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, as clinical signs lack sensitivity and are unreliable predictors of the requirement for intubation 1.
Key Indications for Intubation
- Dyspnoea
- Desaturation
- Stridor
- Carbon monoxide or cyanide poisoning, which can worsen tissue hypoxia and compound the emergency 1
- Clinical signs of thermally-induced potential airway obstruction, including hoarseness, dysphagia, drooling, wheeze, carbonaceous sputum, soot in the airway, singed facial or nasal hairs, or a history of confinement in a burning environment 1
Approach to Intubation
In the absence of urgent indications for intubation, the decision to intubate early or manage conservatively should be made by a senior decision-maker, with consideration of obtaining specialist advice from a burns centre 1. Awake intubation may be an option in cooperative, stable patients with minimal airway soot and swelling, but modified rapid sequence intubation (RSI) is usually the most appropriate technique 1. It is essential to avoid succinylcholine from 24 hours post-injury to prevent hyperkalaemia and to use an uncut tracheal tube to allow for subsequent facial swelling 1.
Post-Intubation Care
After securing the airway, a gastric tube should be inserted, as this may become difficult later 1. Patients who are 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 1. Large volume fluid resuscitation should be avoided, as it can worsen airway swelling 1.
From the Research
Indications for Intubation in Inhalation Injury
The indications for intubation in a patient with an inhalation injury include:
- Respiratory distress 2
- Stridor 2
- Hypoventilation 2
- Use of accessory respiratory muscles 2, 3
- Blistering or edema of the oropharynx 2
- Deep burns to the face or neck 2
- Burn size, facial burns, and neck burns may also be related to the need for intubation 3
- Carboxyhemoglobin levels (COHb) and bronchial wall thickness (BWT) can be useful tools for determining the indication for early intubation 3
Reliable Symptoms and Findings for Intubation
The following symptoms and findings are reliable indicators for intubation:
- Use of accessory respiratory muscles 3
- Burn size ≥27% total body surface area and BWT ≥3.5 mm 3
- Patients' symptoms, especially use of accessory respiratory muscles, are reliable for determining the indication for early intubation 3
- Fiberoptic bronchoscopy findings from above the glottis are mainly related to patients' symptoms, while findings from below the glottis are mainly related to BWT and COHb 3
Importance of Early Intubation
Early intubation is crucial for patients with inhalation injury to ensure upper-airway protection and maintain distal airway patency 4. It is also important to note that intubation should be considered early in the management of patients with inhalation injury to avoid complications such as pneumonia and other respiratory problems 2, 4.