From the Guidelines
Intubation should be performed urgently in patients with suspected inhalation injury who exhibit signs of upper airway obstruction, respiratory distress, or deteriorating respiratory status, such as dyspnoea, desaturation, and stridor, as indicated by the 2018 guidelines for the management of tracheal intubation in critically ill adults 1. When managing patients with suspected inhalation injury, it is crucial to prioritize early intubation to prevent deterioration and increased difficulty in securing the airway. The decision to intubate should be based on clinical signs and symptoms, including:
- Dyspnoea
- Desaturation
- Stridor
- Hoarseness
- Drooling
- Wheeze
- Carbonaceous sputum
- Soot in the airway
- Singed facial or nasal hairs
- History of confinement in a burning environment In the absence of indications for urgent intubation, the decision to intubate early or manage conservatively requires a senior decision-maker and should involve obtaining specialist advice early from a burns centre 1. Patients managed conservatively should be observed in a high-dependency area, nursed head-up, and remain nil-by-mouth, with regular reassessment to detect deterioration early. Modified RSI is usually the most appropriate technique for intubation, and an uncut tracheal tube should be used to allow for subsequent facial swelling 1. It is also essential to avoid succinylcholine from 24 h post-injury to avoid hyperkalaemia and insert a gastric tube after securing the airway, as this may become difficult later 1. The use of lung-protective ventilation strategies with tidal volumes of 6-8 mL/kg ideal body weight and adequate PEEP is recommended for post-intubation management. Early intubation is justified because thermal injury and chemical irritants cause progressive inflammation and edema of the airway mucosa, which can lead to complete airway obstruction within hours of the initial injury.
From the Research
Indications for Intubation
- Respiratory distress
- Stridor
- Hypoventilation
- Use of accessory respiratory muscles
- Blistering or edema of the oropharynx
- Deep burns to the face or neck 2
Diagnostic Tools
- Flexible fiberoptic laryngoscopy (FFL) can be used to diagnose upper airway thermal and inhalation injury and guide airway management 3
- FFL can help reduce unnecessary intubations in acute burn patients with a stable respiratory status 3
Airway Management
- Supportive respiratory care remains essential in managing inhalation injury 4
- Adjuncts such as bronchodilators, mucolytic agents, inhaled anticoagulants, nonconventional ventilator modes, prone positioning, and extracorporeal membrane oxygenation may be used, but lack definitive evidence of efficacy 4
- Patients with inhalation injury should receive a high concentration of supplemental oxygen to quickly reverse hypoxia and to displace carbon monoxide from protein binding sites 2