What systems should be prioritized when assessing a patient exposed to wildfire smoke?

Assessment of Wildfire Smoke Exposure: Priority Body Systems

When assessing a patient exposed to wildfire smoke, prioritize the respiratory system and cardiovascular system in your review of systems, as these are the two body systems with the strongest evidence for acute morbidity and mortality.

Respiratory System Assessment

The respiratory system is the primary target of wildfire smoke exposure and should be thoroughly evaluated for the following:

Immediate Respiratory Concerns

• Assess for signs of smoke inhalation: soot on face or in nares, dysphonia, dyspnea, wheezing, and blackish sputum 1, 2
• Evaluate airway patency: look for voice modification, stridor, and laryngeal dyspnea, as airway edema can develop progressively even after initial exposure 1, 2
• Monitor oxygen saturation and provide supplemental oxygen as needed 1, 2

Respiratory Disease Exacerbations

• Screen for asthma exacerbations: consistent evidence documents strong associations between wildfire smoke exposure and asthma exacerbations 3
• Assess for COPD exacerbations: there is consistent evidence linking wildfire smoke to chronic obstructive pulmonary disease exacerbations 3
• Evaluate for respiratory infections: growing evidence suggests increased risk of acute respiratory infections and pneumonia following smoke exposure 3, 4

Common Pitfall

Do not be falsely reassured by normal oxygen saturation, normal chest X-ray, or normal arterial blood gases—these do not exclude inhalation injury 5

Cardiovascular System Assessment

The cardiovascular system is the second priority, with substantial evidence linking wildfire smoke to cardiovascular morbidity and mortality:

Acute Cardiovascular Events

• Screen for acute coronary syndrome symptoms: chest pain, dyspnea, diaphoresis, as substantial evidence links short-term wildfire smoke exposure to acute coronary syndrome 6
• Assess for signs of heart failure exacerbation: dyspnea, orthopnea, peripheral edema 4
• Evaluate for arrhythmias: palpitations, syncope, or presyncope 4

Specific Cardiovascular Conditions

• Hypertension shows the greatest susceptibility to wildfire smoke exposure, with the highest hospitalization risk among cardiovascular conditions (relative risk: 1.0051 per 0.1 µg/m³ increase in 3-month smoke PM2.5) 4
• Assess for cerebrovascular symptoms: headache, focal neurological deficits, altered mental status 4
• Screen for ischemic heart disease symptoms: angina, exertional chest discomfort 4

Medium-Term Considerations

• Effects can persist for months: 3-month exposure to smoke PM2.5 is associated with increased hospitalization risks for most cardiorespiratory diseases, with effects persisting up to 3 months after exposure ends 4
• Cardiovascular mortality risk: growing evidence supports an association between wildfire smoke exposure and all-cause mortality, with cardiovascular causes being a significant contributor 6, 3

Vulnerable Populations Requiring Enhanced Surveillance

• Patients with pre-existing respiratory conditions (asthma, COPD) show consistent evidence of increased morbidity 7, 3
• Patients with chronic cardiovascular disease require aggressive management during and after smoke exposure 6
• Pregnant women should be assessed for both maternal and fetal effects, as landscape fire smoke exposure during pregnancy is associated with adverse perinatal outcomes 7
• Neighborhoods with higher deprivation levels show larger effects from smoke exposure 4