From the Guidelines
Intubation should be performed urgently in patients with inhalation injuries who exhibit signs of airway compromise, such as dyspnoea, desaturation, and stridor, as these are indications for immediate intervention. The decision to intubate early or manage conservatively can be complex and requires a senior decision-maker, with consideration of obtaining specialist advice from a burns centre 1.
Key Indications for Intubation
- Dyspnoea
- Desaturation
- Stridor
- Carbon monoxide or cyanide poisoning, which can worsen tissue hypoxia
- Clinical signs of 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, although these lack sensitivity and are unreliable predictors of the requirement for intubation 1.
Approach to Intubation
When intubation is required, 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. Awake intubation can be considered in cooperative, stable patients with minimal airway soot and swelling. It is also recommended to avoid succinylcholine from 24 hours post-injury to prevent hyperkalaemia and to insert a gastric tube after securing the airway 1.
Post-Intubation Care
Post-intubation care should include lung-protective ventilation strategies and close monitoring for signs of deterioration, with the understanding that large volume fluid resuscitation can worsen airway swelling 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.
From the Research
Indications for Intubation in Patients with Inhalation Injuries
The following are indications for intubation in patients with inhalation injuries:
- Respiratory distress 2
- Stridor 2
- Hypoventilation 2
- Use of accessory respiratory muscles 2
- Blistering or edema of the oropharynx 2
- Deep burns to the face or neck 2
- Suspicion of inhalation trauma, such as closed-space exposure or facial burns 3
- Upper airway obstruction 4
Importance of Early Assessment and Intubation
Early assessment and intubation are crucial in patients with inhalation injuries to ensure adequate oxygenation and ventilation 5, 2. A standardized workflow for patients with inhalation injury can help improve outcomes 5.
Considerations for Intubation
Intubation should not be performed prophylactically in all cases of inhalation injury, as it carries its own risks 4. The decision to intubate should be based on individual patient assessment and the presence of indications for intubation 3, 2.