Chemical Burn Inhalation Treatment and Evaluation
Immediate oxygen therapy should be administered to all patients with suspected or confirmed chemical inhalation injury, via high concentration mask or 100% FiO2 if mechanically ventilated, for 6-12 hours. 1
Initial Assessment
Evaluate for signs of upper airway obstruction:
- Stridor, hoarseness, facial burns
- Carbonaceous sputum
- Singed nasal hairs
- Respiratory distress
Assess for carbon monoxide (CO) poisoning:
- Measure carboxyhemoglobin levels
- Evaluate neurological status
- Check for cardiac symptoms
Identify the chemical agent if possible:
- Acids vs alkalis (alkalis typically cause deeper tissue damage)
- Reactive substances that may cause ongoing damage
Immediate Management
Airway Management
- Secure airway early if signs of obstruction or severe injury
- Consider early intubation for:
- Progressive respiratory distress
- Significant facial burns
- Stridor or hoarseness
- Decreased level of consciousness
Oxygen Therapy
- Administer high-flow oxygen immediately 1
- For mechanically ventilated patients, maintain 100% FiO2 for 6-12 hours 1
Bronchodilator Therapy
- Use nebulized bronchodilators for bronchospasm
- Monitor for paradoxical bronchospasm with mucolytics like acetylcysteine 2
- Discontinue medication immediately if bronchospasm progresses 2
Pain Management
- Implement multimodal analgesia titrated based on validated pain assessment scales 1
- Consider intravenous ketamine combined with other analgesics for severe burn-induced pain 1
- For stable patients, incorporate non-pharmacological techniques alongside analgesic drugs 1
Hyperbaric Oxygen Therapy (HBOT)
HBOT is not routinely recommended for chemical inhalation injuries but may be considered on a case-by-case basis for CO poisoning 1, 3. The decision should account for:
- Patient demographics (children and pregnant women may benefit more)
- Severity of poisoning and burn
- Patient stability
- Availability of specialized HBOT equipment and team
- Presence of neurological, respiratory, cardiac, or psychological symptoms
For children with CO poisoning who exhibit impaired consciousness or neurological, cardiac, respiratory, or psychological symptoms, HBOT is strongly recommended regardless of carboxyhemoglobin levels 1.
Mucolytic Therapy
- N-acetylcysteine may be considered for thick secretions
- Monitor closely for bronchospasm, which can occur unpredictably 2
- Have bronchodilators readily available when administering mucolytics 2
- Most effective at pH 7-9 2
Ongoing Management and Monitoring
- Serial assessment of respiratory status
- Chest imaging to evaluate progression
- Bronchoscopy for direct visualization of airway damage
- Monitor for development of:
- Pulmonary edema (may be delayed)
- Bacterial pneumonia (common complication)
- Airway stenosis (may develop weeks to months later) 4
Complications to Anticipate
- Acute respiratory distress syndrome (ARDS)
- Pneumonia (occurs in most patients who survive initial injury) 5
- Airway stenosis requiring surgical intervention 4
- Systemic toxicity from chemical absorption
Special Considerations
- Chemical burns combined with inhalation injury have worse prognosis 6
- Older age and higher total body surface area burned are independent predictors of mortality 6
- Understanding the specific chemical agent is crucial for effective management 7
- Alkali burns often cause more severe and deeper tissue damage than acid burns
Pitfalls to Avoid
- Delaying oxygen administration
- Failing to secure airway early in progressive respiratory distress
- Overlooking systemic effects of absorbed chemicals
- Underestimating the risk of delayed complications like airway stenosis
- Not monitoring for paradoxical bronchospasm with mucolytic therapy