Case report
Proposal for an algorithm for the management of the patient's airway after smoke inhalation
Propuesta de algoritmo para el manejo de la vía aérea del paciente tras inhalación de humo
P. Kot Baixauli
, J.E. Morales Sarabia, L. Rovira Soriano, J. De Andrés Ibáñez
Corresponding author
Servicio de Anestesia, Reanimación y Terapia del Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
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Kot Baixauli, J.E. Morales Sarabia, L. Rovira Soriano, J. De Andrés Ibáñez" "autores" => array:4 [ 0 => array:4 [ "nombre" => "P." "apellidos" => "Kot Baixauli" "email" => array:1 [ 0 => "skakeops@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J.E." "apellidos" => "Morales Sarabia" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Rovira Soriano" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "De Andrés Ibáñez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesia, Reanimación y Terapia del Dolor, Consorcio Hospital General Universitario de Valencia, Valencia, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Propuesta de algoritmo para el manejo de la vía aérea del paciente tras inhalación de humo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2496 "Ancho" => 1583 "Tamanyo" => 224772 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Airway management algorithm for patients with suspected smoke inhalation injury.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Smoke inhalation is the main cause of morbidity and mortality in burn patients.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–7</span></a> The lack of precise diagnostic criteria, coupled with the wide array of clinical manifestations, often complicates diagnosis of this type of lesion. A history of exposure to smoke, together with the presence of certain signs and symptoms such as hoarseness, cough, sooty sputum, singed nasal hairs or dyspnoea, may indicate the presence of inhalation lesions, but are insufficient for a definitive diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,4,8,9</span></a> The toxicity of smoke particles and the high temperature at which they are inhaled can cause upper airway lesions, such as erythema, ulcerations and edoema. One of the main risks in these patients is airway compromise secondary to oedema, so it is essential to evaluate the need for intubation in the emergency room.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> In these cases, securing the airway is not without risks; it can cause a false airway, increase the risk of pneumonia, and lead to tracheal stenosis, while accidental extubation can be life-threatening due to difficulty involved in re-intubation in these cases.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,7–9</span></a> For all these reasons, prophylactic intubation is not recommended in these cases.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,7</span></a> Given that clinical signs are poor predictors of the severity of the lesion, fibreoptic endoscopy should be performed in certain cases in order to determine when intubation is required. This is the <span class="elsevierStyleItalic">gold standard</span> method for diagnosing inhalation injuries,<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,6,8,10</span></a> and has also been used by several authors to create a severity scale<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,4</span></a> to guide prognosis and treatment. We present a case of smoke inhalation injury and propose an airway management algorithm for these cases.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 44-year-old man who was rescued from his home after a fire broke out. He was unconscious when the fire fighters found him. After evacuation, the patient was assessed by paramedics and transferred to our emergency department by ambulance for suspicion of smoke inhalation. By the time he arrived at the hospital's critical care unit he had recovered consciousness, albeit with poor response to stimuli and a score of >9 on the Glasgow scale. Blood oxygen measured by pulse oximetry was 98%, blood pressure was 110/70<span class="elsevierStyleHsp" style=""></span>mmHg and pupils were mydriatic and responsive to light. Lab tests showed 3<span class="elsevierStyleHsp" style=""></span>mmol/L lactate and 14.8% carboxyhaemoglobin. There were no signs of burns on the skin. Auscultation showed generalised hypoventilation. In view of his clinical status, we decided to perform nasal fibreoptic endoscopy (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) to evaluate the upper airway. The examination revealed a blackish endotracheal exudate and oedema of the vocal cords, so it was decided to perform intubation under conscious sedation and transfer the patient to the Intensive Care Unit to facilitate control of possible complications. After 2 days of favourable evolution, the patient was extubated without incident, and was discharged, clinically stable, 10 days later. The fibreoptic endoscopy findings were the key factor in our decision to secure the airway.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">Airway management in patients with suspected smoke inhalation injury should take into account the severity of the injury and the possibility of obstruction. The first measure to be taken in these patients is high flow delivery of 100% oxygen.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Burns on the face and/or neck can distort the anatomical structures or cause compression of the upper airway,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> so intubation is mandatory in burn patients with clear signs of airway obstruction or severely impaired level of consciousness (Glasgow score <9). If none of these signs are present, a physical examination will be needed to detect the presence of clinical predictors of airway compromise, such as sooty sputum, singed nasal hairs, cough, hoarseness, odynophagia, dyspnoea, stridor, cyanosis or neurological symptoms. If one or more signs are detected, a fibreoptic endoscopy should be performed to confirm the presence of oedema, erythema or adhesive residues that indicate the need for intubation. If none of the foregoing signs are found, the patient should be given general supportive measures and kept under observation with frequent re-evaluations, bearing in mind that in smoke inhalation injury, airway oedema can develop over the course of several hours in a previously asymptomatic patient.</p><p id="par0020" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> shows the airway management algorithm we have designed for patients with suspected smoke inhalation injury. In conclusion, based on the existing literature on this subject and given that intubation is not entirely without risks and complications, we advise clinicians to follow these diagnostic-therapeutic guidelines to determine when intubation is required to avoid a possible obstruction, and when non-invasive measures will suffice.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1008350" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec968024" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1008351" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec968023" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-08-01" "fechaAceptado" => "2017-12-12" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec968024" "palabras" => array:4 [ 0 => "Smoke inhalation" 1 => "Orotracheal intubation" 2 => "Fibroscopy" 3 => "Airway" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec968023" "palabras" => array:4 [ 0 => "Inhalación de humo" 1 => "Intubación orotraqueal" 2 => "Fibroscopia" 3 => "Vía aérea" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Smoke inhalation represents the leading cause of mortality and morbidity in burns patients. Given the injuries that can occur in the airway after this exposure, it is imperative to evaluate the need for orotracheal intubation in the emergency department and even in the place of first assistance by healthcare workers. Since the clinical signs are poor predictors of the severity of the lesion, in selected cases, it is advisable to perform a diagnostic fibroscopy. We present a case report of a patient with a smoke inhalation lesion in which the fibroscopy was determinant to proceed to intubation, and we propose an algorithm of action for the management of the airway in this type of patients.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La inhalación de humo representa la principal causa de morbimortalidad en pacientes quemados. Dadas las lesiones que pueden producirse en la vía aérea tras esta exposición, es imprescindible evaluar en el servicio de urgencias, e incluso en el lugar de primera asistencia por personal sanitario, la necesidad de realizar una intubación orotraqueal. Puesto que los signos clínicos son pobres predictores de la severidad de la lesión, en casos seleccionados es recomendable la realización de una fibroscopia diagnóstica. Presentamos un caso clínico de un paciente con lesión por inhalación de humo en el que la realización de la fibroscopia fue determinante para proceder a la intubación, y proponemos un algoritmo de actuación para el manejo de la vía aérea en este tipo de pacientes.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Kot Baixauli P, Morales Sarabia JE, Rovira Soriano L, De Andrés Ibáñez J. Propuesta de algoritmo para el manejo de la vía aérea del paciente tras inhalación de humo. Rev Esp Anestesiol Reanim. 2018;65:170–172.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1193 "Ancho" => 1750 "Tamanyo" => 160633 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Nasal fibreoptic endoscopy showing vocal fold oedema and endotrachael blackish exudate.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2496 "Ancho" => 1583 "Tamanyo" => 224772 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Airway management algorithm for patients with suspected smoke inhalation injury.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of acute smoke inhalation injury" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.H. 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