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Smoke inhalation

Jess Mandel, MD
Section Editor
Scott Manaker, MD, PhD
Deputy Editor
Geraldine Finlay, MD


Smoke inhalation is the leading cause of death due to fires [1]. It causes three types of injuries: thermal injury to the upper airways, chemical injury to the tracheobronchial tree, and systemic poisoning due to carbon monoxide and/or cyanide. The clinical manifestations, evaluation, and management of smoke inhalation are reviewed here. The emergency care of thermal burns is discussed separately. (See "Emergency care of moderate and severe thermal burns in adults" and "Emergency care of moderate and severe thermal burns in children".)


Deaths from fires and burns are the third leading cause of fatal injuries at home, accounting for approximately 2600 deaths and 13,000 injuries in the United States during 2009 [2]. The majority of the deaths were due to smoke inhalation, among which, up to 80 percent were attributable to carbon monoxide poisoning [3-5]. Among patients with inhalational and cutaneous injuries who die, it is estimated that 77 percent of the deaths are related to pulmonary complications [6-8].


When a patient presents with smoke inhalation, immediate assessment of the patient’s airway, breathing, and circulation is indicated. This should take only a few seconds to perform. (See "Advanced cardiac life support (ACLS) in adults".)

Intubation is justified if any of the following signs are present: stridor, use of accessory respiratory muscles, respiratory distress, hypoventilation, deep burns to the face or neck, or blistering or edema of the oropharynx. If these findings are absent, the oropharynx should be examined, followed by laryngoscopy if there is erythema. Although some centers routinely perform bronchoscopy rather than laryngoscopy, we believe that laryngoscopy is preferable to bronchoscopy because thermal injuries tend to be limited to the supraglottic airways and the appearance of the subglottic airways does not definitively affect management or predict the need for ventilator support [3,9,10]. An exception is that we routinely perform bronchoscopy instead of laryngoscopy if there is a history of inhalation of superheated particles or steam, since thermal injury may involve the lower respiratory tract in these situations [11]:

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation. These findings indicate that the upper airway is at risk for developing severe edema, which may compromise the patency of the airway. Intubation with a large lumen endotracheal tube is preferable to facilitate optimal management of secretions [12]. Humidified oxygen may help avoid inspissation.


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Literature review current through: Jan 2016. | This topic last updated: Dec 8, 2014.
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