Smoke Inhalation

Key Features

• Among patients treated for burn injuries, 33% also have pulmonary injury from smoke inhalation

• Inhalation injury occurs as a result of impaired oxygenation, thermal injury to the upper airway, and lung injury to the lower airways and lung parenchyma

Clinical Findings

• Bronchorrhea and bronchospasm are seen early after exposure along with dyspnea, tachypnea, and tachycardia

• Labored breathing and cyanosis may follow

• Diffuse wheezing and rhonchi

• Acute respiratory distress syndrome (ARDS) may develop 1–2 days after exposure

• Sloughing of the airway mucosa may occur in 2–3 days, leading to airway obstruction, atelectasis, and worsening hypoxemia

• Bacterial colonization and pneumonia are common 5–7 days after exposure

• Complications become evident by 18–24 hours and include

  • Mucosal edema, upper airway obstruction, and impaired ability to clear secretions, all of which produce inspiratory stridor

  • Respiratory failure in severe cases

Diagnosis

• Arterial blood gases (ABGs) are necessary to evaluate oxygenation and rule out carbon monoxide poisoning

• Examination of the upper airway with a laryngoscope or bronchoscope is superior to physical examination

Treatment

• Supplemental oxygen, humidified air, bronchodilators, and suctioning of mucosal debris and secretions, elevation of the head to 30 degrees, topical epinephrine

• Endotracheal intubation often necessary to establish airway patency and likely needed with deep facial burns or oropharyngeal or laryngeal edema; tracheostomy should be avoided

• Positive end-expiratory pressure has been advocated when there is pulmonary edema

• Fluid management and close monitoring for secondary bacterial infection

• Helium-oxygen (Heliox) helpful if labored breathing

• Corticosteroids may be harmful

• Monitoring for bacterial infection is important, but prophylactic antibiotics are not recommended

• Close monitoring with ABGs and oximetry