Smoke inhalation injury is a major determinant of morbidity and mortality in fire victims. It is a complex multifaceted injury affecting initially the airway; however, in short time, it can become a complex life-threatening systemic disease affecting every organ in the body. In this review, we provide a summary of the underlying pathophysiology of organ dysfunction and provide an up-to-date survey of the various critical care modalities that have been found beneficial in caring for these patients. Major pathophysiological change is development of edema in the respiratory tract. The tracheobronchial tree is injured by steam and toxic chemicals, leading to bronchoconstriction. Lung parenchyma is damaged by the release of proteolytic elastases, leading to release of inflammatory mediators, increase in transvascular flux of fluids, and development of pulmonary edema and atelectasis. Decreased levels of surfactant and immunomodulators such as interleukins and tumor-necrosis-factor-α accentuate the injury. A primary survey is conducted at the site of fire, to ensure adequate airway, breathing, and circulation. A good intravenous access is obtained for the administration of resuscitation fluids. Early intubation, preferably with fiberoptic bronchoscope, is prudent before development of airway edema. Bronchial hygiene is maintained, which involves therapeutic coughing, chest physiotherapy, deep breathing exercises, and early ambulation. Pharmacological agents such as beta-2 agonists, racemic epinephrine, N-acetyl cysteine, and aerosolized heparin are used for improving oxygenation of lungs. Newer agents being tested are perfluorohexane, porcine pulmonary surfactant, and ClearMate. Early diagnosis and treatment of smoke inhalation injury are the keys for better outcome.
Yurt RW, Bessey PQ, Bauer GJ, Dembicki R, Laznick H, Alden N, et al. A regional burn center's response to a disaster: September 11, 2001, and the days beyond. J Burn Care Rehabil 2005;26:117-24.
You K, Yang HT, Kym D, Yoon J, HaejunYim, Cho YS, et al. Inhalation injury in burn patients: Establishing the link between diagnosis and prognosis. Burns 2014;40:1470-5.
Einhorn IN. Physiological and toxicological aspects of smoke produced during the combustion of polymeric materials. Environ Health Perspect 1975;11:163-89.
Rong YH, Liu W, Wang C, Ning FG, Zhang GA. Temperature distribution in the upper airway after inhalation injury. Burns 2011;37:1187-91.
Gamsu G, Weintraub RM, Nadel JA. Clearance of tantalum from airways of different caliber in man evaluated by a roentgenographic method. Am Rev Respir Dis 1973;107:214-24.
Moore SJ, Ho IK, Hume AS. Severe hypoxia produced by concomitant intoxication with sublethal doses of carbon monoxide and cyanide. Toxicol Appl Pharmacol 1991;109:412-20.
Cox RA, Burke AS, Jacob S, Oliveras G, Murakami K, Shimoda K, et al. Activated nuclear factor kappa B and airway inflammation after smoke inhalation and burn injury in sheep. J Burn Care Res 2009;30:489-98.
Baile EM, Dahlby RW, Wiggs BR, Paré PD. Role of tracheal and bronchial circulation in respiratory heat exchange. J Appl Physiol (1985) 1985;58:217-22.
Traber DL, Traber LD. Airway blood flow changes and airway obstruction following lung injury. Arch Physiol Biochem 2003;111:297-300.
Hamahata A, Enkhbaatar P, Sakurai H, Nozaki M, Traber DL. Effect of ablated bronchial blood flow on survival rate and pulmonary function after burn and smoke inhalation in sheep. Burns 2009;35:802-10.
Lund T. The 1999 everett idris evans memorial lecture. Edema generation following thermal injury: An update. J Burn Care Rehabil 1999;20:445-52.
Cox RA, Mlcak RP, Chinkes DL, Jacob S, Enkhbaatar P, Jaso J, et al. Upper airway mucus deposition in lung tissue of burn trauma victims. Shock 2008;29:356-61.
Maybauer MO, Rehberg S, Traber DL, Herndon DN, Maybauer DM. Pathophysiology of acute lung injury in severe burn and smoke inhalation injury. Anaesthesist 2009;58:805-12.
de Carvalho FO, Felipe FA, de Melo Costa AC, Teixeira LG, Silva ÉR, Nunes PS, et al. Inflammatory mediators and oxidative stress in animals subjected to smoke inhalation: A Systematic review. Lung 2016;194:487-99.
