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|Specialty||Emergency medicine, pulmonology, critical care|
Smoke inhalation is the breathing in of harmful fumes produced as by-products of combusting substances through the respiratory tract. This can cause smoke inhalation injury (subtype of acute inhalation injury) which is damage to the respiratory tract caused by chemical and/or heat exposure as well as possible systemic toxicity after smoke inhalation. Smoke inhalation can occur from fires of various sources such as residential, vehicle, and wildfires. Morbidity and mortality rates in fire victims with burns are increased in those with smoke inhalation injury. Victims of smoke inhalation injury can present with cough, difficulty breathing, low oxygen saturation, smoke debris and/or burns on the face. Smoke inhalation injury can affect the upper respiratory tract (above the larynx), usually due to heat exposure, or the lower respiratory tract (below the larynx), usually due to exposure to toxic fumes. Initial treatment includes taking the victim away from the fire and smoke, give 100% oxygen at high flow through face mask (non-rebreather if available), and check the victim for injuries to the body. Treatment for smoke inhalation injury is largely supportive with varying degrees of consensus on benefits of specific treatments.
The U.S. Fire Administration reported almost 1.3 million fires in 2019 causing 3,704 deaths and almost 17,000 injuries. Residential fires were found to be most often cooking related and resulted in the highest amount of deaths when compared to other fire types such as vehicle and outdoor fires. Sex differences: Men were found to have higher rates of death and injury related to fires. Ethnic/Race differences: African American and American Indian males were found to have higher rates of death and injury related to fires than other ethnicities/races. Age differences: Highest death rate was found in those over age 85 and highest injury rate was found in those age 50-54. Some report increased rates of death and injury in children as well due to less physical and mental capability. Overall in 2019, the U.S. national fire death rate was 10.7 people per million population and the injury rate was 50.6 people per million population. Smoke inhalation injury is the most common cause of death in fire victims. Fire victims with both burns to their body and smoke inhalation injury have increased morality rate and length of hospital stay compared to those with burns alone.
Signs and symptoms
Some of the signs and symptoms of smoke inhalation injury include recent fire exposure followed by cough, wheezing, stridor, confusion, difficulty breathing, low oxygen saturation, smoke debris (especially on face and/or in saliva), burns (especially of the face), singed facial or nose hairs, and/or hoarse voice. A careful history can be helpful in determining where the fire occurred and therefore, what chemical fumes could have been inhaled with accompanying systemic toxicities.
Smoke inhalation injury can lead to respiratory complications ranging from minor to major. Acute Respiratory Distress Syndrome (ARDS) is a relatively delayed complication of smoke inhalation injury caused by chemical fumes inducing an inflammatory response in the lung tissue especially the small air sacs known as alveoli where critical gas exchange occurs. Another potential complication is swelling of the upper airway from both heat and chemical damage and can become profound enough to obstruct breathing. The onset of airway swelling can be relatively delayed making it difficult to intubate later on thus endotracheal intubation should be considered early in certain patients. Other possible complications include pneumonia, vocal cord damage and/or dysfunction, and tracheal stenosis (usually delayed).
Inhalation of chemical toxins produced by combusting materials can cause damage to tissues of both the upper (above larynx) and lower respiratory tract (below larynx). Damage to lower airways, air sacs, and lung tissue is due to an inflammatory cascade in response to the noxious chemicals which causes a variety of downstream effects such as increased secretions and exudative material thus clogging the airways and/or air sacs, collapse of air sacs (atelectasis), vascular permeability leading to pulmonary edema (fluid in the lungs), bronchoconstriction, activation of the coagulation cascade, and impaired function of the mucociliary escalator.
Inhalation of hot fumes can cause thermal damage to tissues usually limited to the upper respiratory tract (above larynx). Damage in this location can result in sloughing of the damaged tissue and swelling both of which can cause obstruction of the respiratory tract, ulceration, increased secretions, and redness (erythema).
Systemic toxicity can occur from inhalation of chemical compounds produced as byproducts of combustion in a fire. Carbon monoxide poisoning is the most common systemic toxicity after smoke inhalation and can cause organ failure from lack of oxygen (often heart attack). Carbon monoxide is a common byproduct of combusting substances in fires and is colorless and odorless. It has a much higher binding affinity for hemoglobin compared to oxygen and thus can block oxygen from binding to hemoglobin causing hypoxia. Additionally, carbon monoxide decreases the ability of oxygen to dissociate from hemoglobin to diffuse into tissues thus causing hypoxia.
First responders often take the victim away from the fire and smoke, give 100% oxygen at high flow through a face mask (non-rebreather if available), assess level of consciousness, and check the victim for burns and/or injuries to the body for initial care. Upper respiratory tract injury due to heat exposure often results in swelling. Intubation should be considered early given that the swelling can have a slow, delayed onset but once present, will make intubation very difficult.
Lower respiratory tract injury due to exposure to noxious fumes often consists of supportive measures such as intubation and ventilator support if indicated, suctioning of the airways (pulmonary hygiene), and other supportive measures. Intravenous fluids are a mainstay in treatment of fire victims with extensive burns to the body, however, there are differing perspectives on the risks/benefits of IV fluids in fire victims with both burns and smoke inhalation injury due to the potential worsening of pulmonary edema with large amounts of IV fluids typically given in burn victims.
Other treatments with differing perspectives and study findings on utility in smoke inhalation injury include nebulized bronchodilators (such as beta-2-agonists), IV corticosteroids, nebulized corticosteroids, nebulized epinephrine, nebulized heparin, and nebulized N-acetylcysteine.
Carbon monoxide poisoning is initially treated with high flow 100% oxygen. Hyperbaric oxygen therapy can be considered but there are differing views on its clinical benefit in terms of outcomes.
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