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Smoke Inhalation Injury

Inhalation Injuries Smoke

Smoke inhalation injury refers to the chemical and thermal injury of the respiratory tract, as well as systemic toxicity, arising from inhalation of various irritants found in smoke. Either occupational or accidental exposure (fires, blast injuries, excessive steam, etc.) may be responsible for this type of injury. Symptoms range from mild bronchial irritation to life-threatening hypoxia and respiratory insufficiency. A thorough clinical assessment is the most important step in the diagnostic workup, followed by laboratory and imaging studies.


Presentation

Smoke inhalation injury is roughly defined as the injury of the bronchial tree and the respiratory system developing as a result of inhalation of particulate matter (soot) and chemical or thermal irritants found in smoke and accounts for up to 10,000 deaths every year in the United States [1]. Some of the most important compounds responsible for this type of injury are carbon monoxide (CO), hydrogen cyanide (HCN), free oxygen radicals (reactive oxygen species, or ROS), sulfur dioxide (SO2), benzene and other aromatic hydrocarbons, as well as ammonia (NH3) [2] [3] [4]. Despite their increasing concentrations in the industrial setting and markedly higher occupational exposure, inhalation of smoke during fires is the predominant mode of smoke related injury, as extensive nasopharyngeal irritation promotes breathing through the mouth and subsequent introduction of large amounts of smoke directly into the bronchial tree [1]. The clinical presentation depends on the amount of smoke inhaled, the concentration of gasses found in the smoke, and the ability of the individual's respiratory tract to cope with chemical and thermal injury [1] [2]. In most cases, mucosal edema and irritation eventually result in stridor, hoarseness, dyspnea, hypoxia, and tachypnea, whereas accompanying burns on the face and surrounding area is quite common [1] [3]. The presence of soot in the nasopharynx and sputum has also been documented as an important finding [3]. Loss of consciousness and respiratory insufficiency are signs of life-threatening smoke inhalation injury, in which case rapid therapeutic measures (mainly in the form of cessation of exposure to smoke) are mandatory [3] [4] [5].