Murakami K, Enkhbaatar P, Yu YM, Traber LD, Cox RA, Hawkins HK, et al. L-arginine attenuates acute lung injury after smoke inhalation and burn injury in sheep. Shock 2007;28:477-83.
Gerö D, Szabó C. Poly (ADP-ribose) polymerase: A new therapeutic target? Curr Opin Anaesthesiol 2008;21:111-21.
Westphal M, Cox RA, Traber LD, Morita N, Enkhbaatar P, Schmalstieg FC, et al. Combined burn and smoke inhalation injury impairs ovine hypoxic pulmonary vasoconstriction. Crit Care Med 2006;34:1428-36.
Davis CS, Albright JM, Carter SR, Ramirez L, Kim H, Gamelli RL, et al. Early pulmonary immune hyporesponsiveness is associated with mortality after burn and smoke inhalation injury. J Burn Care Res 2012;33:26-35.
Rose JJ, Wang L, Xu Q, McTiernan CF, Shiva S, Tejero J, et al. Carbon monoxide poisoning: Pathogenesis, management, and future directions of therapy. Am J Respir Crit Care Med 2017;195:596-606.
Hampson NB. Noninvasive pulse CO-oximetry expedites evaluation and management of patients with carbon monoxide poisoning. Am J Emerg Med 2012;30:2021-4.
Anseeuw K, Delvau N, Burillo-Putze G, De Iaco F, Geldner G, Holmström P, et al. Cyanide poisoning by fire smoke inhalation: A European expert consensus. Eur J Emerg Med 2013;20:2-9.
Lawson-Smith P, Jansen EC, Hyldegaard O. Cyanide intoxication as part of smoke inhalation – A review on diagnosis and treatment from the emergency perspective. Scand J Trauma Resusc Emerg Med 2011;19:14.
Cha SI, Kim CH, Lee JH, Park JY, Jung TH, Choi WI, et al. Isolated smoke inhalation injuries: Acute respiratory dysfunction, clinical outcomes, and short-term evolution of pulmonary functions with the effects of steroids. Burns 2007;33:200-8.
Rue LW 3rd, Cioffi WG, Mason AD Jr., McManus WF, Pruitt BA Jr. The risk of pneumonia in thermally injured patients requiring ventilatory support. J Burn Care Rehabil 1995;16:262-8.
Edelman DA, Khan N, Kempf K, White MT. Pneumonia after inhalation injury. J Burn Care Res 2007;28:241-6.
Fang-Gang N, Yang C, Yu-Xuan Q, Yan-Hua R, Wei-Li D, Cheng W, et al. Laryngeal morphologic changes and epidemiology in patients with inhalation injury: A retrospective study. Burns 2015;41:1340-6.
Cao L, Zhang XG, Wang JG, Wang HB, Chen YB, Zhao DH, et al. Pulmonary function test findings in patients with acute inhalation injury caused by smoke bombs. J Thorac Dis 2016;8:3160-7.
Ogura H, Sumi Y, Matsushima A, Tohma Y, Inoue Y, Tasaki O, et al. Smoke inhalation injury: Diagnosis and respiratory management. Nihon Geka Gakkai Zasshi 2005;106:740-4.
Sheridan RL. Airway management and respiratory care of the burn patient. Int Anesthesiol Clin 2000;38:129-45.
Toon MH, Maybauer MO, Greenwood JE, Maybauer DM, Fraser JF. Management of acute smoke inhalation injury. Crit Care Resusc 2010;12:53-61.
Enkhbaatar P, Pruitt BA Jr., Suman O, Mlcak R, Wolf SE, Sakurai H, et al. Pathophysiology, research challenges, and clinical management of smoke inhalation injury. Lancet 2016;388:1437-46.
Koljonen V, Maisniemi K, Virtanen K, Koivikko M. Multi-detector computed tomography demonstrates smoke inhalation injury at early stage. Emerg Radiol 2007;14:113-6.
Mosier MJ, Pham TN, Park DR, Simmons J, Klein MB, Gibran NS, et al. Predictive value of bronchoscopy in assessing the severity of inhalation injury. J Burn Care Res 2012;33:65-73.
