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Lesson

Smoke Inhalation and the Airway

10 min Airway & Breathing Skip to quiz

Objective: Spot the smoke airway that will swell. Give oxygen even if the sat looks normal. Go to a hospital that can manage a difficult burn airway.

Why this matters

They walked out of the house talking. Twenty minutes later they cannot swallow. Suspect an inhalation injury from a closed space, soot, black sputum, a changing voice, or singed hair. Do not wait for a normal room-air sat. Carbon monoxide makes the pulse oximeter look better than the patient.

Verbalize
  • I put high-flow oxygen on the face now. I do not wait for a carboxyhemoglobin number I cannot measure.
  • A sat of 99% or 100% after a house fire does not clear them. The pulse oximeter misses carbon monoxide.
  • If the voice is changing, we go to a hospital that can manage a difficult airway, or to a burn center. We do not go to a clinic.

Clinical sequence

  1. Make the scene safe. Then put high-flow oxygen on the face. Treat them as exposed to carbon monoxide until someone proves they are not. Your protocol owns the oxygen fraction.
  2. Look for a closed-space fire, soot around the mouth or nose, singed nasal hair, black sputum, hoarseness, stridor, and facial burns.
  3. If the voice is changing or they are drooling, sit them up, keep oxygen on, and leave. Do not take repeated looks on scene while the neck swells. One more look while the neck swells is how you reach cannot-intubate, cannot-oxygenate in the ambulance.
  4. If they are still getting oxygen, move. If they are not, use a two-person bag or a supraglottic airway. Say the cannot-intubate, cannot-oxygenate plan out loud before anyone starts rapid sequence intubation because they might swell.
  5. Cyanide treatment is a protocol question in some systems, especially soot plus shock plus arrest in a fire. Follow yours. This lesson does not give an antidote dose.

Teaching points

  • If they are still talking, position them, give oxygen, and go. Do not start a tube on scene just because the airway might swell later, unless they are failing in front of you and you have a backup plan.
  • Black sputum and singed nasal hair are clues to inhalation injury. They are not a reason to trust the pulse oximeter.

Common errors

  • Trusting a sat of 100% after a house fire.
  • Going to a clinic for facial burns and a changing voice.
  • Starting rapid sequence intubation without a cannot-intubate, cannot-oxygenate plan because they might swell.

Practice

One-minute check

Partner: apartment fire, soot, a hoarse whisper, and SpO₂ 99%. Name the oxygen plan, the kind of hospital you need, and one thing the pulse oximeter cannot tell you.

Related: Burns, Carbon monoxide.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.

Check Your Understanding

Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.

1. SpO₂ 99% after a house fire means:
2. Hoarseness and soot after a closed-space fire mean:
3. Carbonaceous sputum (black spit) and singed nasal hair are:
4. The pulse oximeter in CO exposure:
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