV group was lower than that
injury group. Recent studies showed that area and content of
perivascular edema increased, intra-alveolar fluid and interal-
veolar space decreased, extravascular water was distributed
and transferred to area of non-gas exchange, consequently
intrapulmonary shunt decreased, and PaO2 rose when dogs
with high permeability. Pulmonary edema were ventilated in
PEEP. In this study, enlargement of perivascular edema rate
(ER) was more obvious 9 h post inhalation injury in HFJV
group than that in injury group (Table 11.37). Types of these
vessels were mainly partial muscular small vessels
(Table 11.38), which are located in area of respiratory bronchi
and interlobular septum. Above results presented HFJV dis-
tributed again pulmonary extravascular water and improved
gas exchange in similar to PEEP mode.
Effect of HFJV on Lympha of Right Lymphatic Duct
(RLD) of Dogs with Smoke Inhalation Injury
Fluent drainage of pulmonary lympha is an important factor of
prevention of pulmonary edema, which improves the ability of
clearing fluid and proteins and reduces pulmonary edema.
Lymphatic quantity of RLD, ratio of lympha to plasma pro-
teins, and clear rate of total proteins were increased and reached
peak level at 7–9 h posttreatment with HFJV. The results indi-
cated that HFJV plays some role in the reduction of pulmonary
edema owing to strengthening ability of clearing pulmonary
Fig. 11.6  Trachea tube of HTJV (a) jet in way; (b) jet out way 1. Gas
source (1); 2. gas source (2); 3. electromagnetic valve (1); 4. electro-
magnetic valve (2); 5. jet needle in way; 6. jet tube out way; 7. tube for
determination of airway pressure
Table 11.37  Perivascular ER in different pulmonary lobes
Groups
Right apical
lobe
Right phenic
lobe
Total
Injury
ER
0.70 ± 0.44
1.03 ± 0.63
0.88 ± 0.54
n
76
68
144
HFJV
ER
0.87 ± 0.54*
1.29 ± 0.70**
1.07 ± 0.65**
n
61
68
129
n number of determination of vessels
*p < 0.05, **p < 0.01 (When compared to injury group)
Table 11.38  Perivascular ER in different typal vessels in lungs
Groups
Partial muscular small vessel
Muscular vein
Muscular artery
Elastic artery
Injury
ER
0.64 ± 0.43
0.71 ± 0.33
1.15 ± 0.66
1.25 ± 0.37
n
58
28
45
13
HFJV
ER
0.89 ± 0.61*
1.14 ± 0.57**
1.16 ± 0.62
1.22 ± 0.52
n
35
37
44
13
n number of determination of vessels
*p < 0.05, **p < 0.01 (When compared to injury group)
11.2  Study of the Treatment of Inhalation Injury with High-Frequency Ventilation

280
fluid and proteins through pulmonary lymphatic system. It may
be that higher mechanical ventilation rate and lower PEEP
(3–6 cmH2O) may affect rhythm of respiratory movement and
systolic movement of lymphatic vessels and transfer pulmo-
nary interstitial fluid to area of non gas exchange, as a result
return and clearing of tissue fluid are improved.
11.2.1.2  Effect of HFJV and HFTJV
on Respiratory Airflow and Gas
Exchange in Dogs with Inhalation Injury
HFJV elevated PaO2 obviously and lowered PaCO2 slightly in
dogs with severe steam inhalation injury, and HFTJV
enhanced the elimination of CO2 in addition to effective ele-
vation of PaO2, which suggested HFJV and HFTJV might
improve pulmonary functions of ventilation and gas exchange.
To investigate the mechanism of effect of HFJV on gas
exchange, 3D particle dynamic analyzer was used to deter-
mine the inspiratory and expiratory flow velocity (Table 11.39).
The change of inspiratory flow velocity: The inspiratory
flow velocity in HFJV group increased significantly com-
pared with autonomic respiration group (p < 0.05). That in
HFTJV groups also increased significantly compared with
HFJV group (p < 0.05).
The change of expiratory flow velocity: There was no sig-
nificant difference between HFJV group and autonomic res-
piration group. The expiratory flow velocity in HFTJV
groups besides group 3 increased significantly compared
with HFJV group (p < 0.05). Positive correlation appeared
between inverse jet pressure and respiratory flow velocity
(Y = 4.8818 + 0.4203X, r = 0.9216, p < 0.05).
The change of Renole’s number (Re) with different venti-
lation models includes (Tables 11.40):
The change of inspiratory Re: Inspiratory Re in HFJV
group increased significantly compared with autonomic res-
piration group (p < 0.05). That in HFTJV group also increased
significantly compared with HFJV group (p < 0.05).
The change of expiratory Re: There was no significant
difference between HFJV group and autonomic respiration
group. The expiratory Re in HFTJV groups besides group
3 were higher significantly than that in HFJV group
(p < 0.05).
The change of PaCO2, PaO2, and PIP with different venti-
lation models includes (Table  11.41): PaCO2 in HFTJV
groups was lower significantly than that in HFJV group
(p < 0.05). PaO2 and PIP were no obviously different between
HFTJV groups and HFJV group. Obvious negative correla-
tion was found between increase of expiratory flow velocity
and decrease of PaCO2 in HFTJV (Y = 7.25−0.647X,
r = −0.916, p < 0.05).
Re is an indication on fluid status. The airflow is laminar
flow when Re < 1,000, turbulent when >1,500, either laminar
or turbulent when 1,000 > Re < 1,500. The experimental results
indicated that during autonomic respiration, inspiratory air-
flow is laminar flow (Re = 543.9 ± 377.40) and expiratory air-
flow was either laminar or turbulent (Re = 1283.9 ± 703.3).
During HFJV, both inspiratory (Re = 1500.8 ± 762.2) and expi-
ratory (Re = 1602 ± 462.5) airflow were turbulent. The basic
manners of gas transportation are convection as a whole and
molecular diffusion. Recently many scholars believe that the
mechanism of gas exchange with HFJV is TAYOR diffusion
as well as convection. When turbulent flow increases in air-
way, diffusion between oxygen and carbon dioxide enhances
as well. During HFJV, both inspiratory and expiratory airflow
are turbulent; consequently normal ventilation functions are
maintained. Turbulent flow is an important mechanism of
improving gas exchange with HFJV. On the basis of HFJV,
HFTJV increases inverse jet airflow; thus the expiratory air-
flow velocity may be increased and CO2 elimination improved.