Suri JC, Sen MK. Respiratory tract injury in burns. In: Sarabahi S, editor. Principles and Practice of Burn Care. 1st ed. New Delhi: Jaypee Brothers Medical Publishers Ltd.; 2010. p. 129-30.
Yamamura H, Kaga S, Kaneda K, Mizobata Y. Chest computed tomography performed on admission helps predict the severity of smoke-inhalation injury. Crit Care 2013;17:R95.
Albright JM, Davis CS, Bird MD, Ramirez L, Kim H, Burnham EL, et al. The acute pulmonary inflammatory response to the graded severity of smoke inhalation injury. Crit Care Med 2012;40:1113-21.
Hassan Z, Wong JK, Bush J, Bayat A, Dunn KW. Assessing the severity of inhalation injuries in adults. Burns 2010;36:212-6.
Wachtel TL. Major burns. What to do at the scene and en route to the hospital. Postgrad Med 1989;85:178-83, 186-93, 196.
Madnani DD, Steele NP, de Vries E. Factors that predict the need for intubation in patients with smoke inhalation injury. Ear Nose Throat J 2006;85:278-80.
Haponik EF, Meyers DA, Munster AM, Smith PL, Britt EJ, Wise RA, et al. Acute upper airway injury in burn patients. Serial changes of flow-volume curves and nasopharyngoscopy. Am Rev Respir Dis 1987;135:360-6.
Purdue GF. To trach or not to trach. J Burn Care Res 2009;30:192-3.
Inoue T, Okabayashi K, Ohtani M, Yamanoue T, Wada S, Iida K, et al. Effect of smoke inhalation injury on fluid requirement in burn resuscitation. Hiroshima J Med Sci 2002;51:1-5.
Silverberg R, Johnson J, Gorga D, Nagler W, Goodwin C. A survey of the prevalence and application of chest physical therapy in U.S. Burn centers. J Burn Care Rehabil 1995;16:154-9.
Palmieri TL, Enkhbaatar P, Bayliss R, Traber LD, Cox RA, Hawkins HK, et al. Continuous nebulized albuterol attenuates acute lung injury in an ovine model of combined burn and smoke inhalation. Crit Care Med 2006;34:1719-24.
Palmieri TL, Enkhbaatar P, Sheridan R, Traber DL, Greenhalgh DG. Studies of inhaled agents in inhalation injury. J Burn Care Res 2009;30:169-71.
Jonkam C, Zhu Y, Jacob S, Rehberg S, Kraft E, Hamahata A, et al. Muscarinic receptor antagonist therapy improves acute pulmonary dysfunction after smoke inhalation injury in sheep. Crit Care Med 2010;38:2339-44.
Lopez E, Fujiwara O, Lima-Lopez F, Suman OE, Mlcak RP, Hawkins HK, et al. Nebulized epinephrine limits pulmonary vascular hyperpermeability to water and protein in ovine with burn and smoke inhalation injury. Crit Care Med 2016;44:e89-96.
Foncerrada G, Lima F, Clayton RP, Mlcak RP, Enkhbaatar P, Herndon DN, et al. Safety of nebulized epinephrine in smoke inhalation injury. J Burn Care Res 2017;38:396-402.
Csontos C, Rezman B, Foldi V, Bogar L, Drenkovics L, Röth E, et al. Effect of N-acetylcysteine treatment on oxidative stress and inflammation after severe burn. Burns 2012;38:428-37.
Miller AC, Elamin EM, Suffredini AF. Inhaled anticoagulation regimens for the treatment of smoke inhalation-associated acute lung injury: A systematic review. Crit Care Med 2014;42:413-9.
Enkhbaatar P, Herndon DN, Traber DL. Use of nebulized heparin in the treatment of smoke inhalation injury. J Burn Care Res 2009;30:159-62.
McCall JE, Cahill TJ. Respiratory care of the burn patient. J Burn Care Rehabil 2005;26:200-6.
Desai MH, Mlcak R, Richardson J, Nichols R, Herndon DN. Reduction in mortality in pediatric patients with inhalation injury with aerosolized heparin/N-acetylcystine [correction of acetylcystine] therapy. J Burn Care Rehabil 1998;19:210-2.
