From the Guidelines
Intubation should be performed urgently in patients with inhalation injury who exhibit signs of airway compromise, such as dyspnoea, desaturation, and stridor, as these are indications for immediate intervention. The decision to intubate is complex and requires careful consideration of the patient's clinical presentation and potential for deterioration. According to the guidelines for the management of tracheal intubation in critically ill adults 1, clinical signs such as hoarseness, dysphagia, drooling, wheeze, carbonaceous sputum, soot in the airway, singed facial or nasal hairs, or a history of confinement in a burning environment are classic features of thermally-induced potential airway obstruction, but lack sensitivity and are unreliable predictors of the requirement for intubation.
Some key considerations for intubation in patients with inhalation injury include:
- The presence of carbon monoxide or cyanide poisoning, which can worsen tissue hypoxia and compound the emergency 1
- The need for specialist advice from a burns centre, particularly in cases where the decision to intubate is uncertain 1
- The importance of regular reassessment to detect deterioration early in patients who are managed conservatively 1
- The potential for large volume fluid resuscitation to worsen airway swelling, and the need for careful fluid management 1
In terms of the intubation procedure itself, modified rapid sequence intubation (RSI) is usually the most appropriate technique, and an uncut tracheal tube should be used to allow for subsequent facial swelling 1. Additionally, succinylcholine should be avoided from 24 hours post-injury to prevent hyperkalaemia. Post-intubation care should include lung-protective ventilation strategies and careful fluid management to minimize the risk of complications and optimize patient outcomes.
From the Research
Indications for Intubation in Inhalation Injury
The decision to intubate a patient with an inhalation injury is critical and depends on several factors. Some of the indications for intubation include:
- Airway compromise and potential respiratory complications 2
- Airway edema and obstruction, hypoxemic respiratory failure, and pneumonia 3
- Need for mechanical ventilation to support respiratory function 4, 5
- Presence of severe acute respiratory distress syndrome (ARDS) that is unresponsive to conventional therapy 3
- Requirement for protective airway management to prevent further injury and complications 2, 6
Timing of Intubation
The timing of intubation is also important, with some studies suggesting that early intubation may be beneficial in preventing further complications 2, 5. However, the decision to intubate should be made on a case-by-case basis, taking into account the individual patient's condition and needs.
Alternative Ventilatory Support
In some cases, non-invasive mechanical ventilatory (NIMV) support may be used as an alternative to intubation, particularly in patients with less severe inhalation injuries 5. However, the use of NIMV support should be carefully monitored and adjusted as needed to ensure adequate respiratory support.