From the Guidelines
Heavy smoke inhalation injury with ground-glass opacities (GGOs) requires immediate oxygen therapy to maintain saturation above 94%, with consideration for intubation and mechanical ventilation in severe cases, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1. Management of smoke inhalation with GGOs involves a multifaceted approach to address the inflammatory response, prevent complications, and promote recovery.
- Immediate oxygen therapy is crucial to maintain adequate oxygenation and prevent hypoxia.
- Bronchodilators such as albuterol (2.5-5 mg nebulized every 4-6 hours) may be used to reduce bronchospasm, while corticosteroids like methylprednisolone (1-2 mg/kg/day IV for 3-5 days) may be considered to decrease inflammation.
- Prophylactic antibiotics are not routinely recommended unless there's evidence of infection, as stated in the 2024 guidelines 1.
- Fluid management is critical, with careful monitoring to prevent both dehydration and fluid overload, as patients with large surface area burns can lead to significant fluid loss and multisystem organ failure 1.
- N-acetylcysteine (600 mg orally twice daily) may be beneficial as an antioxidant, although its use is not specifically mentioned in the provided guidelines.
- Patients require close monitoring with serial chest imaging to track GGO progression or resolution, typically showing improvement within 1-2 weeks with appropriate treatment. The pathophysiology of smoke inhalation injury involves direct thermal injury to airways, chemical irritation from combustion products, and systemic effects of carbon monoxide and cyanide, all contributing to the inflammatory response visible as GGOs on imaging, as discussed in the context of carbon monoxide poisoning 1.
- It is essential to consider the potential for carbon monoxide poisoning in patients with smoke inhalation injury, as it can lead to severe metabolic acidosis and high short-term mortality rates 1.
- Hyperbaric oxygen treatment may be considered in cases of severe carbon monoxide poisoning, although its use is not specifically recommended for smoke inhalation injury with GGOs 1.
From the Research
Heavy Smoke Inhalation Injury
- Heavy smoke inhalation injury can lead to severe complications, including airway patency impairment and respiratory insufficiency, and requires adequate and timely airway management 2, 3.
- The injury can cause damage to the respiratory cilia and epithelial cells, leading to severe bronchospasm and alveolar damage, and resulting in acute respiratory distress syndrome 4.
- Diagnosis of smoke inhalation injury is mostly clinical, aided by bronchoscopy and other supplementary tests, and treatment includes airway and respiratory support, lung protective ventilation, and management of carbon monoxide and cyanide poisoning 5, 6.
- Management of smoke inhalation injury remains mostly supportive, and clinicians should maintain a high index of suspicion for concomitant traumatic injuries 5, 6.
- Respiratory management plays a vital role in the treatment of smoke inhalation injury, and may include aerosol therapy, bronchial hygiene therapy, advanced ventilation modes, and heated humidified high-flow nasal cannula 4.
Treatment Options
- Airway management decisions can be guided by direct visual inspection via nasolaryngoscopy, and bronchoscopy is recommended to remove casts and estimate the extent of the injury in intubated patients 2.
- High-frequency percussive ventilation is an interesting modality that has been studied, but there is no sound evidence that patients with inhalation injury should be ventilated with modes other than those applied to non-burn patients 2.
- Carbon monoxide poisoning should be treated with an inspiratory oxygen fraction of 100%, whereas cyanide poisoning should be treated with hydroxocobalamin 2, 5, 6.
- Lung protective ventilation and 100% oxygen or hyperbaric oxygen therapy may also be used in the treatment of smoke inhalation injury 5, 6.