Niedermayr M, Schramm W, Kamolz L, Andel D, Römer W, Hoerauf K, et al. Antithrombin deficiency and its relationship to severe burns. Burns 2007;33:173-8.
Murakami K, McGuire R, Cox RA, Jodoin JM, Schmalstieg FC, Traber LD, et al. Recombinant antithrombin attenuates pulmonary inflammation following smoke inhalation and pneumonia in sheep. Crit Care Med 2003;31:577-83.
Kowal-Vern A, Orkin BA. Antithrombin in the treatment of burn trauma. World J Crit Care Med 2016;5:17-26.
Nakae H, Tanaka H, Inaba H. Failure to clear casts and secretions following inhalation injury can be dangerous: Report of a case. Burns 2001;27:189-91.
Weaver LK, Howe S, Hopkins R, Chan KJ. Carboxyhemoglobin half-life in carbon monoxide-poisoned patients treated with 100% oxygen at atmospheric pressure. Chest 2000;117:801-8.
Fisher JA, Iscoe S, Fedorko L, Duffin J. Rapid elimination of CO through the lungs: Coming full circle 100 years on. Exp Physiol 2011;96:1262-9.
Wu W, Ma Y, Jiang F. A clinical study of treatment for delayed psychoneural sequela caused by acute CO poisoning with clear mate gas poisoning first aid ventilator. Chin J Hosp Pharm 2016;36:425.
Bebarta VS, Pitotti RL, Dixon P, Lairet JR, Bush A, Tanen DA, et al. Hydroxocobalamin versus sodium thiosulfate for the treatment of acute cyanide toxicity in a swine (Sus scrofa) model. Ann Emerg Med 2012;59:532-9.
Nguyen L, Afshari A, Kahn SA, McGrane S, Summitt B. Utility and outcomes of hydroxocobalamin use in smoke inhalation patients. Burns 2017;43:107-13.
Mlcak R, Cortiella J, Desai M, Herndon D. Lung compliance, airway resistance, and work of breathing in children after inhalation injury. J Burn Care Rehabil 1997;18:531-4.
Dries DJ. Key questions in ventilator management of the burn-injured patient (second of two parts). J Burn Care Res 2009;30:211-20.
Reper P, van Looy K. Chest physiotherapy using intrapulmonary percussive ventilation to treat persistent atelectasis in hypoxic patients after smoke inhalation. Burns 2013;39:192-3.
Miller AC, Ferrada PA, Kadri SS, Nataraj-Bhandari K, Vahedian-Azimi A, Quraishi SA, et al. High-frequency ventilation modalities as salvage therapy for smoke inhalation-associated acute lung injury: A Systematic review. J Intensive Care Med 2017;1-11:885066617714770. doi: 10.1177/0885066617714770. [Epub ahead of print]
Hale DF, Cannon JW, Batchinsky AI, Cancio LC, Aden JK, White CE, et al. Prone positioning improves oxygenation in adult burn patients with severe acute respiratory distress syndrome. J Trauma Acute Care Surg 2012;72:1634-9.
Thompson JT, Molnar JA, Hines MH, Chang MC, Pranikoff T. Successful management of adult smoke inhalation with extracorporeal membrane oxygenation. J Burn Care Rehabil 2005;26:62-6.
Ding H, Lv Q, Wu S, Hou S, Liu Z, Landén NX, et al. Intratracheal instillation of perfluorohexane modulates the pulmonary immune microenvironment by attenuating early inflammatory factors in patients with smoke inhalation injury: A Randomized controlled clinical trial. J Burn Care Res 2017;38:251-9.
Sun Y, Qiu X, Wu G, Wang J, Li J, Tang H, et al. The effects of porcine pulmonary surfactant on smoke inhalation injury. J Surg Res 2015;198:200-7.
Hamahata A, Enkhbaatar P, Lange M, Yamaki T, Nakazawa H, Nozaki M, et al. Administration of a peroxynitrite decomposition catalyst into the bronchial artery attenuates pulmonary dysfunction after smoke inhalation and burn injury in sheep. Shock 2012;38:543-8.
Han ZH, Jiang YI, Duan YY, Wang XY, Huang Y, Fang TZ, et al. Protective effects of hydrogen sulfide inhalation on oxidative stress in rats with cotton smoke inhalation-induced lung injury. Exp Ther Med 2015;10:164-8.