Cough
  • […] with corrosives Soot on lips Burns of the mucosa Mucosal oedema Pharynx Inhalation of superheated smoke or steam Carbonised material in the pharynx Pharyngeal oedema Difficulty swallowing Larynx Inhalation of superheated smoke or steam Hoarse voice Cough[derangedphysiology.com]
  • Your recognised location is United States (US) Chronic cough in a child This article is freely available only to users in the UK.[evidence.nhs.uk]
  • Smoke inhalation can cause a host of other injuries, including: Difficulty breathing Coughing Nose or throat irritation Nausea Headaches Fainting Confusion Seizures Coma Corneal and other eye damage If negligence played any kind of role in a fire, the[winstonbriggslaw.com]
  • Increased mucus production causes coughing.[work4youlaw.com]
  • In some cases, there is a lower respiratory tract injury that results in wheezing, coughing, rhonchi, and dyspnea, among other symptoms.[pulgininorton.com]
Hoarseness
  • No statistically significant correlation was found between intubation and any of the classic symptoms of smoke inhalation: stridor, hoarseness, drooling, and dysphagia (all p 1.0).[ncbi.nlm.nih.gov]
  • Clinical features of airway burns include soot in the airway, stridor, hoarseness, singed nose hair, and mucosal ulceration Historically, survivors of explosions and fires in enclosed spaces are more likely to have suffered airway burns Consequences of[derangedphysiology.com]
  • In most cases, mucosal edema and irritation eventually result in stridor, hoarseness, dyspnea, hypoxia, and tachypnea, whereas accompanying burns on the face and surrounding area is quite common.[symptoma.com]
  • Hoarseness: This may be a sign that fluids are collecting in the upper airway causing a blockage. The victim’s upper airways or vocal cords may also become affected by the smoke causing him or her to become hoarse.[work4youlaw.com]
  • When a doctor examines someone for smoke inhalation, some signs that there may be smoke inhalation include hoarseness, blistering, and upper airway mucosal lesions.[pulgininorton.com]
Stridor
  • No statistically significant correlation was found between intubation and any of the classic symptoms of smoke inhalation: stridor, hoarseness, drooling, and dysphagia (all p 1.0).[ncbi.nlm.nih.gov]
  • Clinical features of airway burns include soot in the airway, stridor, hoarseness, singed nose hair, and mucosal ulceration Historically, survivors of explosions and fires in enclosed spaces are more likely to have suffered airway burns Consequences of[derangedphysiology.com]
  • In most cases, mucosal edema and irritation eventually result in stridor, hoarseness, dyspnea, hypoxia, and tachypnea, whereas accompanying burns on the face and surrounding area is quite common.[symptoma.com]
  • Stridor Stridor is a wheezing or whistling sound when you breath in. Blockages in your lung narrow your airways and as the air forces past the whistling sound is heard. You might need a breathing tube to allow air to reach your lungs. 8.[accident-claim-expert.co.uk]
Dyspnea
  • In most cases, mucosal edema and irritation eventually result in stridor, hoarseness, dyspnea, hypoxia, and tachypnea, whereas accompanying burns on the face and surrounding area is quite common.[symptoma.com]
  • In some cases, there is a lower respiratory tract injury that results in wheezing, coughing, rhonchi, and dyspnea, among other symptoms.[pulgininorton.com]
  • […] inhalation effects if exposed to fire in a confined space assess for airway injury and respiratory compromise — features of airway burns — upper airways: singed nasal airs, facial burns, soot in nose and pharynx, stridor, hoarseness — lower airways: wheeze, dyspnea[lifeinthefastlane.com]
Rales
  • Note rhonchi, rales, wheeze and use of accessory muscles of respiration. Facial burns show nearness to the fire. Other burns demonstrate an inability to escape.[patient.info]
Choking
  • If the patient has respiratory distress or mental status changes, they may also be intubated to enable the staff to help with breathing, to suction mucus, and keep the patient from choking on secretions.[emedicinehealth.com]
Chest Pain
  • Primary endpoints were death, chest pain, and adverse changes in cardiopulmonary hemodynamics (arrhythmia, arterial blood pressure, electrocardiographic [ST segment] changes, and peak inspiratory pressure).[ncbi.nlm.nih.gov]
  • But they often include Coughing and phlegm A scratchy throat Irritated sinuses Shortness of breath Chest pain or tightness Headaches Stinging eyes A runny nose If you have a chronic heart or lung problem, an inhalation injury can make it worse.[medlineplus.gov]
Tachycardia
  • […] icteric sclera, neck supple, no lymphadenopathy, no mass/carotid bruit, unable to assess oral cavity due to presence of endotracheal tube, dry and mild swollen lips Cardiovascular : S1/S2 with regular rate and rhythm, no murmurs/rubs/gallops, sinus tachycardia[ispub.com]