Table 11.39  The change of respiratory flow velocity in different ven-
tilation conditions m / s, x
s, n =
±
(
)
8
Flow velocity
Vi (m/s)
Ve (m/s)
Autonomic respiration
1.47 ± 1.02
3.47 ± 1.90
HFJV
3.94 ± 2.06△
4.33 ± 1.25
HFTJV
5.42 ± 1.84*
5.98 ± 1.95
HFTJV
5.80 ± 1.55*
7.30 ± 2.95*
HFTJV
5.87 ± 1.80*
7.38 ± 2.90*
HFTJV
5.97 ± 1.44*
7.64 ± 2.78*
*p < 0.05 (When compared to HFJV), △p < 0.05 (When compared to
Autonomic respiration)
Table 11.40  The change of respiratory Re in different ventilation
models
Re
Rei
Ree
Autonomic respiration
543.9 ± 377.4
1283.9 ± 703.0
HFJV
1500.8 ± 762.2△
1602.1 ± 462.5
HFTJV
2005.4 ± 680.8*
2212.6 ± 721.5
HFTJV
2146.8 ± 573.5*
2701.0 ± 1091.5*
HFTJV
2171.9 ± 666.0*
2730.6 ± 1073.0
HFTJV
2268.9 ± 532.8*
2826.8 ± 1028.6*
Note: Rei (inspiratory Re), Ree (expiratory Re)
△p < 0.05 (When compared to Autonomic respiration); *p < 0.05
(When compared to HFJV)
Table 11.41  The change of PaCO2, PaO2, and PIP in different ventila-
tion conditions x – s, n = 8
(
)
PaCO2 (kPa)
PaO2 (kPa)
PIP (kPa)△
Autonomic
respiration
5.27 ± 0.35
14.71 ± 1.95
0.20 ± 0.08
HFJV
5.71 ± 0.51
39.85 ± 4.18
0.60 ± 0.17
HFTJV
3.41 ± 0.90*
44.23 ± 10.04
0.63 ± 0.30
HFTJV
3.22 ± 1.02*
51.05 ± 9.46
0.63 ± 0.19
HFTJV
3.17 ± 0.99*
53.91 ± 9.08
0.61 ± 0.19
HFTJV
2.88 ± 0.91*
53.24 ± 8.05
0.52 ± 0.26
△PIP (peak airway pressure), *p < 0.05 (When compared to HFJV)
11  Inhalation Injury

281
11.2.1.3  Effect of HFJV, HFTJV, and Conventional
Mechanical Ventilation (CMV)
on Respiratory Mechanics and Gas
Exchange in Dogs with Severe Steam
Inhalation Injury
Li Guohui studied the effectiveness of HFJV, HFTJV, and
CMV in dogs inflicted with steam inhalation89. Indices of
respiratory mechanics, hemodynamics, and blood analysis
were monitored, respectively. The experimental results
(Tables 11.42 and 11.43) showed total respiratory resistance
(Rrs), and resistance of lungs (RL) were higher evidently, and
total respiratory compliance (Crs) and compliance of lungs
(CL) were lower obviously in three models of ventilation
than that in control, but with no significant difference among
the above three groups, which revealed these ventilations
might overcome airway resistance to assistant respiration,
but could not recover high airway resistance and low compli-
ance of lungs post injury to normal levels. These may be
related to severe pulmonary edema induced by wide tracheo-
broncheal spasm and increased pulmonary microvascular
permeability. The experimental results showed that inspira-
tory peak pressure was obviously higher and cardiac output
significantly lower in CMV than that in HFJV, which indi-
cated CMV increased intrathoracic pressure and affected
venous return. Many scholars noticed that the ability of over-
coming airway resistance in HFJV was lower than that in
CMV.  On conditions of increase of airway resistance and
decrease of lung compliance, HFJV might result in CO2
retention. HFTJV can effectively eliminate CO2, the mecha-
nisms of which are (1) strengthening expiratory velocity and
turbulent flow and (2) reducing anatomic dead space (VD
anat)
and physiological dead space (VD
phys) (Table 11.44).
Table 11.42  The effect of three ventilations on respiratory and blood circular mechanics
x
s, n =
±
(
)
9
Indices
Control
Post injury
CMV
HFJV
HFTJV
PIP (kPa)
0.66 ± 0.12
0.89 ± 0.09*#
0.68 ± 0.17
0.70 ± 0.18
Paw (kPa)
0.32 ± 0.05
0.44 ± 0.10
0.35 ± 0.01
0.34 ± 0.08
Rrs (kPa · s/L)
0.35 ± 0.18
0.94 ± 0.50##
0.97 ± 0.53##
0.86 ± 0.36##
RL (kPa · s/L)
0.42 ± 0.15
0.89 ± 0.45##
0.94 ± 0.44##
0.82 ± 0.38##
Crs (L/kPa)
0.16 ± 0.04
0.12 ± 0.05#
0.13 ± 0.05#
0.14 ± 0.05#
CL (L/kPa)
0.19 ± 0.07
0.13 ± 0.06#
0.13 ± 0.05#
0.16 ± 0.06#
MAP (kPa)
11.15 ± 2.17
10.62 ± 0.99
11.03 ± 1.83
10.92 ± 3.56
HR (beats/min)
143.11 ± 19.64
84.89 ± 23.10##
82.11 ± 18.00##
84.67 ± 21.29##
CO (ml · min−1/kg)
145.40 ± 43
96.30 ± 12*#
119.7 ± 62#
97.6 ± 39#
*p < 0.05 (When compared to HFJV); #p < 0.05; ##p < 0.01 (When compared to control)
Table 11.43  The effect of three ventilations on pulmonary volume and blood gas x – s n =
,
9
(
)
Indices
Control
Post injury
CMV
HFJV
HFTJV
VT (ml)
103.7 ± 32
162.6 ± 20**
94.7 ± 34
85.6 ± 26*
VA (ml)
1433 ± 256
969 ± 228*
1198 ± 236
1100 ± 282
FRC (ml)
467 ± 66
427 ± 55
433 ± 56
444 ± 56
VCO2 (ml · min−1/kg)
4.82 ± 0.52
4.83 ± 0.63
4.90 ± 0.65
6.32 ± 1.30**
PaCO2 (kPa)
5.60 ± 0.38
7.45 ± 0.68#
7.05 ± 1.37#
5.99 ± 0.90**
PaO2 (kPa)
10.65 ± 0.65
9.20 ± 2.13
9.33 ± 2.18
9.44 ± 1.98
pH
7.27 ± 0.06
7.11 ± 0.09
7.17 ± 0.07
7.18 ± 0.09
*p < 0.05; **p < 0.01,(When compared to HFJV); #p < 0.05 (When compared to control)
Table 11.44  The change of VD
anat and VD
phys in three ventilations
Indices
Control
Post injury
CMV
HFJV
HFTJV
VD
anat (ml)
90.69 ± 19
103.7 ± 12**
88.17 ± 22
76.66 ± 19*
VD
phys (ml)
94.77 ± 20
110.0 ± 19**
90.69 ± 22
80.87 ± 20*
*p < 0.05; **p < 0.01,(When compared to HFJV)
11.2  Study of the Treatment of Inhalation Injury with High-Frequency Ventilation

282
11.2.1.4  Comparison of Ventilatory
Effectiveness of Normal Frequency Jet
Ventilation (NFJV) and HFJV in Dogs
with Steam Inhalation Injury
The effect of NFJV and HFJV on airway pressure, oxygen-
ation, and gas exchange was studied in dogs with severe
inhalation injury. Compared with HFJV, a marked decrease
in cardiac output (CO), oxygen delivery (DO2), oxygen con-
sumption (VO2) and PAO2, and obvious increase in PaO2
occurred during NFJV, but no significant differences were
observed in other indices (Tables  11.45 and11.46). The
results suggested that NFJV produced insufficiency of alveo-
lar ventilation, compromise in tissue perfusion, and enhance-
ment of hypoxia. The causes of decrease of cardiac output in
NFJV might be that lower ventilatory rate, larger tide vol-
ume, and higher peak airway pressure affected venous return.
