Smoke inhalation

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Smoke inhalation
Accompanying Red Cross Ambulance in northern Gaza - 3188893808.jpg
A patient being treated for smoke inhalation in an ambulance by the Palestine Red Crescent Society in Jabaliya
Specialty Emergency medicine, pulmonology, critical care

Smoke inhalation is the breathing in of harmful fumes (produced as by-products of combusting substances) through the respiratory tract. [1] This can cause smoke inhalation injury (subtype of acute inhalation injury) which is damage to the respiratory tract caused by chemical and/or heat exposure, as well as possible systemic toxicity after smoke inhalation. [2] [3] [4] Smoke inhalation can occur from fires of various sources such as residential, vehicle, and wildfires. Morbidity and mortality rates in fire victims with burns are increased in those with smoke inhalation injury. [3] [4] Victims of smoke inhalation injury can present with cough, difficulty breathing, low oxygen saturation, smoke debris and/or burns on the face. [2] [5] Smoke inhalation injury can affect the upper respiratory tract (above the larynx), usually due to heat exposure, or the lower respiratory tract (below the larynx), usually due to exposure to toxic fumes. [2] [4] [6] [5] Initial treatment includes taking the victim away from the fire and smoke, giving 100% oxygen at a high flow through a face mask (non-rebreather if available), and checking the victim for injuries to the body. [5] [6] Treatment for smoke inhalation injury is largely supportive, with varying degrees of consensus on benefits of specific treatments. [3]

Contents

Epidemiology

The U.S. Fire Administration reported almost 1.3 million fires in 2019 causing 3,704 deaths and almost 17,000 injuries. [7] Residential fires were found to be most often cooking related and resulted in the highest amount of deaths when compared to other fire types such as vehicle and outdoor fires. [7] It has been found that men have higher rates of fire-related death and injury than women do, and that African American and American Indian men have higher rates of fire-related death and injury than other ethnic and racial groups. The age group with the highest rate of death from smoke inhalation is people over 85, while the age group with the highest injury rate is people of ages 50–54. [7] Some reports also show increased rates of death and injury in children, due to their lower physical and mental capabilities. [2] [4] In 2019, the overall U.S. national fire death rate was 10.7 people per million population and the injury rate was 50.6 people per million population. [7] According to the U.S. Fire Administration, the deaths in the United States that were caused by a fire fluctuated over the past 10 years. The administration recorded the increase of deaths between 2012 and 2021, and concluded an increase of 18% per million. [8] Smoke inhalation injury is the most common cause of death in fire victims. [2] Fire victims with both burns to their body and smoke inhalation injury have increased mortality rate and length of hospital stay compared to those with burns alone. [2] [4]

Signs and symptoms

Some of the signs and symptoms of smoke inhalation injury include recent fire exposure followed by cough, wheezing, stridor, confusion, difficulty breathing, low oxygen saturation, smoke debris (especially on face and/or in saliva), burns (especially of the face), singed facial or nose hairs, and/or hoarse voice. [2] [6] A careful history can be helpful in determining where the fire occurred and therefore, what chemical fumes could have been inhaled with accompanying systemic toxicities. [2] [3]

Smoke inhalation injury can lead to respiratory complications ranging from minor to major. Acute Respiratory Distress Syndrome (ARDS) is a relatively delayed complication of smoke inhalation injury caused by chemical fumes inducing an inflammatory response in the lung tissue, especially the small air sacs known as alveoli where critical gas exchange occurs. [2] [3] [4] Another potential complication is swelling of the upper airway from both heat and chemical damage, and can become profound enough to obstruct breathing. The onset of airway swelling can be relatively delayed making it difficult to intubate later on, thus endotracheal intubation should be considered early in certain patients. [2] [6] Other possible complications include pneumonia, vocal cord damage and/or dysfunction, and tracheal stenosis (usually delayed). [5]

Mechanism

Inhalation of chemical toxins produced by combusting materials can cause damage to tissues of both the upper (above larynx) and lower respiratory tract (below larynx). Damage to lower airways, air sacs, and lung tissue is due to an inflammatory cascade in response to the noxious chemicals which causes a variety of downstream effects such as increased secretions and exudative material thus clogging the airways and/or air sacs, collapse of air sacs (atelectasis), vascular permeability leading to pulmonary edema (fluid in the lungs), bronchoconstriction, activation of the coagulation cascade, and impaired function of the mucociliary escalator. [2] [3] [5] [6]

Inhalation of hot fumes can cause thermal damage to tissues, usually limited to the upper respiratory tract (above larynx). Damage in this location can result in sloughing of the damaged tissue and swelling, both of which can cause obstruction of the respiratory tract, ulceration, increased secretions, and redness (erythema). [2] [3] [5] [6]

