Inhalation Injury

Immediately remove smoldering or restrictive clothing, administer oxygen, and perform an ABC assessment. A closed-space explosion or fire, singed nasal vibrissae, carbonaceous sputum, or elevated carbon monoxide or cyanide levels should trigger focused evaluation for inhalation injury. acepacepAmerican College of Emergency Physicians | ACEP

Proceed with early endotracheal intubation when airway injury is present or there is concern for progressive obstruction. Mucosal swelling and edema can progressively obliterate normal upper-airway structures; delaying airway control converts a controlled procedure into a difficult or failed airway. acepacepAmerican College of Emergency Physicians | ACEP

Separate upper-airway thermal injury from lower-airway toxic injury at the bedside. Inhaled heat predominantly injures the upper airway because heat dissipates efficiently above the vocal cords, whereas smoke particulates and respiratory irritants produce distal airway inflammation, edema, casts, obstruction, and ventilation-perfusion mismatch. A reassuring initial oropharyngeal examination does not exclude evolving tracheobronchial injury. ScienceDirect+1ScienceDirect2 Smoke inhalation and airway injury - ScienceDirectScienceDirectManagement of acute smoke inhalation injury - ScienceDirect

If respiratory failure develops, use invasive mechanical ventilation and frequent reassessment for obstruction, declining compliance, pulmonary edema, and acute respiratory distress syndrome. In inhalation injury associated with blast exposure, positive-pressure ventilation may increase barotrauma risk; use the lowest effective pressures and evaluate abrupt deterioration for air leak or other blast-lung complications. acepacepAmerican College of Emergency Physicians | ACEP

Frame the evaluation around three anatomically and clinically distinct injuries: supraglottic thermal injury, subglottic airway and alveolar poisoning, and systemic toxicity from absorbed low-molecular-weight toxins. Exposure duration, smoke temperature, smoke composition, and patient airway size influence severity; infants can obstruct more rapidly because of their smaller airway diameter. CDCCDCInhalation Injury in the Burned Patient

For suspected tracheobronchial injury, use fiberoptic bronchoscopy to inspect the airway and remove obstructing material when needed. Bronchoscopy is both diagnostic and therapeutic, and fiberoptic airway evaluation at admission can identify patients who need subsequent airway intervention or aggressive pulmonary toilet. Wiley+1WileyGuidelines for Essential Trauma Care: Second Edition (2026)acepAmerican College of Emergency Physicians | ACEP

Use chest CT as an adjunct when the clinical course or prognostic assessment is unclear; CT and bronchoscopic grading may provide a more nuanced assessment than nonspecific examination findings alone. Bronchoscopy with biopsy has been reported to predict ARDS in burn patients, but routine biopsy is not required for initial stabilization and should not delay airway management. PubMed+1PubMedDiagnosis and management of inhalation injury: an updated review - PubMedjournal chestnetUsing Bronchoscopy and Biopsy to Diagnose Early Inhalation Injury - CHEST

Obtain oxygenation assessment with pulse oximetry and, when respiratory distress or an abnormal pulmonary examination is present, arterial blood gas measurement and chest radiography. This approach is specifically recommended in hydrocarbon vapor exposure and provides a practical escalation pathway for inhalational respiratory injury more broadly. CDCCDCGasoline, Automotive | Medical Management Guidelines | Toxic Substance Portal | ATSDR

Evaluate carbon monoxide and cyanide exposure in the clinical context of a closed-space fire or combustion exposure. Carbon monoxide or cyanide levels support the diagnosis when available; cyanide poisoning should be suspected when hypotension and acidemia persist despite adequate arterial oxygenation. acep+1acepAmerican College of Emergency Physicians | ACEPCDCAcute Chemical Emergencies

Use humidification and aggressive pulmonary toilet for smoke-related tracheobronchial injury, particularly when soot, tenacious secretions, or bronchial casts impair ventilation. Smoke particulate injury initiates airway inflammation that promotes pulmonary edema, cast formation, airway obstruction, loss of hypoxic pulmonary vasoconstriction, and ventilation-perfusion mismatch. ScienceDirectScienceDirectManagement of acute smoke inhalation injury - ScienceDirect