11.2.1.5  Study of Clinical Application of HFJV
From 1989 to 1998, 148 cases with inhalation injury were
treated with HFJV in Burn Institute of Jiangxi Medical
College. HFJV began to be used average 4.3 days post injury
and lasted for average 6.8 days. Indications with HFJV were
dyspnea, chest distress, respiratory rate >35 times/min, and
PaO2 < 8.00 kPa. Blood gas analyses were monitored every
day during HFJV. During HFJV, average value of PaO2 was
14.57 kPa, but without HFJV that of PaO2 was 7.89 kPa with
hypoxemia, there was significant difference between two
conditions (Table  11.47). The lowest value of PaO2 was
5.73 kPa without HFJV, when using HFJV PaO2 was ­elevated
to 13.6 kPa. It indicated HFJV might improve PaO2 effec-
tively. In the same time the average value of PaCO2 was
4.48 kPa with HFJV and 4.38 kPa without HFJV, there was
no significant difference, which showed retention of CO2
was not found. The results of clinical application proved pri-
marily that HFJV might treat inhalation injury effectively.
But HFJV has not yet been used widely; there is shortage of
statistical analysis of massive cases in multiple centers. Its
effectiveness still needs to be established further.
11.2.1.6  Experimental Study of the Therapy
of High-Frequency Jet Ventilation
combined Partial Liquid Ventilation
for Inhalation Injury
In the early 1990s last century, Fuhrman et al. proposed partial
liquid ventilation (PLV) initially. Fluorocarbon (PFC) with the
characteristics of capacity of carrying a large number of oxy-
gen and carbon dioxide and high density and low surface
­tension is used for gas exchange in lung and enters and recruit
the collapse alveolar under gravity so that blood in the lung of
gravity-dependent area and non-gravity-­dependent area
Table 11.45  The effect of NFJV and HFJV on tissular oxygenation x
s
±
(
)
Basic
Post injury
NFJV
HFJV
CO [ml/(min · kg)]
208.98 ± 57.28
144.49 ± 24.91**
126.59 ± 26.94#
146.50 ± 28.49
DO2 [ml/(min · kg)]
43.07 ± 15.47
24.33 ± 5.76**
20.51 ± 5.85##
25.57 ± 6.13
VO2 [ml/(min · kg)]
9.35 ± 7.21
9.02 ± 4.91
7.26 ± 4.21#
9.57 ± 4.22
ERO2
0.21 ± 0.04
0.43 ± 0.10*
0.33 ± 0.15
0.40 ± 0.11
P v O2 (kPa)
6.50 ± 0.22
4.22 ± 1.38**
4.69 ± 1.37
4.78 ± 0.78
S v O2 (%)
75.95 ± 2.46
52.09 ± 13.19**
48.10 ± 18.23
45.85 ± 15.84
*p < 0.05; **p < 0.01 (When compared to basic); #p < 0.05; ##p < 0.01 (When compared to HFJV)
Table 11.47  Comparison of gas exchange between HFJV and without
HFJV x – s n =
,
30
(
)
PaO2 (kPa)
PaCO2 (kPa)
Without HFJV
7.89 ± 0.31
4.38 ± 0.23
HFJV
14.57 ± 0.88
4.48 ± 0.24
P
<0.01
>0.05
Table 11.46  The effect of NFJV and HFJV on gas exchange x
s
±
(
)
Basic
Post injury
NFJV
HFJV
pH
7.36 ± 0.05
7.13 ± 0.23*
7.11 ± 0.14
7.15 ± 0.17
PaCO2 (kPa)
4.91 ± 0.51
8.11 ± 3.93*
7.95 ± 1.91##
6.77 ± 1.85
PaO2 (kPa)
12.88 ± 1.41
7.63 ± 2.99*
8.26 ± 2.31##
9.12 ± 2.94
SaO2 (%)
96.08 ± 2.33
78.23 ± 14.21*
76.89 ± 12.78
81.79 ± 10.09
PAO2 (kPa)
14.37 ± 0.64
11.84 ± 2.36*
10.95 ± 2.23#
12.26 ± 2.10
PA-aO2 (kPa)
1.68 ± 1.03
3.88 ± 2.50*
2.69 ± 1.88
2.83 ± 2.78
PaO2/F1O2
460.00 ± 50.34
236.84 ± 117.05**
295.40 ± 76.44
333.03 ± 98.77
*p < 0.05; **p < 0.01 (When compared to basic); #p < 0.05; ##p < 0.01 (When compared to HFJV)
11  Inhalation Injury

283
­redistributes and improve the ratio of ventilation and flow.
However, PLV has some unfavorable factors, for example,
spontaneous breath always has to be inhibited and needs seda-
tives and muscle relaxants to maintain the effect. Hemodynamics
instability and pneumothorax may have occurred because of
PFC overdose and so on. In the late 1990 last century, Guo
Gonghua et al. from Jiangxi Medical College carried out the
experimental study of the therapy of high-frequency jet ventila-
tion combined PLV for inhalation injury. The results demon-
strated that PaO2 increased progressively, especially within
30–90 min, PaO2 higher than pre-injury significantly in severe
steam inhalation injury of dogs treated with HFJV combined
with small-dose PFC but no significant change in HFJV group
(control group, Table  11.48). We found that PaCO2 had no
change at 30 min post-PLV in therapy group but increased sig-
nificantly at 60–90 min implying that alveolar hypoventilation
might occur that led to slight CO2 retention. In spite of that,
slight CO2 retention could be tolerant by self-regulation
called permissive hypercapnia. Parameters such as heart rates,
cardic output, mean artery pressure, etc., had no adverse effect
in therapy group implying that PLV has no adverse effect on
hemodynamics (Tables 11.49, 11.50, and 11.51).
Histopathological observation demonstrated that the tra-
cheobronchial mucosal congestion and edema, ulcers and
pseudomembrane-like structures, the bubble-like secretions
in lumen, pulmonary alveolar wide hemorrhage, interstitial
edema, and inflammatory cell infiltration in bronchiole in
HFPLV group were all slighter than those in control group.
Type II alveolar epithelial were intact, the swelling of endo-
thelial cells attenuated, and no phenomenon of lamellar body
emptying.
Experimental study demonstrated that the therapy of
high-frequency ventilation combined PLV for inhalation
injury is better than the therapy of high-frequency ventila-
tion. Histopathological change indicated that the pulmonary
congestion, edema, and inflammatory infiltration were
slighter in high-frequency ventilation combined PLV group
compared with the high-frequency ventilation group.
