What is the treatment for smoke inhalation?

Treatment of Smoke Inhalation

Immediately administer 100% oxygen to all patients with suspected smoke inhalation, secure the airway early if any signs of compromise are present, and avoid routine use of hydroxocobalamin or hyperbaric oxygen therapy unless specific high-risk criteria are met. 1

Immediate Oxygen Therapy

• Administer high-concentration oxygen (100% FiO2) immediately to all patients with suspected smoke inhalation, regardless of pulse oximetry readings, which can be falsely elevated in carbon monoxide poisoning 1
• Continue oxygen therapy via high-concentration mask for spontaneously breathing patients, or 100% FiO2 for 6-12 hours if mechanically ventilated 1
• Do not delay oxygen therapy pending diagnostic test results—this is mandatory for all suspected cases 1

Airway Assessment and Management

Initial Assessment Signs

• Look for voice modification, stridor, laryngeal dyspnea, dysphonia, or hoarse voice as indicators of airway compromise 1
• Assess for soot on face/in nares, blackish or carbonaceous sputum, facial burns, or singed nasal hairs 1, 2
• Monitor for wheezing, dyspnea, polypnea, or respiratory distress 1, 2

Immediate Intubation Indications

Intubate immediately without delay if any of the following are present: 1, 2

• Severe hypoxia or hypercapnia
• Altered mental status, confusion, or coma (GCS ≤13)
• Signs of airway obstruction (stridor, severe respiratory distress)
• Deep circular neck burns or extensive facial burns with TBSA ≥40% 2

Monitoring Without Immediate Intubation

• For patients without immediate intubation indications, closely monitor and regularly reassess airway status as edema may develop progressively over hours 1
• Common pitfall: Delaying intubation when signs of airway compromise are present—intubate early before edema makes the procedure difficult 1

Carbon Monoxide Poisoning Management

• Continue 100% oxygen therapy until carboxyhemoglobin levels normalize and symptoms resolve 2
• Hyperbaric oxygen therapy (HBOT) should NOT be routinely administered for smoke inhalation with CO poisoning due to conflicting evidence and potential risks 1
• Consider HBOT only in highly selected cases: 1
  • Pregnant women with any CO exposure
  • Patients with altered consciousness or coma
  • Neurological, respiratory, cardiac, or psychological symptoms
  • Children with CO poisoning and impaired consciousness

Cyanide Poisoning Management

When to Restrict Hydroxocobalamin

• Hydroxocobalamin should NOT be routinely administered after smoke inhalation 1, 2
• Common pitfall: Routine administration of hydroxocobalamin without clear indications of cyanide toxicity 1

Specific Indications for Hydroxocobalamin

Consider hydroxocobalamin only in these scenarios: 1, 2

Adults:

• High suspicion of severe cyanide poisoning
• Severe metabolic acidosis
• Plasma lactate ≥8-10 mmol/L
• Dosage: 5g (10g for cardiac arrest) 1

Children:

• Moderate poisoning: GCS ≤13, confusion, stridor, hoarse voice, polypnea, dyspnea, soot particles in airways 2
• Severe poisoning: GCS ≤8, seizures, coma, mydriasis, severe hemodynamic disorders, collapse, respiratory depression, plasma lactate >8 mmol/L 2
• Dosage: 70 mg/kg (maximum 5g) 1, 2

Respiratory Support and Diagnostics

• Perform flexible bronchoscopy at a burn center to assess severity of inhalation injury, as findings correlate with morbidity, ICU length of stay, duration of mechanical ventilation, and hypoxemia severity 1, 2
• Implement bronchial hygiene measures including chest physiotherapy, therapeutic coughing, and deep breathing exercises 3
• Consider bronchodilators (beta-2 agonists, racemic epinephrine) and nebulization therapy for airway management 4, 3
• Aerosolized N-acetylcysteine and heparin may improve oxygenation 3

External Burn Management

• Remove all burning materials and flammable substances from the patient 1
• Cool thermal burns with clean running water for 5-20 minutes 1, 2
• Remove all jewelry before swelling occurs 2
• Monitor for hypothermia during cooling, especially in children 2
• Consider escharotomy if deep burns induce compartment syndrome affecting airways, respiration, or circulation 1, 2

Referral to Specialized Care

Seek immediate referral to a burn center for: 1, 2

• Any suspected smoke inhalation injury
• Second- or third-degree burns involving face, hands, feet, or genitals
• Burns >5% body surface area in children
• Admit directly to a burn center rather than transferring through intermediate facilities, as this reduces time to definitive treatment and improves morbidity and mortality 1, 2
• Consider telemedicine for initial assessment if burn specialists are not readily available 1

Follow-Up Care

• All patients treated for acute CO poisoning require clinical follow-up at 1-2 months post-event to assess for delayed neurological sequelae, including memory disturbance, depression, anxiety, vestibular problems, and motor dysfunction 1, 2