Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – upper airway management + supportive care

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ACUTE
|
all patients
1st line – 

upper airway management + supportive care

An airway should be immediately secured with an endotracheal tube (ETT) if the patient has diminished mental status with poor airway reflexes or history and examination is suggestive of injury with threatened patency.

Patients with inhalation injury often have difficult airways to secure, and preparations for a surgical airway should be made in anticipation of ETT placement failure.

Patients presenting with only inhalation exposure or mild clinical disease should be closely observed and monitored during treatment for evolution or worsening of symptoms, which may be delayed for up to 1 day.[1] High-risk exposures or even subtle worsening of symptoms should be interpreted as poor prognostic signs, and the period of observation and monitoring should be increased.

Critically ill patients with burns and inhalation injury are at high risk for complications; preventative measures, including hand hygiene, head-of-bed elevation, catheter care, and deep vein thrombosis prophylaxis, are essential.

Comorbid conditions or injuries should be evaluated and treated in a patient with inhalation injury. Therapies for individual conditions are often at odds (such as aggressive volume infusion for cutaneous burns and the conservative fluid approach for acute respiratory distress syndrome), and clinicians must carefully develop a treatment strategy unique to the individual patient.

Plus – analgesia + sedation/anxiolytic

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ACUTE
|
all patients
Plus – 

analgesia + sedation/anxiolytic

Treatment recommended for ALL patients in selected patient group

Analgesia is often indicated to relieve the discomfort of an endotracheal tube, tissue oedema, coincident trauma, and cutaneous burns.

Opioid drugs (e.g., morphine, fentanyl) have the additional benefit of relieving dyspnoea.[45]

Patients not ventilated through an endotracheal tube should be monitored closely, as respiratory suppression can occur.

Continuous intravenous morphine or fentanyl provide excellent analgesia for invasive mechanical ventilation.

Sedation and anxiolysis are also indicated for patients receiving invasive mechanical ventilation. Propofol and dexmedetomidine are commonly used agents. In March 2022, the European Medicines Agency (EMA) issued a warning about an increased risk of mortality with dexmedetomidine treatment in critically ill patients aged ≤65 years compared with alternative sedatives. This recommendation follows results from an open-label, randomised trial, comparing dexmedetomidine with usual care (propofol, midazolam, or other sedatives) in critically ill adult patients undergoing mechanical ventilation. The study showed no difference in overall 90-day mortality between treatments. However, dexmedetomidine was associated with an increased risk of mortality in patients ≤65 years old, compared with alternative sedatives.[46] The EMA advises clinicians to weigh these findings against the expected clinical benefit of dexmedetomidine in this age group.[47]

Primary options

morphine sulfate: 2-10 mg/hour intravenous infusion

or

fentanyl: 12.5 to 200 micrograms/hour intravenous infusion

-- AND / OR --

propofol: see local protocol for guidance on dose

or

dexmedetomidine injection: see local protocol for guidance on dose

Plus – high-flow supplemental oxygen therapy

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ACUTE
|
all patients
|
with carbon monoxide poisoning
Plus – 

high-flow supplemental oxygen therapy

Treatment recommended for ALL patients in selected patient group

Carbon monoxide (CO) poisoning should be treated to prevent the associated persistent and delayed neurological sequelae.[28]

All patients should receive high-flow supplemental oxygen to decrease hypoxia and facilitate removal of CO. Current guidelines recommend using high flow oxygen therapy for at least 6 hours, or longer if symptoms persist.[27]

Consider – hyperbaric oxygen

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ACUTE
|
all patients
|
with carbon monoxide poisoning
Consider – 

hyperbaric oxygen

Additional treatment recommended for SOME patients in selected patient group

The use of hyperbaric oxygen has been considered controversial by some.[28][29] While some have recommended its use for pregnant patients or patients with severe disease (coma, seizure, cardiovascular disease, acidosis), the data specific to certain subgroups are unclear.[28] One clinical trial found evidence to suggest that hyperbaric oxygen reduces cognitive sequelae both acutely and at 12 months.[35]

One retrospective study found that (after adjusting for age, sex, and underlying comorbidities) patients with carbon monoxide poisoning who were treated with hyperbaric oxygen therapy had a lower mortality rate compared with patients who did not receive hyperbaric oxygen.[31] The reduction in mortality risk was greatest among patients aged younger than 20 years and those with acute respiratory failure.[31] ​Because of this data, a 2023 Delphi panel deemed hyperbaric oxygen therapy to be of uncertain benefit in patients for whom a hyperbaric chamber is available onsite.[32] This panel recommended against hyperbaric oxygen if it required transfer away from a burn centre.