Table 11.48  The effect of HFPLV on blood gas in inhalation injury dogs
Time
PaO2 (kPa)
PaCO2 (kPa)
pH
BE
Control
Therapy
Control
Therapy
Control
Therapy
Control
Therapy
Pre-injury
14.26 ± 2.32
14.67 ± 2.36
5.04 ± 0.97
5.09 ± 0.91
7.33 ± 0.05
7.33 ± 0.06
−6.20 ± 2.82
−5.88 ± 2.13
Post injury
9.01 ± 2.16
9.89 ± 3.19
3.82 ± 0.81
4.57 ± 0.87
7.26 ± 0.17
7.32 ± 0.08
−12.43 ± 6.83
−7.79 ± 2.58
PLV30min
14.24 ± 8.00
17.09 ± 8.06△
3.94 ± 1.16
4.09 ± 0.84
7.27 ± 0.18
7.37 ± 0.07
−12.30 ± 6.15
−6.98 ± 1.87*
PLV60min
14.30 ± 7.09
19.03 ± 8.99△
4.87 ± 1.83
7.05 ± 3.91△
7.18 ± 0.19
7.22 ± 0.18△
−13.88 ± 5.78
−9.27 ± 2.61
PLV90min
13.22 ± 9.02
19.44 ± 10.58△
4.53 ± 1.87
7.14 ± 2.59*△
7.22 ± 0.18△
7.16 ± 0.16△
−13.38 ± 5.57
−9.99 ± 5.31
Comparison at the same time point between two groups:* p < 0.05
Compared with point of post injury △ p < 0.05,△△ p < 0.01
Table 11.49  The effect of HFPLV on compliance in inhalation injury dogs ( x – s n =
,
8 )
Time
Csta (L/kPa)
Cdyn (L/kPa)
Ctot (L/kPa)
Control
Therapy
Control
Therapy
Control
Therapy
Pre-injury
0.205 ± 0.023
0.202 ± 0.025
0.212 ± 0.022
0.215 ± 0.028
0.202 ± 0.023
0.203 ± 0.028
Post injury
0.158 ± 0.034
0.175 ± 0.027
0.170 ± 0.036
0.179 ± 0.025
0.160 ± 0.037
0.176 ± 0.029
HFPLV30min
0.153 ± 0.041
0.172 ± 0.034
0.160 ± 0.041
0.182 ± 0.038
0.154 ± 0.043
0.170 ± 0.032
HFPLV30min
0.149 ± 0.033
0.161 ± 0.030
0.156 ± 0.032
0.170 ± 0.031
0.150 ± 0.036
0.163 ± 0.030△
HFPLV30min
0.137 ± 0.033
0.156 ± 0.039△
0.145 ± 0.034△△
0.170 ± 0.040
0.142 ± 0.033△△
0.156 ± 0.034△△
Compared with point of post injury △ p < 0.05,△△ p < 0.01
Table 11.50  The effect of HFPLV on airway resistance in inhalation injury dogs
Time
RAWe-st (kPa · S/L)
RAWi-dyn
(kPa · S/L)
RAWe-dyn
(kPa · S/L)
Control
Therapy
Control
Therapy
Control
Therapy
Pre-injury
1.216 ± 0.159
1.110 ± 0.131
0.699 ± 0.059
0.659 ± 0.065
0.707 ± 0.058
0.681 ± 0.073
Post injury
1.854 ± 0.445
1.418 ± 0.384
0.964 ± 0.234
0.832 ± 0.154
0.995 ± 0.245
0.941 ± 0.199
HFPLV30min
1.826 ± 0.573
1.545 ± 0.352
0.897 ± 0.251
0.889 ± 0.239
0.934 ± 0.278
0.908 ± 0.237
HFPLV60min
1.821 ± 0.441
1.590 ± 0.311
0.912 ± 0.198
0.915 ± 0.174
0.944 ± 0.217
0.933 ± 0.192
HFPLV90min
1.996 ± 0.627
1.684 ± 0.497*△
1.020 ± 0.558
0.999 ± 0.182
1.118 ± 0.561
1.033 ± 0.174
Compared with point of post injury :△ p < 0.05,△△ p < 0.01
11.2  Study of the Treatment of Inhalation Injury with High-Frequency Ventilation

284
11.2.1.7  Experimental Study of the Therapy
of High-Frequency Oscillatory
Ventilation Combined with Inhaling
Surfactant for Inhalation Injury
Activity of pulmonary surfactant (PS) in inhalation injury
decreases obviously. Researchers from Jiangxi Medical
College carried out the experimental study of the therapy of
high-frequency oscillatory ventilation combined with pul-
monary surfactant for steam inhalation injury in rabbits.
Animals were divided into five groups randomly: CMV
group, HFOV group, CMV+PS group, HFOV+PS group
(n = 8), and control group (n = 5). Exogenous PS was natural
PS extracted from flesh swine lung (researched and devel-
oped by Pediatric Hospital of Fudan University, produced by
Hong Qi pharmaceutical factory).
The result of the effect on gas exchange was shown in
Tables 11.52, 11.53, 11.54, 11.55, 11.56, and 11.57. In steam
inhalation injury rabbits, treatment with CMV or HFOV
(including two groups using exogenous PS) could increase
PaO2 and decrease P(A-a)O2, but PaO2 in HFOV group was
higher than that in CMV group significantly. When exoge-
nous PS was used, P(A-a)O2 decreased and PaO2 increased sig-
nificantly. Lung water decreased, and hemorrhage, exudation,
inflammatory infiltration, alveolar atelectasis were slighter
than those in CMV and CMV+PS group. Lung injury score of
HFOV+PS group was the lowest. All results illustrated that
combination of CMV or HFOV and exogenous PS had syn-
ergy effect on the therapy of inhalation injury.
The mechanism of the effect of mechanical ventilation
combined with exogenous PS is not clear, but the study dem-
onstrated that may be related to inhibition of inflammation
response. In severe steam inhalation injury rabbits, TNF-α
and IL-18 in HFOV+PS group decreased significantly and
IL-10 and IL-13 increased remarkably (Table 11.58). In lung
Table 11.51  The effect of HFPLV on hemodynamics in inhalation injury dogs ( x – s n =
,
8 )
HR (beats/min)
CO (L/min)
MPA (kPa)
PAP (kPa)
Time
Control
Therapy
Control
Therapy
Control
Therapy
Control
Therapy
Pre-injury
188.00 ± 30.95
189.13 ± 35.83
1.89 ± 0.29
2.10 ± 0.51
18.73 ± 1.68
18.12 ± 2.51
2.05 ± 0.51
1.73 ± 0.68
Post injury
167.38 ± 44.02
151.50 ± 49.44
1.33 ± 0.32
1.52 ± 0.33
17.65 ± 1.85
17.83 ± 3.70
2.20 ± 0.63
1.98 ± 0.71
HFPLV30min
174.50 ± 41.23
156.25 ± 44.91
1.36 ± 0.49
1.67 ± 0.36
17.60 ± 1.87
17.50 ± 3.11
2.37 ± 0.62
1.97 ± 1.02
HFPLV60min
160.25 ± 49.59
146.00 ± 54.56
1.43 ± 0.56
1.63 ± 0.36
16.90 ± 2.71
16.82 ± 3.00
2.65 ± 0.69
2.37 ± 1.11△
HFPLV90min
172.50 ± 50.32
138.38 ± 36.96
1.34 ± 0.59
1.59 ± 0.61
16.58 ± 3.15
18.37 ± 1.64
2.73 ± 0.70
2.63 ± 1.43△
Comparison at the same time point between two groups:* p < 0.05, ** p < 0.01, compared with point of post injury △ p < 0.05,△△ p < 0.01
Table 11.52  Comparison of pH at different time point among five groups ( x
s
±
)
Group
Baseline
0.5 h post injury
Ventilation
0.5 h
1.5 h
2.5 h
3.5 h
CMV group
7.40 ± 0.18
7.18 ± 0.11**
7.29 ± 0.13
7.23 ± 0.13
7.25 ± 0.18
7.21 ± 0.16
HFOV group
7.47 ± 0.20