Cyanosis
  • Note whether there is cyanosis. Note whether the chest wall moves normally and symmetrically. Assess the airway but, if there is any risk of cervical spine trauma, be careful with the neck. Note respiratory rate. Listen to the chest.[patient.info]
Facial Burn
  • Intubation was positively correlated with physical examination findings of soot in the oral cavity (p 0.001), facial burns (p 0.025), and body burns (p 0.025).[ncbi.nlm.nih.gov]
  • Chest radiographs on admission are often non-specific (5, 6), but indicators include indoor fires, facial burns, bronchoscopic findings of soot in the airways, and detection of carbon monoxide or cyanide in the blood (7).[ncbi.nlm.nih.gov]
  • Furthermore, findings such as facial burns, soot in the nasopharynx and sputum, as well as voice changes are highly indicative signs of smoke inhalation injury, which is why the role of a proper physical exam must not be overlooked.[symptoma.com]
  • "Acute management of the upper airway in facial burns and smoke inhalation." Archives of Surgery 111.7 (1976): 744-749. Gaissert, Henning A., Robert H. Lofgren, and Hermes C. Grillo. "Upper airway compromise after inhalation injury.[derangedphysiology.com]
  • Facial burns show nearness to the fire. Other burns demonstrate an inability to escape. Investigations [ 10 ] A baseline CXR may be useful for comparison if pulmonary oedema ensues.[patient.info]
Irritability
  • Smoke inhalation injury refers to the chemical and thermal injury of the respiratory tract, as well as systemic toxicity, arising from inhalation of various irritants found in smoke.[symptoma.com]
  • Smoke is heterogeneous and unique to each fire; it comprises particulates, respiratory irritants and systemic toxins as well as heat, all contributing to the pathological insult.[ncbi.nlm.nih.gov]
  • Upper airway thermal burns, inflammation from lower airway irritants, and systemic effects of carbon monoxide and cyanide can contribute to injury.[ncbi.nlm.nih.gov]
  • It is more common for smoke to cause mild throat irritation, which is not a sign of a significant burn to the airway.[uhs.berkeley.edu]
Confusion
  • As many patients develop altered consciousness and confusion, a heterogeneous anamnesis (friends, relatives, or coworkers who were exposed together with the patient) can be of great help in identifying the circumstances that preceded the development of[symptoma.com]
  • Smoke inhalation can cause a host of other injuries, including: Difficulty breathing Coughing Nose or throat irritation Nausea Headaches Fainting Confusion Seizures Coma Corneal and other eye damage If negligence played any kind of role in a fire, the[winstonbriggslaw.com]
  • Changes in mental status: The presence of chemicals and low levels of oxygen can cause symptoms such as dizziness, confusion, seizures or even lack of consciousness and fainting.[work4youlaw.com]
  • Dyspnoea, decreased level of consciousness, or confusion Hypoxaemia (low pulse oximetry saturation or arterial oxygen tension) or increased carbon monoxide levels ( 2%) Pathophysiologic consequences of airway burns Mechanisms organised by pathophysiological[derangedphysiology.com]
  • Signs and symptoms [ edit ] Symptoms range from coughing and vomiting to nausea, sleepiness and confusion. [ citation needed ] Burns to the nose, mouth and face, singed nostril hairs, difficulty breathing, and carbonaceous sputum (burned saliva) are signs[en.wikipedia.org]
Altered Mental Status
  • Pulmonary injury should be considered in any patient with history of burn in a closed space, loss of consciousness, or altered mental status.[totalburncare.com]
  • Carboxyhemoglobin and methemoglobin levels : This level should be obtained in all smoke inhalation victims with respiratory distress, altered mental status, low blood pressure, seizures, fainting, and blood pH changes.[webmd.com]
  • Carboxyhemoglobin and methemoglobin levels: These levels should be measured in all smoke inhalation victims with respiratory distress, altered mental status, low blood pressure , seizures , fainting, and blood pH changes.[emedicinehealth.com]
Personality Change
  • Within 1 month, he developed neuropsychiatric problems including toxic encephalopathy, cognitive disorder, depression symptoms and personality change.[ncbi.nlm.nih.gov]
  • Within 1 month, he developed neuropsychiatric problems including toxic encephalopathy, cognitive disorder, depression symptoms and personality change.[casereports.bmj.com]
Dizziness
  • Common side effects of carbon monoxide poisoning include: Dizziness Headaches Nausea Vomiting Carbon Monoxide is especially dangerous because it can not be smelled (odorless) or seen (colorless).[skylawgroup.com]
  • Changes in mental status: The presence of chemicals and low levels of oxygen can cause symptoms such as dizziness, confusion, seizures or even lack of consciousness and fainting.[work4youlaw.com]

