Management of Inhalation Injury in the ICU
Early recognition and aggressive airway management are the cornerstones of inhalation injury treatment in the ICU, with prompt intubation recommended for patients showing signs of respiratory distress, stridor, or oropharyngeal edema to prevent mortality from airway compromise.
Initial Assessment and Airway Management
- Classic features of inhalation injury requiring urgent attention include hoarseness, dysphagia, drooling, wheeze, carbonaceous sputum, soot in the airway, singed facial/nasal hairs, or history of confinement in a burning environment 1
- Clinical signs lack sensitivity and are unreliable predictors of intubation requirements - nasendoscopy should be performed to assess mucosal appearance 1, 2
- Dyspnea, desaturation, and stridor are absolute indications for urgent intubation 1
- Consider early intubation if any of the following exist: respiratory distress, stridor, hypoventilation, use of accessory respiratory muscles, blistering/edema of oropharynx, or deep burns to face/neck 3
Intubation Technique for Inhalation Injury
- Modified rapid sequence induction (RSI) is usually the most appropriate technique for most patients with inhalation injury 1
- Use an uncut endotracheal tube to allow for subsequent facial swelling 1
- Videolaryngoscopy increases intubation success and should be readily available 1
- Avoid succinylcholine from 24 hours post-injury to prevent hyperkalemia 1
- Insert a gastric tube after securing the airway as this may become difficult later due to facial swelling 1
Oxygenation and Ventilation Strategies
- Provide thorough pre- and peroxygenation in head-up position with CPAP/NIV or high-flow nasal oxygen (HFNO) 1
- Apply PEEP of at least 5 cmH₂O after intubation of hypoxemic patients 1
- Consider post-intubation recruitment maneuvers in hypoxemic patients 1
- Administer high concentration supplemental oxygen to quickly reverse hypoxia and displace carbon monoxide from protein binding sites 3
- Non-invasive mechanical ventilation (NIMV) may be considered in select patients with less severe inhalation injury to potentially avoid intubation 4
Hemodynamic Management
- Include a cardiovascular component in the management protocol by defining conditions for fluid challenge and early administration of vasopressors 1
- Ketamine is recommended as the induction agent of choice in hemodynamically unstable patients 1
- Proactive use of inotropes or pressors may be necessary during intubation 1
Special Considerations
- Carbon monoxide poisoning artificially increases peripheral oximetry readings and may worsen tissue hypoxia 1
- Consider cyanide antidote administration when cyanide poisoning is clinically suspected 3
- Large volume fluid resuscitation will worsen airway swelling - careful fluid management is essential 1
- Lung injury typically worsens over the first 72 hours - the Lung Injury Score nadir often occurs on Day 3 5
Monitoring and Ongoing Care
- Waveform capnography plays a critical role in monitoring, recognition, and management of airway complications 6
- Regular humidification and tracheal suction help reduce tube blockage 6
- Fiberoptic bronchoscopy should be performed for assessment of lower airway injury and for clearance of secretions 2
- Monitor for late-onset airway complications which may manifest after several weeks and require repeated intervention 5
- Patients with inhalation injury should be observed in a high-dependency area, nursed head-up, and remain nil-by-mouth if not intubated 1