7.22 ± 0.22**
7.25 ± 0.11
7.35 ± 0.10
7.30 ± 0.12
7.26 ± 0.14
CMV+PS group
7.36 ± 0.12
7.27 ± 0.13**
7.21 ± 0.14
7.23 ± 0.14
7.23 ± 0.19
7.21 ± 0.15
HFOV+PS group
7.43 ± 0.18
7.25 ± 0.12**
7.21 ± 0.10
7.33 ± 0.11
7.32 ± 0.21
7.28 ± 0.17
Control group
7.40 ± 0.18
7.26 ± 0.14**
–
–
**Compared with baseline, p < 0.01
Table 11.53  Comparison of PaO2 at different time point among five groups ( x
s
±
)
Group
Baseline
0.5 h post injury
Ventilation
0.5 h
1.5 h
2.5 h
3.5 h
CMV group
128.73 ± 11.42
54.18 ± 5.67**
211.21 ± 45.78
175.00 ± 52.43
194.48 ± 58.44
179.25 ± 51.78
HFOV group
129.02 ± 10.48
54.74 ± 4.21**
206.72 ± 30.45
240.94 ± 33.42△
272.42 ± 38.62△
235.16 ± 32.08△
CMV+PS group
125.80 ± 9.18
51.46 ± 7.12**
214.43 ± 40.48
212.86 ± 37.18☆
189.04 ± 51.15
184.04 ± 49.18
HFOV+PS group
121.80 ± 10.45
53.20 ± 6.41**
203.32 ± 34.66
273.05 ± 39.78▲★
298.62 ± 40.02▲★
229.04 ± 34.48▲
Control group
127.02 ± 11.48
54.46 ± 8.21**
–
–
**Compared with baseline, p < 0.01; △Compared with CMV at corresponding time point, p < 0.01; ▲Compared with CMV+PS at corresponding
time point, p < 0.01; ☆Compared with CMV at corresponding time point, p < 0.05; ★Compared with HFOV at corresponding time point, p < 0.05
11  Inhalation Injury

285
tissue homogenate, expression of TNF-α and IL-18 mRNA
decreased obviously, IL-10 and IL-13 increased remarkably
in HFOV+PS group (Table 11.59), concentration of TNF-α
and IL-18 decreased obviously, and IL-10 and IL-13
increased remarkably in plasma in HFOV+PS group
(Table 11.60).
The study also found that the activity of MPO and
­caspase-­1 decreased significantly, the concentration and
Table 11.55  Comparison of OI (oxygen index) at different time point among five groups ( x
s
±
)
Group
Baseline
0.5 h post injury
Ventilation
0.5 h
2 h
2.5 h
3.5 h
CMV group
1.63 ± 0.42
4.28 ± 1.07**
4.44 ± 0.78
4.60 ± 0.43
4.48 ± 0.54
4.51 ± 0.87
HFOV group
1.58 ± 0.46
4.14 ± 0.88**
4.42 ± 0.45
3.84 ± 0.42△
3.42 ± 0.68△#
3.85 ± 0.58△
CMV+PS group
1.62 ± 0.38
4.25 ± 0.78**
4.33 ± 0.48
3.86 ± 0.98☆
3.64 ± 0.75
3.94 ± 0.78
HFOV+PS group
1.59 ± 0.55
4.20 ± 0.84**
4.48 ± 0.66
3.45 ± 0.78▲★#
3.26 ± 0.62▲★#
3.64 ± 0.48▲
Control group
1.62 ± 0.48
4.24 ± 0.94**
–
–
**Compared with baseline, p < 0.01; △Compared with CMV at corresponding time point, p < 0.01; ▲Compared with CMV+PS at corresponding
time point, p < 0.01; ☆Compared with CMV at corresponding time point, p < 0.05; ★Compared with HFOV at corresponding time point, p < 0.05
Table 11.54  Comparison of PaO2/FiO2 at different time point among five groups ( x
s
±
)
Group
Baseline
0.5 h post injury
Ventilation
0.5 h
2 h
2.5 h
3.5 h
CMV group
614.73 ± 41.42
234.18 ± 15.17**
211.21 ± 45.78
175.00 ± 52.43
194.48 ± 58.44
179.25 ± 51.78
HFOV group
619.58 ± 40.46
245.74 ± 14.28**
206.72 ± 30.45
240.94 ± 33.42△
272.42 ± 38.62△#
235.16 ± 32.08△
CMV+PS group
622.80 ± 49.08
225.46 ± 17.88**
214.43 ± 40.48
212.86 ± 37.18☆
189.04 ± 51.15
184.04 ± 49.18
HFOV+PS group
612.80 ± 30.55
235.20 ± 16.44**
203.32 ± 34.66
273.05 ± 39.78▲★#
298.62 ± 40.02▲★#
229.04 ± 34.48▲
Control group
626.02 ± 31.88
240.46 ± 18.24**
–
–
** Compared with baseline, p < 0.01; △Compared with CMV at corresponding time point, p < 0.01; ▲Compared with CMV+PS at corresponding
time point, p < 0.01; ☆Compared with CMV at corresponding time point, p < 0.05; ★Compared with HFOV at corresponding time point, p < 0.05
Table 11.56  Comparison of PaCO2at different tiem point among five groups x
s
±
(
)
Group
Baseline
0.5 h post injury
Ventilation
0.5 h
2 h
2.5 h
3.5 h
CMV group
26.58 ± 4.17
35.44 ± 5.15**
29.95 ± 7.78
39.30 ± 11.25
35.72 ± 5.42
38.03 ± 9.12
HFOV group
21.40 ± 3.42
35.16 ± 5.95**
37.22 ± 5.18
38.50 ± 9.42
37.00 ± 6.42
35.90 ± 7.18
CMV+PS group
22.37 ± 4.10
30.96 ± 4.92**
37.59 ± 10.42
47.06 ± 9.10
37.01 ± 6.08
45.97 ± 9.92
HFOV+PS group
25.48 ± 5.11
35.07 ± 2.14**
34.07 ± 2.55
42.85 ± 6.45
37.32 ± 6.09
42.78 ± 6.46
Control group
24.68 ± 4.78
34.17 ± 3.18**
–
–
**Compared with baseline, p < 0.01
Table 11.57  Comparison of P(A-a)O2 at different time point among five groups x
s
±
(
)
Group
Baseline
0.5 h post injury
Ventilation
0.5 h
2 h
2.5 h
3.5 h
CMV group
5.25 ± 2.10
50.58 ± 8.14**
452.64 ± 71.55
485.26 ± 79.56
474.22 ± 66.87
473.62 ± 68.45
HFOV group
7.45 ± 2.25
49.52 ± 6.38**
468.04 ± 52.05
452.84 ± 56.16△
402.26 ± 60.32 △
439.52 ± 62.42△
CMV+PS group
7.48 ± 2.08
61.21 ± 4.55**
461.03 ± 78.98
462.65 ± 80.78 ☆
397.18 ± 85.16 ☆
397.66 ± 70.15 ☆
HFOV+PS group
7.50 ± 1.65
44.04 ± 3.85**
463.47 ± 71.22
435.50 ± 94.28▲★
385.02 ± 76.13▲★
389.98 ± 74.22▲★
Control group
7.46 ± 2.25
51.28 ± 4.85**
–
–
**Compared with baseline, p < 0.01; △Compared with CMV at corresponding time point, p < 0.01; ▲Compared with CMV+PS at corresponding
time point, p < 0.01; ☆Compared with CMV at corresponding time point, p < 0.05; ★Compared with HFOV at corresponding time point, p < 0.05
11.2  Study of the Treatment of Inhalation Injury with High-Frequency Ventilation

286
expression of TNF-α and IL-18 mRNA decreased obviously,
and IL-10 and IL-13 increased remarkably in HFOV+PS
(Table 11.61) which displayed the anti-inflammation effect
of HFOV combined with exogenous PS. Concentration of
pre-inflammatory cytokines in plasma in HFOV group was
lower than those in CMV group and was the lowest in
HFOV+PS group implying that the therapy of combination
of HFOV and exogenous PS could reduce cytokines to spread
from lung tissue to the blood.