Workup

The need for rapid treatment necessitates a prompt clinical workup by the physician, but in order to gain sufficient evidence for a presumptive diagnosis, a detailed patient history, and a thorough physical examination must be performed. As many patients develop altered consciousness and confusion, a heterogeneous anamnesis (friends, relatives, or coworkers who were exposed together with the patient) can be of great help in identifying the circumstances that preceded the development of symptoms [4]. Furthermore, findings such as facial burns, soot in the nasopharynx and sputum, as well as voice changes are highly indicative signs of smoke inhalation injury, which is why the role of a proper physical exam must not be overlooked [1]. As soon as clinical suspicion is raised, both laboratory and imaging studies should be performed [3] [6]. A complete blood count (CBC), pulse oximetry, and arterial blood gas (ABG) analysis are vital for evaluating the status of tissue perfusion and oxygen content, whereas computed tomography (CT) of the thorax is the recommended imaging modality [1] [3] [4] [5]. Pulmonary function testing (spirometry), electrocardiography (ECG), and measurements of carboxyhemoglobin are also a part of the initial workup, but in order to make a definite diagnosis and establish the severity of smoke inhalation injury, fiberoptic bronchoscopy (FOP), although being an invasive procedure, is the gold standard [2] [6].

Atelectasis
  • Although he survived the acute stages following injury, his pulmonary function subsequently deteriorated with a damaged trachea and bronchi, repeated attacks of pneumonia, atelectasis, pneumothorax and lung fibrosis, leading to death with hypercapnia[ncbi.nlm.nih.gov]
  • Subglottic stenosis, bronchiectasis, pulmonary oedema and atelectasis can occur.[patient.info]
  • Results in: increased airway resistance post-obstructive atelectasis and emphysema 24-48 h after injury microvascular permeability is increased with resultant low pressure pulmonary oedema Clinical features Following should raise suspicion of inhalation[aic.cuhk.edu.hk]
  • Inhalation injury is associated with a high risk of occlusion of smaller airways leading to atelectasis and infection.1 As a result, patients frequently develop acute lung injury, acute respiratory distress syndrome (ARDS), and pneumonia.[ispub.com]
Pulmonary Infiltrate
  • On ICU day 5, she was weaned from vasopressor support, her chest x-ray showed decreasing bilateral pulmonary infiltrates, and she had a decreased FiO2 requirement with increasing PaO2/FiO2 ratio of 210.[ispub.com]
Bilateral Pulmonary Infiltrate
  • On ICU day 5, she was weaned from vasopressor support, her chest x-ray showed decreasing bilateral pulmonary infiltrates, and she had a decreased FiO2 requirement with increasing PaO2/FiO2 ratio of 210.[ispub.com]
Hypercapnia
  • Although he survived the acute stages following injury, his pulmonary function subsequently deteriorated with a damaged trachea and bronchi, repeated attacks of pneumonia, atelectasis, pneumothorax and lung fibrosis, leading to death with hypercapnia[ncbi.nlm.nih.gov]
  • Severe hypercapnia tended to be more frequent during HFOV among patients with smoke inhalation.[ncbi.nlm.nih.gov]
  • […] instituting ventilation a balance has to be struck between providing sufficient oxygenation and causing as little collateral harm as possible. [ 5 ] Lower tidal volumes and plateau pressures with high positive end-expiratory pressure (PEEP) and permissive hypercapnia[patient.info]
  • Patients must be closely monitored and early intubation should be considered if the patient demonstrates hypoxia/hypercapnia or carbon monoxide/cyanide toxicity [3].[nuemblog.com]

Treatment

  • This case review details the treatment of a 32-year-old woman who was at 36 weeks of gestation on admission to the Evans-Haynes Burn Center. The authors will report her injuries and the course of treatment.[ncbi.nlm.nih.gov]
  • Nebulisation of n2-agonists, heparin and N-acetylcysteine have a role in management, as does more specific treatment of carbon monoxide or cyanide intoxication. Many promising treatments are currently under investigation.[ncbi.nlm.nih.gov]
  • Pulmonary toilet and infection control, as well as close management of fluid shifts, is the major treatment.[ncbi.nlm.nih.gov]
  • Changes in respiratory system dynamic compliance, mean airway pressure, PaO2/FiO2 ratio, and oxygenation index were also attenuated with epinephrine treatment. No considerable systemic effects were observed with epinephrine treatment.[ncbi.nlm.nih.gov]
  • Early diagnosis and treatment of inhalation injury are important, but a major problem in planning treatment and evaluating the prognosis has been the lack of consensus about diagnostic criteria (4).[ncbi.nlm.nih.gov]

