What is the most appropriate management for a patient with symptoms of tracheal irritation, sore throat, and dysphonia (voice change) after smoke inhalation, presenting with tachypnea (increased respiratory rate), tachycardia (increased heart rate), and normal oxygen saturation on room air, but without signs of severe respiratory distress or failure?

From the Guidelines

The most appropriate management for this patient is bronchoscopy (option A). This 35-year-old man presents with symptoms concerning for inhalation injury following smoke exposure in a house fire, including tracheal irritation, sore throat, voice changes, and dysphonia. Despite having normal oxygen saturation and clear lung fields, the presence of oropharyngeal edema is particularly concerning for upper airway involvement. According to the clinical practice guideline on hoarseness (dysphonia) 1, clinicians should assess the patient with dysphonia by history and physical examination to identify factors where expedited laryngeal evaluation is indicated, such as recent surgical procedures involving the head, neck, or chest, or respiratory distress. Although this patient does not exhibit respiratory distress or stridor, the recent smoke exposure and presence of dysphonia warrant further evaluation.

• Key points to consider in this patient's management include:
  • The need for direct visualization of the airway to assess the extent of thermal injury
  • The potential for inhalation injuries to progress over 24-48 hours, leading to life-threatening airway compromise
  • The importance of guiding subsequent management decisions, including the potential need for intubation
• Other options, such as methylprednisolone (option B), nebulized epinephrine (option C), and noninvasive positive pressure ventilation (option D), are not the first-line approach in this scenario. Methylprednisolone might help reduce inflammation, but its use should be guided by the diagnosis and extent of injury. Nebulized epinephrine could temporarily reduce airway edema but does not address the underlying need for assessment. Noninvasive positive pressure ventilation is not indicated in a patient with potential upper airway obstruction as it may worsen the situation. The guideline recommends against routine prescription of corticosteroids for patients with dysphonia prior to visualization of the larynx 1, which further supports the decision to prioritize bronchoscopy.

From the Research

Management of Inhalation Injury

The patient presents with symptoms of tracheal irritation, sore throat, and a change in voice after being rescued from a burning home. The physical examination reveals dysphonia, nonobstructing edema of the oropharynx, and no soot or burns on the face, neck, or thorax.

Diagnostic Approach

• The use of bronchoscopy is recommended to assess the severity of inhalation injury 2, 3, 4.
• Bronchoscopy can help identify the extent of the injury and guide appropriate airway management decisions 2.
• A study suggests that stratification of bronchoscopically-assessed inhalational injury into three categories can provide useful prognostic information about duration of ventilation and mortality 3.

Treatment Options

• The patient's symptoms and physical examination findings suggest the need for further evaluation and management of the inhalation injury.
• Bronchoscopy is the most appropriate management option to assess the severity of the injury and guide further treatment 5, 2, 3, 6, 4.
• The other options, such as methylprednisolone, nebulized epinephrine, and noninvasive positive pressure ventilation, may be considered based on the results of the bronchoscopy and the patient's overall clinical condition.

Recommended Course of Action

• Perform bronchoscopy to assess the severity of the inhalation injury and guide further management 2, 3, 4.