Glutathione for Smoke and Ash Exposure: Not Recommended
Glutathione is not recommended for detoxification from smoke and ash exposure, as there is no evidence supporting its use in this clinical scenario. The established treatment for smoke inhalation focuses on oxygen therapy, bronchodilators, and supportive care for respiratory complications 1, 2.
Evidence-Based Treatment for Smoke and Ash Exposure
Immediate Management Priorities
Oxygen therapy is the cornerstone of treatment for smoke inhalation injury:
- Administer high-flow oxygen (40-60%) via face mask or Venturi mask to maintain oxygen saturation ≥90% (≥92% preferred) 1, 3
- For severe cases with carbon monoxide poisoning, hyperbaric oxygen at 3.0 atm abs should be considered, with up to three treatments for persistently symptomatic patients 1
- Arterial blood gas monitoring is essential to assess for hypoxemia and metabolic acidosis 1
Respiratory Support and Bronchodilator Therapy
Bronchodilators should be administered for bronchospasm and airway irritation:
- Nebulized salbutamol 5 mg via oxygen-driven nebulizer every 20-30 minutes for initial treatment 3, 4
- Add ipratropium bromide 100 mcg to nebulizer, repeated every 6 hours for severe bronchospasm 3
- Continue bronchodilators every 4 hours as symptoms improve 3
Assessment for Severe Complications
Evaluate for life-threatening complications that require immediate intervention:
- Check for signs of severe metabolic acidosis (pH <7.20) or lactate ≥10 mmol/L, which may indicate concomitant cyanide poisoning if exposure was from a house fire 1
- Consider empiric treatment with hydroxocobalamin for cyanide poisoning in patients with severe metabolic acidosis from structural fires 1
- Assess for upper airway obstruction (singed nasal hair, carbonaceous sputum, stridor) which may require early intubation 2, 5
Corticosteroid Consideration
For patients developing significant airway inflammation or bronchospasm:
- Oral prednisolone 1-2 mg/kg (maximum 40-60 mg) as a single dose for moderate to severe bronchospasm 3, 4
- Continue daily corticosteroids if persistent airway hyperreactivity develops 3
Why Glutathione Is Not Indicated
The rationale against glutathione use:
While glutathione is an important endogenous antioxidant that protects against oxidative stress 6, 7, 8, there is no clinical evidence from any guideline or high-quality study supporting exogenous glutathione administration for smoke inhalation injury. The body synthesizes glutathione endogenously, and supplementation has not been validated for this indication 8.
The established guidelines for smoke inhalation from the American Journal of Respiratory and Critical Care Medicine make no mention of glutathione or antioxidant supplementation 1. Treatment focuses exclusively on oxygen therapy, airway management, and supportive care 1, 2.
Monitoring and Follow-Up
All patients require structured follow-up:
- Clinical reassessment 1-2 months after exposure to evaluate for delayed neurological sequelae (memory disturbance, depression, anxiety, motor dysfunction) 1
- Pulmonary function testing if respiratory symptoms persist 2
- Chest imaging if pneumonia develops, as bacterial pneumonia is common in patients surviving initial smoke injury 2
Critical Pitfalls to Avoid
- Do not delay oxygen therapy while pursuing unproven "detoxification" treatments 1
- Do not miss cyanide poisoning in house fire victims with severe metabolic acidosis 1
- Do not underestimate delayed complications such as pulmonary edema (may occur days after exposure) or pneumonia (occurs in most survivors) 2
- Do not discharge patients prematurely without ensuring adequate oxygenation and resolution of bronchospasm 3