Intubation in inhalational injuries

FIRE SAFE: What are the indications for intubation in inhalational injuries?

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Inhalational injuries occur as a complication of approximately one-third of burns and may lead to significant morbidity and mortality if not correctly managed.​1​ Inhalational injury to the upper airway can occur as a result of direct thermal injury, leading to airway swelling and necessitating the need for early intubation for airway protection.​2​ Inhalational injuries can also damage the lower airways due to exposure to smoke and other chemicals. Respiratory distress may be further exacerbated by exposure to carbon monoxide, cyanide, and the development of methemoglobinemia.​2​ Lower airway injuries can result in delayed respiratory failure, occurring up to 48 hours after the initial injury.​2​

The literature currently demonstrates no clear consensus on criteria for intubation in patients with inhalation injuries, making it challenging to predict which patients with inhalational injuries will require intubation.​3​ As a result, recent research suggests that providers have moved towards a more aggressive prophylactic intubation strategy.​3​ It is important to consider the risks associated with intubation and mechanical ventilation when choosing an airway management strategy.

The decision to intubate should be made with consideration of the individual clinical context. The mnemonic FIRE SAFE highlights the most important criteria when considering early intubation in burn patients.​2​

F: Facial burns

I:  Increasing in size (airway swelling/edema)

R: Respiratory distress or failure (hypoxia, hypercapnia)

E: Extensive burns (head, neck, chest wall)

S: Soot or carbonaceous material in airway

A: Altered mental status (GCS <8)

F: Funny sound (stridor/wheeze, hoarseness)

E: Esophageal symptoms (dysphagia, drooling)

This post was reviewed by Dr. Daniel Ting and copy-edited by Noaah Reaume.

References:

  1. 1.
    Heimbach D, Waeckerle J. Inhalation injuries. Ann Emerg Med. 1988;17(12):1316-1320. doi:10.1016/s0196-0644(88)80357-3
  2. 2.
    Badulak J, Schurr M, Sauaia A, Ivashchenko A, Peltz E. Defining the criteria for intubation of the patient with thermal burns. Burns. 2018;44(3):531-538. doi:10.1016/j.burns.2018.02.016
  3. 3.
    Palmieri T. Inhalation injury: research progress and needs. J Burn Care Res. 2007;28(4):549-554. doi:10.1097/BCR.0B013E318093DEF0

Reviewing with the Staff

Dr. Hedlin has reviewed this article and approved its content.

Dr. Peter Hedlin
Dr. Hedlin is an Anesthesiologist at the University of Saskatechewan. He is also involved in the Department’s Simulation Program both as an instructor, and as the local coordinator for the Canadian National Anesthesiology Simulation Curriculum (CanNASC). His current research interests include exploring the impact that both surgery and anesthesia have on patient’s post-operative cognitive function. He has no conflicts of interest to declare.
Noaah Reaume

Noaah Reaume

Noaah is currently a fourth-year medical student at the University of Saskatchewan. Her academic interests include airway management and regional anesthesia. When not working, you can find her spending time with family, hiking in the mountains, or finding new coffee shops to try. She has no conflicts of interest to declare.
Retaj Ramadan

Retaj Ramadan

Retaj is a current fourth year medical student at the University of Saskatchewan. She is particularly interested in burn care and has fostered this interest through work with burn survivor and facial difference organizations. In her spare time, she enjoys traveling, spending time with family, and painting. She has no conflicts of interest to declare.