What is the management protocol for a patient with suspected smoke inhalation during intubation?

From the Guidelines

The management protocol for a patient with suspected smoke inhalation during intubation requires rapid assessment and decisive action, with immediate intubation using a large endotracheal tube and rapid sequence intubation with etomidate or ketamine for induction, along with rocuronium or succinylcholine for paralysis, as recommended by the most recent guidelines 1. The goal of this protocol is to secure the airway before progressive edema develops, while minimizing the risk of aspiration and optimizing intubating conditions.

• Pre-oxygenation with 100% oxygen is crucial to prevent hypoxemia during the intubation process.
• The use of a videolaryngoscope is recommended for tracheal intubation, as it allows for prompt first-pass tracheal intubation and minimizes the risk of difficult airways 1.
• Post-intubation, lung-protective ventilation strategies should be used, with tidal volumes of 6-8 mL/kg ideal body weight and PEEP of 5-10 cmH2O, to minimize the risk of barotrauma and ventilator-induced lung injury.
• Bronchoscopy should be performed early to assess airway damage and clear carbonaceous debris, and nebulized bronchodilators such as albuterol should be administered to manage bronchospasm.
• Aggressive fluid resuscitation is necessary, but should be carefully monitored to prevent pulmonary edema, as recommended by the guidelines 1. Key considerations in the management of smoke inhalation include the potential for direct thermal injury to the upper airway, chemical irritation to the lower respiratory tract, and systemic toxicity from carbon monoxide and cyanide, which is why early, definitive airway management is critical before progressive inflammation and edema make intubation more difficult or impossible 1.

From the Research

Management Protocol for Suspected 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 Criteria for Intubation

The criteria for intubation in patients with thermal burns include:

• Traditional criteria, such as suspected smoke inhalation, oropharynx soot, hoarseness, dysphagia, singed facial hair, oral edema, oral burn, and non-full thickness facial burns 6
• ABA criteria, including full thickness facial burns, stridor, respiratory distress, swelling on laryngoscopy, upper airway trauma, altered mentation, hypoxia/hypercarbia, and hemodynamic instability 6
• Denver criteria, which combine the ABA criteria with suspected smoke inhalation and singed facial hair, and exhibit increased sensitivity for long-term intubations 6

Treatment and Care

Treatment for patients with smoke inhalation injury includes:

• Airway and respiratory support, including intubation and mechanical ventilation 3, 4, 5
• Lung protective ventilation to maintain distal airway patency 3
• 100% oxygen or hyperbaric oxygen therapy for carbon monoxide poisoning, and hydroxocobalamin for cyanide toxicity 4, 5
• Close monitoring for development of airway compromise and other complications, such as pneumonia 3, 4, 5