Introduction

Injuries which result from smoke inhalation occur in victims with and without thermal injuries to the skin. These injuries may involve the upper airway (larynx, trachea, and bronchi) or lower airway (pulmonary parenchyma) alone or together. The clinical consequences of injuries at these different anatomical sites are not necessarily concurrent or of equal severity. Heat per se is thought to be responsible for only a small portion of these injuries; the primary mechanisms of injury depend on tissue exposure to the chemical species resulting from incomplete combustion. The chemistry of smoke is extraordinarily complex; even though the toxicology of smoke is probably not as complex as its chemistry, toxicological studies have not led to the development of treatment strategies useful to the clinician. In spite of many circumstantial speculations, the sequence of pathophysiological events which leads to the clinical state of most smoke inhalation victims is unknown.

The literature on smoke inhalation is confusing because of the frequent lack of adequate definitions, diagnostic imprecision, a wide range of injury severity, and the failure to differentiate between respiratory insufficiency due to smoke inhalation from that which is a consequence of one or more of the many pulmonary complications of thermal injury alone. The causes of these include fluid overload, massive transfusion, prolonged anaesthesia, sepsis, aspiration, pneumonia, etc.

This chapter will attempt to clarify some of the issues mentioned above and provide some practical guidelines for the assessment and management of patients suspected or known to have a smoke inhalation injury.