Inhalational Injury Management: From Intubation to Nebulized Heparin

Inhalational injury is common during fire accidents. Upper airway injury occurs due to heat, whereas the lower airway injury is caused by chemical irritation. It causes local damage to the upper, lower airway, and lung parenchyma leading to erythema, bronchorrhea, edema, airway obstruction, and surfactant loss. Plasma leakage occurs due to a storm of pro-inflammatory markers and vascular leak, with fibrin deposition, leading to formation of airway cast and debris increasing the risk of airway obstruction. Systemic complications occur due to anoxia, carbon monoxide, and hydrogen cyanide poisoning. An inhalational injury should be suspected in patients with a history of exposure to flames and in those who are entrapped in a closed compartment during the fire. Facial burns, singed facial or nasal hair, stridor, and carbonaceous sputum should raise suspicion of high index of inhalational injury. Severity of inhalational injury can be graded using 133 Xenon (radioisotope) study, bronchoscopy, computerized tomography findings, or virtual endoscopy. In the management of inhalational injury, keeping airway patent and secured is of vital importance. According to the advanced trauma life support principles, these patients should be intubated early, but as per the recent literature, it may not be necessary to intubate all inhalation injury patients. Adjuvant therapy includes bronchodilators, mucolytics, and beta-agonists. Nebulized heparin is found to be useful as it breaks and prevents new clot formations in the airway without any systemic anticoagulant effects. Inhalational injury is an independent risk factor for increase in mortality in burn patients.