References
1. Li A, Yang ZC.  Inhalation injury. Beijing: People’s Military
Medical Press; 1993.
2. Tang XX, Yuan KJ, Shi JX.  Assessment of fiberoptic broncho-
scopic examination in inhalation injury: analysis of 32 cases. Chin
J Plast Surg Burns. 1989;5(1):17–9.
3. Li XH, Yang ZC, Liu ZY, et al. Experimental study on secondary
injury of left lung induced by smoke inhalation of right lung in
dogs. Chin Crit Care Med. 2001;13(12):718–20.
4. Zhao ZD, Li A, Yang ZC, et al. The changes of extravascular lung
water and lung blood volume after smoke inhalation injury in goats.
Chin J Exp Surg. 1988;3(2):115–6.
5. Wang CZ, Yang ZC. Experimental study on the pathogenesis of
acute respiratory failure (ARF) after smoke inhalation. Acta Acad
Med Milit Tert, 1989 (Suppl): 1–23.
6. Wang CZ, Li A, Yang ZC. Establishment of modified chronic lung
lymph fistula in Chongqing goats. J Med Coll PLA (Engl).
1986;1(3):253–8.
Table 11.58  Changes of inflammatory factors concentration in lung tissue after therapy (pg/g)
Group
TNF-α
IL-18
IL-10
IL-13
CMV
465.75 ± 25.42
598.88 ± 71.22
48.40 ± 29.50
27.63 ± 28.58
CMV+PS
313.22 ± 58.18a
340.29 ± 67.88a
170.12 ± 17.80a
185.44 ± 30.76a
HFOV
260.38 ± 29.12c
275.46 ± 78.15c
126.50 ± 20.25c
100.32 ± 26.75c
HFOV+PS
160.98 ± 21.44b, d
129.55 ± 76.78b, d
380.42 ± 20.08b, d
350.45 ± 20.64b, d
aCompared with CMV group, p < 0.05
bCompared with HFOV group, p < 0.05
cCompared with CMV group, p < 0.01
dCompared with CMV + PS group, p < 0.01
Table 11.59  Expression of inflammatory factors mRNA in lung tissue after therapy (RU)
Group
TNF-α
IL-18
IL-10
IL-13
CMV
27.55 ± 5.42
18.86 ± 7.22
4.40 ± 0.50
2.27 ± 0.58
CMV+PS
17.22 ± 5.18a
11.29 ± 6.88a
10.12 ± 1.80a
8.44 ± 3.76a
HFOV
12.38 ± 2.12c
9.46 ± 1.15c
12.50 ± 2.25c
12.32 ± 2.75c
HFOV+PS
6.98 ± 1.44b, d
5.59 ± 1.78b, d
15.42 ± 2.08b, d
15.45 ± 2.64b, d
aCompared with CMV group, p < 0.05
bCompared with HFOV group, p < 0.05
cCompared with CMV group, p < 0.01
dCompared with CMV + PS group, p < 0.01
Table 11.60  Changes of inflammatory factors concentration in plasma after therapy (pg/L)
Group
TNF-α
IL-18
IL-10
IL-13
CMV
855.75 ± 75.42
689.68 ± 67.22
28.40 ± 10.55
106.63 ± 24.18
CMV+PS
403.22 ± 66.18a
390.26 ± 54.88a
94.12 ± 27.84a
155.46 ± 28.16a
HFOV
280.38 ± 23.82c
225.46 ± 48.4 5c
116.50 ± 28.25c
140.12 ± 30.25c
HFOV+PS
170.98 ± 23.14b, d
119.75 ± 46.74b, d
212.42 ± 26.12b, d
225.15 ± 23. 46b, d
aCompared with CMV group, p < 0.05
bCompared with HFOV group, p < 0.05
cCompared with CMV group, p < 0.01
dCompared with CMV + PS group, p < 0.01
Table 11.61  Changes of lung injury score, MPO and caspase-1 activ-
ity after therapy
Group
Lung injury score
MPO (U/g)
Caspase-1
(U/gpro)
CMV
3.71 ± 0.43
3.26 ± 0.91
11.3 ± 3.7
CMV+PS
3.12 ± 0.75a
2.64 ± 0.77a
6.4 ± 2.2a
HFOV
2.87 ± 0.26c
1.85 ± 0.46c
5.9 ± 1.3c
HFOV+PS
2.08 ± 0.28b, d
1.26 ± 0.32b, d
3.6 ± 1.2b, d
aCompared with CMV group, p < 0.05
bCompared with HFOV group, p < 0.05
cCompared with CMV group, p < 0.01
dCompared with CMV + PS group, p < 0.01
11  Inhalation Injury

287
7. Wang CZ, Li A, Yang ZC. The pathophysiology of carbon monox-
ide poisoning and acute respiratory failure in a sheep model with
smoke inhalation injury. Chest. 1990;97(3):736–42.
8. Tao J, Yang ZC, Liu ZY, et al. Change of alveolar epithelial liquid
clearance and its signification in rats after smoke inhalation injury.
Chin J Modern Med. 2000;10(7):13–4.
9. Tao J, Yang ZC, Liu ZY, et al. Effect of terbutaline on alveolar liq-
uid clearance in rats after smoke inhalation injury. Chin Pharmacol
Bull. 2000;16(1):67–9.
10. Li A, Jiang KY, Yang ZC, et al. Roles of some inflammatory media-
tors in the pathogenesis of early pulmonary edema in steam respira-
tory burns. Chin Med J (Engl). 1987;100(2):132–41.
11. Jiang KY, Li A, Yang ZC. Effects of certain inflammatory media-
tors on the development of pulmonary edema induced by steam
inhalation. Chin J Surg. 1985;23(4):247–51.
12. Zhou SZ, Ai YL. Primary observation of the dynamic changes of
anaphylatoxin (AT) level in left ventricle blood plasma in dogs with
severe steam inhalation injury. Acta Acad Med Milit Tert.
1982;4(4):66–72.
13. Huang YH, Yu SL, Lv JS.  Experimental study on severe steam
inhalation injury: changes of histamine content in serum and lung
tissues. Acta Acad Med Milit Tert. 1982;4(4):73–6.
14. Yang TD, Yang ZC, Luo QZ. The changes of mRNA expression and
activity of pulmonary low molecular phospholipase A2 in rats after
smoke inhalation injury. Chongquing Med J. 2004;33(4):581–3.
15. Yang TD, Yang ZC, Luo QZ.  Parimary study on the change of
85KD phospholipase A2 in lung tissue of rats with smoke inhala-
tion injury. Chongquing Med J. 2004;33(10):1517–8.