Prognosis

  • Moreover, no worldwide consensus criteria exist for its diagnosis, severity grading, and prognosis. Therapeutic approaches are highly variable depending on the country and burn centre or hospital.[ncbi.nlm.nih.gov]
  • Early diagnosis and treatment of inhalation injury are important, but a major problem in planning treatment and evaluating the prognosis has been the lack of consensus about diagnostic criteria (4).[ncbi.nlm.nih.gov]
  • Due to its relative rarity, information on prognosis is not abundant.[patient.info]

Epidemiology

  • We aimed to investigate the epidemiology and outcomes of this select patient population.[ncbi.nlm.nih.gov]
  • الصفحة 441 - Becklake MR: Asbestos-related diseases of the lung and other organs: Their epidemiology and implications for clinical practice. ‏ الصفحة 279 - Intravascular activation of complement and acute lung injury.[books.google.com]
  • In contrast, Akgun & Gorguner (2010) report that acute lung injury due to inhalation of flaming gas seems to be epidemiologically more common among miners, because of the combination of inescapable confinement and limited fresh gas supply.[derangedphysiology.com]
  • A further 19% were due to a combination of burns and being overcome by gas or smoke. [ 1 ] Epidemiology [ 2, 3 ] A study from North West England found that the overall admission rate to hospital for smoke inhalation or burns was 0.29/1,000 population[patient.info]
Sex distribution
Age distribution

Pathophysiology

  • Treatment strategies should be planned based on these pathophysiological aspects.[ncbi.nlm.nih.gov]
  • In the present review, we will describe the pathophysiological aspects of acute lung injury induced by combined burn and smoke inhalation and examine various therapeutic approaches.[ncbi.nlm.nih.gov]
  • This article reviews the pathophysiology of smoke-inhalation injury and the clinical pattern of respiratory tract injury.[ncbi.nlm.nih.gov]
  • As part of understanding and improving outcomes from burn injuries, the pathophysiology and inflammatory processes involved in smoke inhalation injury has been extensively investigated in animal models.[ncbi.nlm.nih.gov]
  • Particulate matter is the chief contributor to the pathophysiology of smoke inhalation injury, which has been extensively described.[ncbi.nlm.nih.gov]

Prevention

  • Primary prevention is the most important way to reduce the poor outcome from significant exposure.[ncbi.nlm.nih.gov]
  • How can smoke inhalation be prevented? To prevent fires, make sure that electrical wiring, chimneys, wood stoves, and space heaters are working properly. Use flammable liquids safely and store them in a locked area out of the reach of children.[uhs.berkeley.edu]
  • The therapeutic strategy of decontaminating the lungs early after smoke exposure to prevent inhalation injury has received little attention and may be of significant value.[ncbi.nlm.nih.gov]
  • Our findings affirm the effect of alcohol intoxication at the time of burn and smoke inhalation injury, placing renewed emphasis on injury prevention and alcohol abuse education.[ncbi.nlm.nih.gov]
  • Doherty Lippincott Williams & Wilkins, 2006 - 826 من الصفحات This volume offers authoritative, evidence-based recommendations for preventing and managing complications in all current general surgery procedures.[books.google.com]

References

Article

  1. Rehberg S, Maybauer MO, Enkhbaatar P, Maybauer DM, Yamamoto Y, Traber DL. Pathophysiology, management and treatment of smoke inhalation injury. Expert Rev Respir Med. 2009;3(3):283-297.
  2. Langford RM, Armstrong RF. Algorithm for managing injury from smoke inhalation. BMJ. 1989;299(6704):902-905.
  3. Dries DJ, Endorf FW. Inhalation injury: epidemiology, pathology, treatment strategies. Scand J Trauma Resusc Emerg Med. 2013;21:31.
  4. Walker PF, Buehner MF, Wood LA, et al. Diagnosis and management of inhalation injury: an updated review. Crit Care. 2015;19:351.
  5. Gill P, Martin RV. Smoke inhalation injury. BJA Education. 2015;15(3):143–148.
  6. Demling RH. Smoke Inhalation Lung Injury: An Update. Eplasty. 2008;8:e27.

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Last updated: 2018-06-21 23:51