Treat bronchospasm with inhaled beta2-agonist therapy. For chemical exposures, aerosolized bronchodilators are recommended when bronchospasm is present; in mixed exposures, consider myocardial vulnerability before selecting the bronchodilator, because bronchial sensitizing agents may add risk. ScienceDirect+1ScienceDirectManagement of acute smoke inhalation injury - ScienceDirectCDCChlorine | Medical Management Guidelines | Toxic Substance Portal | ATSDR

Use bronchoscopy for diagnostic inspection and therapeutic clearance when airway debris, casts, or retained secretions are contributing to obstruction or inadequate airway toilet. Repeat airway inspection is part of standardized multidisciplinary management in high-acuity smoke injury when ongoing clearance is needed. Wolters Kluwer+1Wolters KluwerCombined carbon monoxide poisoning and smoke... : Medical Gas ResearchWileyGuidelines for Essential Trauma Care: Second Edition (2026)

Nebulized heparin and N-acetylcysteine are used in some inhalation-injury protocols to address fibrinous casts and secretion burden, often with beta2-agonist therapy. However, adjuncts including bronchodilators, mucolytics, inhaled anticoagulants, nonconventional ventilator modes, prone positioning, and extracorporeal membrane oxygenation lack definitive efficacy evidence; do not substitute these measures for airway protection, ventilation, humidification, and airway clearance. ScienceDirect+1ScienceDirectManagement of acute smoke inhalation injury - ScienceDirectPubMedDiagnosis and management of inhalation injury: an updated review - PubMed

In a smoke-exposed patient, assess for systemic toxic injury concurrently with airway management. Carbon monoxide and cyanide toxicity should be suspected after open-fire exposure, especially in enclosed spaces; elevated carbon monoxide or cyanide levels strengthen suspicion when testing is available. Wiley+1WileyInhalation burn injury in children - FIDKOWSKI - 2009 - Pediatric Anesthesia - Wiley Online LibraryacepAmerican College of Emergency Physicians | ACEP

Prioritize cyanide toxicity when shock physiology is disproportionate to the pulmonary examination: persistent hypotension and acidemia despite adequate arterial oxygenation are hallmark features of severe cyanide poisoning. Hydrogen sulfide poisoning can produce a similar clinical picture, so occupational, industrial, sewage, and confined-space history matters. CDCCDCAcute Chemical Emergencies

Continue respiratory support while toxin-directed therapy is undertaken. Smoke-inhalation reviews identify specific treatment of carbon monoxide and cyanide intoxication as part of management, but treatment of the pulmonary component remains airway control, ventilation, humidification, and airway toilet. ScienceDirectScienceDirectManagement of acute smoke inhalation injury - ScienceDirect

Observe symptomatic inhalation-exposure patients with serial respiratory examinations because pulmonary injury can progress after the initial encounter. After ammonia inhalation, progression may continue for 18 to 24 hours; pulmonary edema requires ICU admission. CDCCDCAmmonia | Medical Management Guidelines | Toxic Substance Portal | ATSDR

For intubated smoke-injury patients, monitor ventilatory requirements, airway patency, secretion burden, oxygenation, and evidence of pulmonary edema, obstruction, or ARDS. Inhalation injury is associated with prolonged ventilatory support and increased ICU and hospital utilization when acute lung injury develops. ScienceDirect+1ScienceDirectManagement of acute smoke inhalation injury - ScienceDirectScienceDirectThe Pathophysiology of Inhalation Injury - ScienceDirect

Plan postacute pulmonary follow-up after severe chemical inhalation injury. Ammonia survivors may have residual bronchoconstriction, bronchiectasis, small-airway disease, chronic obstructive pulmonary disease, chronic cough, asthma, or fibrosis; repeat pulmonary function testing annually is recommended in the ATSDR ammonia guidance. CDCCDCAmmonia | Medical Management Guidelines | Toxic Substance Portal | ATSDR

Maintain a low threshold to reassess chronic respiratory symptoms after major toxic dust or smoke exposure. Occupational toxicant inhalation cohorts demonstrate clinically important coexistence of lower-airway disease with upper aerodigestive disease and GERD-related complexity, which can alter the diagnostic approach to persistent cough or dyspnea. CDCCDC[PDF] Occupational toxicant inhalation injury: the World Trade Center ...