16. Huang YS, Li A, Yang ZC, et  al. Changes of thromboxane and
prostacyclin after smoke inhalation injury in goats. J Med Cell PLA
(Engl). 1988;3(1):41–6.
17. Zhang M, Li A, Yang ZC, et al. The effect of tetrandrine on the
release of leukotriene 4 by inflammatory cells of rabbits with smoke
inhalation injury. J Med Cell PLA (Engl). 1991;6(3):243–8.
18. Luo QZ, Yang TD, Yang ZC. Changes in the polymorphonuclear
neutrophil infiltration, hemorrhage and plasma exudation in the
pulmonary tissue in rats with smoke inhalation injury. Chin J Burns.
2004;20(3):145–7.
19. Zhang M, Huang YH, Li XF. The effects of ginsenosides on smoke
inhalation injury of rats. J Med Coll PLA (Engl). 1990;5(2):176–80.
20. Zhao ZD, Li A, Yang ZC.  The relationship between early lung
injury and active oxygen free radical after smoke inhalation injury
in goats. J Med Coll PLA (Engl). 1988;3(1):6–9.
21. Liu XS, Ao L, Yang ZC. The role of toxic oxygen metabolites of
neutrophil in canine smoke inhalation injury. Ann Medit Burn Club.
1993;6(3):193–9.
22. Liu ZY, Li A, Yang ZC, et al. Changing of pulmonary surfactants
after severe steam inhalation injury in rabbits. Acta Acad Med Milit
Tert. 1984;6(1):1–7.
23. Xie EF, Yang ZC, Wang FJ, et al. Changes and significance of phos-
pholipid composition contents of pulmonary surfactant after smoke
inhalation injury in rats. Chin J Plast surg Burns. 1997;13(6):
428–32.
24. Xie EF, Yang ZC, Wu J, et  al. Effects of smoke inhalation on
expressions of pulmonary surfactant-associated protein A in rats
lung tissues. Chin J Traumatol. 1997;13(6):365–8.
25. Fu ZH, Yang ZC, Hu ZH, et al. Study on the mechanisms of abnor-
mal SPA expression after smoke inhalation injury. Med J Chin
PLA. 2002;27(6):518–9.
26. Luo QZ, Yang ZC, Huang YS. Effects of complex therapy on severe
inhalation injury. J Chin Physician. 2003;5(12):47–9.
27. Chen B, Jia CY, Su YJ, et  al. Experience in the treatment of
severe inhalation injury. Chin J Plast Surg Burns. 1999;15(6):
411–3.
28. Deng SL, Wang YL. Relevant problems in the management of inha-
lation injury. Chin J Plast Surg Burns. 1999;15(6):405–6.
29. Xie EF, Yang ZC, Li A. The treatment of smoke inhalation injury
with lung lavage and exogenous pulmonary surfactant. Med J Chin
PLA. 1997;22(1):26–9.
30. Xie EF, Yang ZC, Li A. Experimental study on the treatment of
smoke inhalation injury with exogenous pulmonary surfactant
replacement. Natl Med J China. 1997;77(4):305–6.
31. Luo QZ, Liu ZY, Yang ZC, et al. Treatment of severe inhalation
injury with endotracheal infusion of exogenous pulmonary surfac-
tant. Chin J Burns. 2000;16(3):145–6. 152.
32. Yang ZC, Li A, Jiang KY, et al. An explorative study on fluid resus-
citation in burns associated with severe inhalation injury. Acta
Acad Med Milit Tert. 1982;4(4):12–9.
33. Guo GH, Li GH, Cao Y, et al. Comparison of normal frequency and
high frequency jet ventilation in canine severe steam inhalation
injury. Acta Acad Med Jiangxi. 1995;35(4):14–7.
34. Li GH, Wu XQ, Tan WY, et al. Changes in blood gas in severely
burned patients with acute pulmonary insufficiency treated by
HFV. Chin J Plast Surg Burns. 1989;5(2):85–7.
35. Wang SG, Guo GH, Fu ZH, et al. Experimental study of high fre-
quency oscillatory ventilation combined with exogenous pulmo-
nary surfactant for the treatment of acute lung injury with acute
respiratory failure induced by vapour inhalation. Chin J Respir Crit
Care Med. 2007;6(1):39–44.
36. Qi SZ, Yang ZC, He BB, et al. An experiment study of reversed
pulmonary hypertension with inhaled nitric oxide on smoke inhala-
tion injury. Chin J Surg. 1997;35(1):56–8.
37. Qi SZ, Yang ZC, Fu QF, et al. Improved oxygenation function of
inhalation injury in dogs by inhaling nitric oxide. Acta Acad Med
Milit Tert. 1997;19(5):460–2.
38. Qi SZ, Yang ZC, He BB, et al. The effect of inhaled nitric oxide on
right ventricular function in smoke inhalation injury in dogs. Med J
Chin PLA. 1998;23(2):124–5.
References

289
Z. Yang, Chinese Burn Surgery, DOI 10.1007/978-94-017-8575-4_12,
© Springer Science+Business Media Dordrecht and People’s Medical Publishing House 2015
12.1
Introduction
An electrical burn is a common and specifi c type of severe
injury, frequently involving the deep tissues and organs. The
disability and mortality from electrical injury are much
higher than for other burn injuries. Hence, in order to
decrease mortality and disability, it is important to focus on
the pathophysiological changes and the repair of the injured
sites as well. From 1958, doctors in China have made great
progress and innovation on the treatment of electrical burns
via constant practice analysis cycles.
In China, because multiple factors are involved in the pro-
cess of injury, there are different names for electrical burns,
e.g., electrical injury, electrical burn, electrical contact injury,
electric shock, and electric arc burn, etc. Electrical injury is
the general name and several agents are involved. Electrical
burn induces electric heat effects, electric physiology effects,
electric chemical effects, arc light, and electric sparks, which
will result in extensive injury, including skin, subcutaneous
tissues, muscles, blood vessels, nerves, bones and joints, and
internal organs. First aid is of paramount importance for
electric shock because it may cause a series of pathophysio-
logical changes, e.g., brief unconsciousness, coma, shock,
sudden apnea, and cardiac arrest.
Electric current causes local and systemic actions. First of
all, megatemperature converted from electric energy induces
tissue injury, hyperemia, edema, and charring. Second, elec-
tric current causes the depolarization of tissues. Finally, elec-
tric current has nonheat effects on tissues, e.g., electroporation
on cellular membrane induced by a powerful electric fi eld.
High electrothermal injury due to the difference in electric
conductivity across cellular membrane causes minipores on
the cellular membrane, and in turn results in an increase in
membrane permeability, the leakage of macromolecules
such as protein and DNA, and the aggregation of intracellu-
lar Ca 2+ and arachidonic acid metabolites. When the electric
current passes through the body it results in unconscious-
ness, inhibition of the apneustic center, sudden cardiac arrest,
and cardiac conduction disorder. The electric current causes
edema and degeneration of the vessel walls, blood coagula-
tion, thrombosis, and in turn induces muscle neorobiosis. A
large amount of muscle hemoglobin is released from the
necrotic tissues, resulting in hyperkalemia, acidosis, hepatic
injury, acute renal failure, and cardiac arrest.
