How to manage a patient with breathing difficulties who was discharged yesterday for inhalation poisoning?

Management of a Patient with Breathing Difficulties Following Inhalation Poisoning

For a patient who was discharged yesterday for inhalation poisoning and is now experiencing breathing difficulties, immediate administration of 100% oxygen therapy is the primary intervention while preparing for possible airway management.1

Initial Assessment

• Assess for warning signs of respiratory compromise: stridor, obstructed breathing pattern, agitation, and oxygen saturation 1
• Check vital signs including respiratory rate, heart rate, blood pressure, peripheral oxygen saturation, and temperature 1
• Evaluate for signs of upper airway obstruction (dysphonia, stridor) which indicate severe poisoning 2
• Monitor for signs of delayed respiratory complications which can occur even in non-burned victims 2

Immediate Management

• Administer 100% high-flow oxygen immediately to accelerate elimination of carbon monoxide (COHb) and alleviate tissue hypoxia 1
• Position the patient upright to optimize respiratory mechanics 1
• Establish IV access for potential medication administration 3
• Consider nebulized albuterol (2.5 mg) for bronchospasm if wheezing is present 4

Respiratory Support

• For mild respiratory distress, consider high-flow nasal oxygen therapy targeting SaO2 92-97% 3
• If respiratory distress worsens or doesn't improve within 1-2 hours, prepare for possible intubation 1
• Non-invasive ventilation (NIV) should be used cautiously as failure rates can be high in acute respiratory distress 1, 3
• Monitor closely for signs of deterioration if using NIV or high-flow oxygen 1

Advanced Airway Management (If Required)

• If intubation becomes necessary due to worsening respiratory status:
  • Ensure appropriate equipment is immediately available including difficult airway trolley 1
  • Use rapid sequence induction technique 3
  • Consider videolaryngoscopy to improve first-pass success 3
  • Ensure proper pre-oxygenation with a well-fitting mask 3

Pharmacological Interventions

• If upper respiratory obstruction/stridor develops, consider nebulized adrenaline (1 mg) to reduce airway edema 1
• For inflammatory airway edema, administer steroids (equivalent to 100 mg hydrocortisone every 6 hours) 1
• Continue steroids for at least 12 hours if started, as single doses are ineffective 1
• For bronchospasm, administer albuterol via nebulization (2.5 mg) three to four times daily 4

Monitoring and Follow-up

• Implement continuous monitoring of oxygen saturation, respiratory rate, and if available, end-tidal carbon dioxide 1
• Consider capnography (using a specially designed facemask) for early detection of airway obstruction 1
• Remember that pulse oximetry alone is not designed to be a monitor of ventilation and can give incorrect readings 1
• Never ignore a patient who is agitated or complains of difficulty breathing, even if objective signs are absent 1

Special Considerations

• If carbon monoxide poisoning is suspected, continue 100% oxygen until COHb levels are normal (<3%) 1
• For patients with significant carbon monoxide exposure, consider hyperbaric oxygen therapy, especially if neurological symptoms are present 1
• Be vigilant for signs of mediastinitis (severe sore throat, deep cervical pain, chest pain, dysphagia, fever, crepitus) which can occur after airway injury 1
• Monitor for delayed neurological and respiratory complications which can develop even after initial stabilization 2

Transport Considerations

• If the patient requires transfer to a higher level of care, ensure continuous oxygen therapy and monitoring during transport 1
• An appropriately skilled provider should accompany the patient during transfer if respiratory status is unstable 1
• Communicate clearly with the receiving facility about the patient's condition and treatments administered 1