Plus – hydroxocobalamin ± sodium thiosulfate

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ACUTE
|
all patients
|
with cyanide toxicity
Plus – 

hydroxocobalamin ± sodium thiosulfate

Treatment recommended for ALL patients in selected patient group

While cyanide toxicity is often cited, its true role in inhalation injury is unclear and its treatment is controversial.[21]

If cyanide toxicity is suspected in a patient with inhalation injury, the recommended therapy is the direct cyanide binder hydroxocobalamin with or without sodium thiosulfate.[27][32]​​[33]​​​

Recommendations regarding the use of sodium thiosulfate as an adjunctive treatment for cyanide toxicity vary across guidelines. A 2013 European expert consensus recommends hydroxocobalamin as the first-line treatment, with sodium thiosulfate as a second-line option.[33]​ In contrast, a 2023 international Delphi panel deemed sodium thiosulfate therapy to be of uncertain benefit.[32]​ Blood cyanide levels of higher than 2.6 to 3.0 mg/L are considered fatal.[34]

The commonly available 'antidote kit' of sodium nitrite and sodium thiosulfate (known as Nithiodote® in the US) should be used very cautiously because nitrates induce methaemoglobin (which binds systemic cyanide). Methaemoglobin, in the presence of significant carboxyhaemoglobin, contributes to critically lowering oxygen delivering capacity. Nitrates are, therefore, contraindicated in the presence of significant carboxyhaemoglobinaemia.

Primary options

hydroxocobalamin: 5 g intravenously as a single dose, may repeat once if needed

More

OR

hydroxocobalamin: 5 g intravenously as a single dose, may repeat once if needed

More

and

sodium thiosulfate: 12.5 g intravenously as a single dose, may repeat once if needed at half the dose

Secondary options

sodium nitrite: consult specialist for guidance on dose

and

sodium thiosulfate: consult specialist for guidance on dose

Plus – inhaled beta-agonist

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ACUTE
|
all patients
|
with lower airway injury
Plus – 

inhaled beta-agonist

Treatment recommended for ALL patients in selected patient group

Airway cellular injury leading to oedema, sloughing, and bronchoconstriction causes obstruction in patients with inhalation injury. This lower airway injury is treated largely with supportive care. Care should be taken to avoid toxic levels of inhaled oxygen (hyperoxaemia) following effective treatment of possible carbon monoxide poisoning.[35]

Inhaled beta-agonists (e.g., nebulised salbutamol [albuterol]) should be used as needed for bronchoconstriction, and evidence suggests that they may also benefit the patient via anti-inflammatory properties.[36]

Airway clearance should be facilitated by humidification of delivered oxygen and aggressive pulmonary toilet.

Primary options

salbutamol inhaled: 2.5 mg nebulised every 4-6 hours when required

Plus – positive pressure ventilation

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ACUTE
|
all patients
|
with lower airway injury
Plus – 

positive pressure ventilation

Treatment recommended for ALL patients in selected patient group

Airway cellular injury leading to oedema, sloughing, and bronchoconstriction causes obstruction in patients with inhalation injury. This lower airway injury is treated largely with supportive care.

Patients should be clinically monitored for evidence of respiratory muscle fatigue and ventilatory failure. While high levels of inhaled oxygen (hyperoxaemia) may be used therapeutically for carbon monoxide poisoning, once excluded or resolved hyperoxaemia is no longer recommended, and the patient may be supported with a standard fraction of inspired oxygen sufficient to maintain adequate haemoglobin saturation.[35]

Plus – oxygen therapy + positive pressure ventilation

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ACUTE
|
all patients
|
with parenchymal lung disease
Plus – 

oxygen therapy + positive pressure ventilation

Treatment recommended for ALL patients in selected patient group

Patients with lung parenchymal injury (which may progress to acute respiratory distress syndrome [ARDS]) should be treated supportively with oxygen and positive pressure ventilation as the clinical situation warrants.

It is reasonable to utilise volume-cycled ventilation with low tidal volume ventilation (4-6 cc/kg of ideal body weight) and avoidance of high plateau pressures (>30 cm H₂O), which has proved beneficial in non-selected ARDS.[40] Alternatively, pressure-cycled ventilation may be used to achieve similar physiological goals. High-frequency oscillatory ventilation was associated with accelerated improvements in pulmonary function in one small randomised controlled trial.[41]

Consider – extracorporeal membrane oxygenation (ECMO)

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ACUTE
|
all patients
|
with severe refractory respiratory failure
Consider – 

extracorporeal membrane oxygenation (ECMO)

Additional treatment recommended for SOME patients in selected patient group

Similar to other cases of severe refractory respiratory failure, ECMO may be considered in inhalation injury patients whose condition is refractory to maximal measures. One 2023 systematic review and meta-analysis of 15 retrospective studies including 318 patients on ECMO in the setting of inhalation injury found a pooled percentage of successful decannulation of 65%, but with an ECMO complication prevalence of 67%.[48] Bleeding and infection were the most common complications.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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