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
• Examine 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

Intubation Criteria

Perform immediate intubation 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

• For patients without immediate intubation indications, closely monitor and regularly reassess as airway edema develops progressively over time 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 carbon monoxide poisoning after smoke inhalation due to conflicting evidence and potential risks 1
• Consider HBOT only on a case-by-case basis for: 1
  • Pregnant women with any CO exposure
  • Patients with altered consciousness or coma
  • Those with neurological, respiratory, cardiac, or psychological symptoms

Cyanide Poisoning Management

• Hydroxocobalamin should NOT be routinely administered after smoke inhalation 1, 2

• Restrict hydroxocobalamin to specific high-risk scenarios only: 1

  • Adults with high suspicion of severe cyanide poisoning AND plasma lactate ≥8-10 mmol/L
  • Children with moderate signs (GCS ≤13, confusion, stridor, hoarse voice, polypnea, dyspnea, soot in airways) 2
  • Children with severe signs (GCS ≤8, seizures, coma, mydriasis, severe hemodynamic disorders, respiratory depression, plasma lactate >8 mmol/L) 2

• Dosing when indicated: 1, 2

  • Adults: 5g (10g for cardiac arrest)
  • Pediatrics: 70 mg/kg (maximum 5g)

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, and duration of mechanical ventilation 1, 2
• Maintain bronchial hygiene through therapeutic coughing, chest physiotherapy, deep breathing exercises, and early ambulation 3
• Consider bronchodilators (beta-2 agonists, racemic epinephrine) and nebulization therapy for airway management 3

External Burn Management

• Remove all burning materials and flammable substances from the patient immediately 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 pediatric patients 2
• Consider escharotomy if deep burns induce compartment syndrome affecting airways, respiration, or circulation 1, 2

Referral to Specialized Care

Transfer directly to a burn center rather than through intermediate facilities if any of the following are present: 1, 2

• Second- or third-degree burns involving face, hands, feet, or genitals

• Burns >5% body surface area in children

• Any smoke inhalation injury (increases pediatric mortality three-fold) 2

• TBSA ≥40% with facial burns 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

Critical Pitfalls to Avoid

• Never delay intubation when signs of airway compromise are present—airway edema progresses rapidly and can make delayed intubation extremely difficult or impossible 1
• Do not rely on pulse oximetry readings alone—they are falsely elevated in carbon monoxide poisoning 1
• Avoid routine administration of hydroxocobalamin without clear indications of cyanide toxicity, as evidence for effectiveness is insufficient and risks exist 1
• Do not routinely use HBOT for all CO poisoning cases—reserve for highly selected patients only 1