From the Guidelines
Management of smoke inhalation injury requires immediate oxygen therapy, airway assessment, and supportive care, with hyperbaric oxygen therapy considered only in severe cases of carbon monoxide poisoning, as recommended by the most recent study 1. Begin by administering 100% oxygen via non-rebreather mask to all patients with suspected smoke inhalation. For patients with signs of respiratory distress or upper airway edema, early intubation with an endotracheal tube is crucial before swelling progresses, as indicated by the study 1. Bronchodilators such as albuterol (2.5-5 mg nebulized every 4-6 hours) help manage bronchospasm. For carbon monoxide poisoning, continue high-flow oxygen until carboxyhemoglobin levels fall below 5%, considering hyperbaric oxygen therapy for severe cases (COHb >25%, neurological symptoms, or pregnancy), as suggested by the study 1. Some key points to consider in the management of smoke inhalation injury include:
- Administering 100% oxygen via non-rebreather mask to all patients with suspected smoke inhalation
- Early intubation with an endotracheal tube for patients with signs of respiratory distress or upper airway edema
- Considering hyperbaric oxygen therapy for severe cases of carbon monoxide poisoning
- Fluid resuscitation following the Parkland formula (4 mL/kg/% TBSA burned) for patients with concurrent burns
- Humidified oxygen to prevent mucus plugging, while chest physiotherapy aids secretion clearance
- Prophylactic antibiotics are not recommended unless infection is confirmed
- N-acetylcysteine (600 mg orally twice daily) may help as a mucolytic and antioxidant
- Mechanical ventilation with low tidal volumes (6-8 mL/kg) and moderate PEEP (5-10 cmH2O) may be necessary for respiratory failure, as indicated by the study 1. These interventions address the pathophysiology of thermal injury, chemical irritation, and systemic toxicity from combustion products, preventing secondary complications like pneumonia and ARDS.
From the Research
Smoke Inhalation Injury Management
- Smoke inhalation injury is related to significant morbidity and mortality, and its management is mostly supportive 2, 3.
- The goals of initial management are to ensure adequate oxygenation and ventilation, and to avoid ventilator-induced lung injury 2.
- Intubation should be considered if signs of respiratory distress, stridor, hypoventilation, or other complications exist 2.
- Patients suspected of having inhalation injuries should receive a high concentration of supplemental oxygen to quickly reverse hypoxia and displace carbon monoxide from protein binding sites 2, 3.
Diagnostic Strategies
- A standardized diagnostic protocol for inhalation injury is lacking, and diagnosis is mostly clinical, aided by bronchoscopy and other supplementary tests 3, 4.
- Clinicians should maintain a high index of suspicion for concomitant traumatic injuries 3, 4.
Treatment Options
- Treatment includes airway and respiratory support, lung protective ventilation, 100% oxygen or hyperbaric oxygen therapy for carbon monoxide poisoning, and hydroxocobalamin for cyanide toxicity 3, 5, 4.
- Hyperbaric oxygen therapy is an important adjunct in the management of respiratory injuries secondary to smoke inhalation, especially when complicated by inhalation of toxic chemicals such as carbon monoxide or cyanide 5.
- 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 6.