Steroid Role in Inhalational Burns
Corticosteroids are not recommended in the treatment of inhalational burns, as prophylactic use has not been shown to be beneficial and is associated with potential harm. 1
Evidence Against Corticosteroid Use
The most recent and highest quality systematic review examining inhalation injury management explicitly states that prophylactic corticosteroids are not recommended in this patient population. 1 This evidence-based review, which analyzed 56 papers using PRISMA guidelines, found no support for steroid use in inhalational burns despite examining multiple therapeutic strategies.
Pathophysiologic Rationale for Avoiding Steroids
Inhalational injury creates a complex cascade of respiratory insults including:
- Mucosal hyperemia leading to airway edema 2
- Increased mucus secretion and plasma transudation into airways 2
- Airway obstruction from casts formed by epithelial debris, fibrin clots, and inspissated mucus 2
- Increased risk for pneumonia (the leading cause of death in these patients) 3
Corticosteroids would theoretically suppress the immune response at a time when patients are already at heightened risk for infectious complications, particularly pneumonia. 3
Supported Treatment Strategies Instead
The evidence supports the following interventions for inhalational burns rather than steroids:
- Bronchoscopy with suctioning to remove debris 1, 2
- Nebulized heparin for fibrin casts 1, 2
- Nebulized N-acetylcysteine for mucus casts 1, 2
- Bronchodilators for airway management 1, 2
- Permissive hypercapnia as a ventilation strategy 1
- Hydroxocobalamin for cyanide toxicity 1, 2
Clinical Outcomes Without Steroids
Studies examining inhalational burn outcomes demonstrate that mortality is primarily driven by:
- Extent of total body surface area (TBSA) involvement (mean 70% TBSA in fatal cases vs 50% in survivors) 4
- Development of acute respiratory distress syndrome 4
- Multi-organ failure 4, 5
- Pneumonia development 3
Mortality rates in inhalational injury patients reach 71% compared to 26% in cutaneous burns alone, emphasizing the severity of this injury pattern. 5 The addition of corticosteroids has not been shown to improve these outcomes and may worsen infectious complications.
Critical Pitfall to Avoid
Do not administer prophylactic antibiotics or corticosteroids in inhalational burns. 1 Antibiotics should only be given when bacterial infection is confirmed, and steroids lack evidence of benefit while carrying potential harm in this immunocompromised, infection-prone population. 1