12.2
Epidemics
More than 200 years ago, electric energy discovered and
studied. In 1746, two physicists from the Netherlands got an
electric shock when they charged a Leyden bottle, which
was the fi rst recorded electric shock. The commercial appli-
cation for electric energy originated in 1849. In 1879, it was
fi rst reported around the world that a carpenter from France
had died of a 250-V electric shock. Nowadays, electrical
accidents have increased gradually with the extensive appli-
cation of electric energy, both in industry and in everyday
life, resulting in more and more disability and deaths
worldwide.
In the USA, the number of electrical burns-related death
is annually increasing. There were 989 electrical burns-
related deaths in 1960 and 1,071 deaths in 1965. The mortal-
ity increased from 4.6 per million in 1962 to 15.5 per million
in 1965, among whom more than 90 % were males aged
from 20 to 34, owing to high-voltage electrical injury. In
1974, 1,157 Americans died of electrical injury, accounting
for 3–5 % of inpatients in burn centers, 30–65 % underwent
amputation, and 13 % with had central nerve or peripheral
nerve injury sequelae. In recent years, there have still been
26.6 % amputations in patients with electrical injury,
although the mortality has decreased.
Cason et al. reported that in 1981 there were 150 electri-
cal injury deaths recorded in the UK. In 1989, Cabanes from
France reported 1,231 electrical injury cases during the pre-
vious 10 years in the National Electric Power and Portable
Gas Company, accounting for a 1 % incidence in 120,000
employees, with 3.3 % mortality, in which 2.4 % occur locus
in quo.
Electrical Burns
Yonghua Sun
12

290
According to statistics from Japan, there were 41,737
deaths in Osaka in 1978, of which 146 were burns-related
cases, accounting for 0.35 %, and 57 electrical-related ones,
accounting for 0.13 %.
A hospital from Kilpank in India reported 8,040 burn
inpatients between 1973 and 1990, 923 electric injury
patients, accounting for 11.48 %, among which 73 % of
cases involved high-voltage electrical injury, 7 % cases were
below the age of 10 years, 77 % of cases were between 20and
40 years old. There were 186 amputations in 923 cases,
accounting for 20 %, 351 deaths of which 71 cases occurred
at the shock stage; 227 cases died of septicemia, with 38 %
mortality.
Until now, there have still been no statistical data for elec-
trical injury in China although the morbidity and mortality in
some burns centers in China are available.
From 1981 to 1996, there were 564 electrical injury
patients hospitalized in Ji Shui Tan Hospital of Beijing,
accounting for 8.3 % of the 6,760 burns patients, 492 male
and 72 female, suggesting differences in occupation, because
most electricians in China are men. More detailed analysis of
the patients is as follows.
The peak age distribution is middle-aged and youths,
accounting for 76.8 %, and then juveniles below 16 %. The
main cause of death is infection, accounting for 62.5 % of the
nonsurviving patients, with invasive systemic infection due
to repair diffi culty of the severely injured extremity joints
and internal organs. Severe electrical injury may precipitate
renal impairment resulting from myohemoglobin and
necrotic tissues released from electrical injured muscles. A
patient with acute renal failure who had merely 15 % of the
total body surface area third-degree burn due to electrical
injury has been documented.
The Burn Center of Rui Jin Hospital in Shanghai dis-
charged 9,291 burns patients between 1958 and 1991, of
whom 367 were electrically injured patients, accounting for
4 % with 2.18 % mortality.
Chang Hai Hospital, the affi liated hospital of The Second
Military Medical University, discharged 4,895 burns patients
from 1975 to 1992, of whom 221 were electrically injured
patients, accounting for 4.5 % with 0.9 % mortality.
Dian Li Hospital of Shanghai, the affi liated hospital of the
Shanghai Electric Power Incorporation, discharged 1,055
burns patients from 1972 to 1997, of whom 820 were electri-
cally injured patients, accounting for 77.73 %, with 68.43 %
involving a high-voltage electrical injury, 76 % an electrical
contact injury, 13.3 % combined injury, 28 % amputation
rate, 0.59 % mortality, and a 10:1 male to female ratio. The
youngest is 4 years old.
A total of 1,190 electrically injured patients were dis-
charged from seven hospitals of the Anhui Province from
1975 to 1999, accounting for 5.88 % of all hospitalized burns
patients, with 63.09 % disability. The First Seminar on
Electrical Burns was held in 1992, with 9,695 documented
electrical burns patients in 84 hospitals from 26 provinces in
China over the past 20 years, accounting for 6.56 % burns
patients with a male to female ratio of 7:1, in whom most
were middle-aged people and youths, with 71.56 % in the
18–50 age group. Seventy percent in the <18 age group were
children aged 5–13, while most of them were from rural
areas. The children, who were very active and restless, e.g.,
climbing a electronic converter, playing near high-voltage
electrical lines in villages, were associated with electrical
injury. With regard to profession distribution, workers
accounted for 47.12 % while peasants accounted for 26.55 %,
and others 26.33 %. The nonprofessional electricians who
had no basic training of electricity security accounted for
58.32 % of the electrical burns patients. Among the patients
with more than 380-V electrical injury, most were profes-
sional electricians, accounting for 63.56 %, while those with
less than 380-V electrical injury accounted for 36.44 %. Four
hundred and eight patients were injured because of quality
problems of household electric appliances or the incorrect
handling of household electrical appliances, accounting for
4.21 %. Forty-one were injured by thunder and lightning,
accounting for 0.42 %, while 153 had high-frequency current
contact, direct current contact, armamentarium electrical
injury, and electrical suicide, accounting for 1.58 %. The fre-
quently injured parts were the extremities, accounting for
82.66 %, in which the upper extremities were most com-
monly injured, while the torso and other parts accounted for
17.34 %. The mortality was 3.11 %.
In 2007, there was a sampling survey in 22 hospital burn
centers from 15 provinces (DianLi Hospital of Shanghai,
Changhai Hospital of Shanghai, Jishuitan Hospital of
Beijing, the First and the Second Affi liated Hospital of
XiangYa Medical School, Zhong Nan University, DianLi
Hospital of Henan, the First Center Hospital of Zhengzhou,
159 Hospital of the Army, the Fourth Hospital of Tianjing,
the Third Hospital of Wuhan, Guangdong Province People’s
Hospital, the First Affi liated Hospital of Yat-sen University
in Guangdong, the Second Affi liated Hospital of Kunming
Medical College, the Second Affi liated Hospital of Zhejiang
University, the General Hospital of Puyang Oil Field, SiPing
Burn Hospital in Jilin, Hainan Province People’s Hospital,
Wuzhishan People’s Hospital, SanYa Nongken Hospital,
Zhanzhou Nongken Hospital, the Fifth Hospital of Harbin,
the Second People’s Hospital of Shenzhen). From 2000 to
2006, 83,744 burns cases were enrolled, in which electrical
injured cases accounted for 9.26 % with a 5:1 male to female
ratio, 72.42 % were aged between 18 and 50, and the most
frequently injured parts were the extremities. Among the
hospitals, Dianli Hospital of Shanghai and DianLi Hospital
of Henan possessed a much higher ratio of electrical injury
and burns injury patients, accounting for 47.1 and 30.9 %
respectively. SiPing Burn Hospital in Jilin and the Third
12 Electrical Burns