What is the treatment for an inhalation burn?

Treatment of Inhalation Burn

Immediately activate EMS for any patient with signs of inhalation injury—this is a life-threatening emergency requiring rapid transport to a specialized burn center, as airway obstruction from edema can develop rapidly and unpredictably. 1

Immediate Recognition and Emergency Activation

Suspect inhalation injury when any of the following are present:

• Fire in an enclosed space 1, 2
• Facial burns 1
• Soot around the nose or mouth 1, 2
• Singed nasal hairs 1, 2
• Difficulty breathing or respiratory distress 1
• Dysphonia (voice changes) 1
• Wheezing 1
• Carbonaceous (blackish) sputum 1, 2
• Stridor or laryngeal dyspnea 1

Critical point: Normal oxygen saturation, normal chest X-ray, and normal arterial blood gases do NOT exclude inhalation injury and should never provide false reassurance. 2

Airway Management - The Priority Decision

Intubate immediately without delay if ANY of these non-specific indications are present:

• Severe respiratory distress 1
• Severe hypoxia or hypercapnia 1
• Coma or altered mental status 1, 2

For patients with severe burns involving the whole face, intubate if ONE OR MORE of these criteria exist:

• Deep circular neck burn 1
• Symptoms of airway obstruction (voice modification, stridor, laryngeal dyspnea) 1
• Very extensive burns (TBSA ≥40%) 1, 2

Important caveat: Patients with face/neck burns who were exposed to vapors or inhaled smoke require close continuous monitoring due to risk of progressive glottic edema and respiratory distress, even if initial assessment appears reassuring. 1, 2 Regular clinical reassessment during transport and after hospital admission is mandatory. 1, 2

Pediatric exception: Tracheal intubation is NOT recommended in children burned by hot fluid (scalding), even with face/skull/neck involvement, unless respiratory distress is present. 1

Technical consideration: Anticipate difficult intubation in these patients and use appropriate difficult airway protocols. 1 Use endotracheal tubes ≥8.0 mm internal diameter when possible. 3

Diagnostic Approach

Bronchoscopy considerations:

• Flexible bronchoscopy is the gold standard for diagnosing smoke inhalation injury, and severity of bronchoscopic findings correlates with morbidity, ICU length of stay, duration of mechanical ventilation, and hypoxemia severity. 1, 2, 3
• However, bronchoscopy should NOT be performed outside burn centers as it delays transfer, carries risk of clinical deterioration, and does not change immediate management decisions. 1
• Bronchoscopy should only be performed in patients who are already intubated due to risk of airway compromise during the procedure. 1
• Bronchoscopy only assesses proximal airways and does not provide comprehensive analysis of pulmonary insult. 2

Carbon monoxide poisoning: Inhalation injury is often indicative of carbon monoxide poisoning, which is the most common cause of death in inhalation injury. 1, 4 Administer 100% oxygen immediately as carbon monoxide dissociation occurs much faster with high-flow oxygen. 4

Supportive Care During Transport

For any associated thermal burns:

• Cool with clean running water for 5-20 minutes if burns are present on skin surfaces. 1
• Remove all jewelry before swelling occurs to prevent vascular ischemia. 1, 5
• Monitor children for hypothermia during cooling. 1

Pain management:

• Administer over-the-counter analgesics (acetaminophen or NSAIDs) for pain control. 1, 5

Transfer to Specialized Care

Direct admission to a burn center is strongly preferred over staged transfer:

• Direct admission reduces time to definitive treatment and improves morbidity and mortality. 1, 5
• The American Burn Association recommends burn center treatment for second- or third-degree burns involving face, hands, feet, genitals, or >10% body surface area (>5% in children). 1
• Smoke inhalation increases pediatric mortality three-fold and significantly increases morbidity even with TBSA <10%. 1

Common pitfall: Approximately one-third of prehospital intubations in burn patients are later deemed unnecessary, and these patients experience more complications than those intubated at burn centers. 1 However, the risk of losing the airway from progressive edema outweighs the risks of intubation when clear criteria are met. The key is careful application of the specific intubation criteria listed above rather than prophylactic intubation based solely on mechanism of injury.