From the Guidelines
The management protocol for a patient with suspected smoke inhalation during intubation requires rapid assessment and decisive action, with the most recent guidelines from 2023 recommending rapid sequence intubation with pre-oxygenation and consideration of agents like etomidate or ketamine for induction, and succinylcholine or rocuronium for paralysis 1.
Key Considerations
- Secure the airway with endotracheal intubation using a larger tube (7.5-8.5 mm) if possible to facilitate bronchoscopy and secretion clearance.
- Pre-oxygenate with 100% oxygen and consider rapid sequence intubation with agents like etomidate (0.3 mg/kg) or ketamine (1-2 mg/kg) for induction, and succinylcholine (1-1.5 mg/kg) or rocuronium (1-1.2 mg/kg) for paralysis.
- Avoid sedatives that cause respiratory depression if possible.
- After intubation, perform bronchoscopy to assess airway damage and clear carbonaceous debris.
- Implement lung-protective ventilation strategies with tidal volumes of 6-8 ml/kg ideal body weight and PEEP of 5-10 cmH2O.
Additional Recommendations
- For carbon monoxide poisoning, administer 100% oxygen to reduce the carboxyhemoglobin half-life from 4-6 hours to 40-80 minutes.
- Consider hyperbaric oxygen therapy for severe cases (COHb >25%, neurological symptoms, or pregnancy).
- Treat bronchospasm with nebulized bronchodilators like albuterol 2.5-5 mg every 20 minutes initially.
- Aggressive fluid resuscitation may be needed but should be balanced against the risk of pulmonary edema.
Rationale
These interventions are critical because smoke inhalation causes direct thermal injury to the upper airway, chemical irritation to the lower respiratory tract, and systemic toxicity from carbon monoxide and cyanide, potentially leading to rapid airway compromise and respiratory failure, as highlighted in recent guidelines 1.
From the Research
Management Protocol for Smoke Inhalation During Intubation
The management protocol for a patient with suspected smoke inhalation during intubation involves several key steps:
- Early identification of patients who will require intubation, with factors such as soot in the oral cavity, facial burns, and body burns being positively correlated with the need for intubation 2
- Close monitoring of patients with these risk factors, as they are at a higher likelihood of developing laryngeal edema and requiring intubation 2
- Maintenance of distal airway patency through therapies such as high-frequency ventilation, inhaled heparin, and aggressive pulmonary toilet 3
- Supportive care, including airway and respiratory support, lung protective ventilation, and treatment for carbon monoxide and cyanide poisoning 4, 5
Diagnostic Considerations
- Diagnosis of smoke inhalation injury is mostly clinical, aided by bronchoscopy and other supplementary tests 4, 5
- Clinicians should maintain a high index of suspicion for concomitant traumatic injuries 4, 5
Emerging Therapies
- Several emerging therapies are being developed to treat smoke inhalation injury, including stem cell therapy, anticoagulation therapy, and selective nitric oxide synthase inhibition 6
- These therapies show promising results in animal models, but further research is needed to ensure safety and efficacy in humans 6