Systemic toxicity can occur from inhalation of chemical compounds produced as byproducts of combustion in a fire. [2] [3] [4] [6] Carbon monoxide poisoning is the most common systemic toxicity after smoke inhalation, and can cause organ failure from lack of oxygen (often heart attack). [2] [4] [6] Carbon monoxide is a common byproduct of combusting substances in fires and is colorless and odorless. It has a much higher binding affinity for hemoglobin compared to oxygen and thus can block oxygen from binding to hemoglobin, causing hypoxia. Additionally, carbon monoxide decreases the ability of oxygen to dissociate from hemoglobin to diffuse into tissues, thus causing hypoxia. [4] [6]

According to the New York Times , a recent study claims that smoke inhalation can also cause lung cancer. While cigarettes are proven to cause cancer, as well as inhaling second hand smoke from a cigarette, the article notes that a cigarette is filtered. In contrast, inhaling wild fire smoke due to the harmful substances found in the air. For example, smoke from burning trees and gardens will present different dangers than smoke from burning houses, cars or electronics. A study published in 2019 recorded firefighters who worked for 25 years, an average of 7 weeks per year, increase their risk of lung cancer by 8 to 26 percent due to the amount of smoke they have been exposed to on duty. [9]

Treatment

First responders often take the victim away from the fire and smoke, give 100% oxygen at high flow through a face mask (non-rebreather if available), assess level of consciousness, and check the victim for burns and/or injuries to the body for initial care. [4] Upper respiratory tract injury due to heat exposure often results in swelling. Intubation should be considered early given that the swelling can have a slow, delayed onset but once present, will make intubation very difficult. [2] [4] [6]

Lower respiratory tract injury due to exposure to noxious fumes often consists of supportive measures such as intubation and ventilator support if indicated, suctioning of the airways (pulmonary hygiene), and other supportive measures. [5] [6] Intravenous fluids are a mainstay in treatment of fire victims with extensive burns to the body, however, there are differing perspectives on the risks/benefits of IV fluids in fire victims with both burns and smoke inhalation injury due to the potential worsening of pulmonary edema with large amounts of IV fluids typically given in burn victims. [4] [6]

Other treatments with differing perspectives and study findings on utility in smoke inhalation injury include nebulized bronchodilators (such as beta-2-agonists), IV corticosteroids, nebulized corticosteroids, nebulized epinephrine, nebulized heparin, and nebulized N-acetylcysteine. [2] [3] [4] [5] [6]

Carbon monoxide poisoning is initially treated with high flow 100% oxygen. Hyperbaric oxygen therapy can be considered but there are differing views on its clinical benefit in terms of outcomes. [2] [4] [6]

Systemic poisonings

Products with systemic effects are mainly asphyxiating gases, such as carbon monoxide and cyanides. [10]

Carbon monoxide

Carbon monoxide (СО), which is absorbed by the lungs, diffuses into the capillaries and dissolves in the plasma and erythrocytes, binding to haemoglobin. As its affinity is more than 200 times that of oxygen, the amount of oxygen bound to haemoglobin is reduced, leading to anoxia. [11] In addition, carbon monoxide released at the tissue level binds to mitochondrial enzyme systems, resulting in the inability of cells to utilise oxygen. When exposed to excess CO, one of the body's natural reactions is to breathe faster. This further increases the CO level in the blood, eventually leading to cardiac arrest.

Cyanides

Once the cyanide ion (CN-) enters the bloodstream, it diffuses into body cells. [12] It binds to the trivalent iron of mitochondrial cytochrome oxidase, causing its inhibition and hence tissue anoxia. The metabolism shifts towards anaerobic metabolism, leading to an increase in lactacidemia.

See also

Related Research Articles

<span class="mw-page-title-main">Hypoxia (medicine)</span> Medical condition of lack of oxygen in the tissues

Hypoxia is a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level. Hypoxia may be classified as either generalized, affecting the whole body, or local, affecting a region of the body. Although hypoxia is often a pathological condition, variations in arterial oxygen concentrations can be part of the normal physiology, for example, during strenuous physical exercise.

<span class="mw-page-title-main">Respiratory system</span> Biological system in animals and plants for gas exchange

The respiratory system is a biological system consisting of specific organs and structures used for gas exchange in animals and plants. The anatomy and physiology that make this happen varies greatly, depending on the size of the organism, the environment in which it lives and its evolutionary history. In land animals, the respiratory surface is internalized as linings of the lungs. Gas exchange in the lungs occurs in millions of small air sacs; in mammals and reptiles, these are called alveoli, and in birds, they are known as atria. These microscopic air sacs have a very rich blood supply, thus bringing the air into close contact with the blood. These air sacs communicate with the external environment via a system of airways, or hollow tubes, of which the largest is the trachea, which branches in the middle of the chest into the two main bronchi. These enter the lungs where they branch into progressively narrower secondary and tertiary bronchi that branch into numerous smaller tubes, the bronchioles. In birds, the bronchioles are termed parabronchi. It is the bronchioles, or parabronchi that generally open into the microscopic alveoli in mammals and atria in birds. Air has to be pumped from the environment into the alveoli or atria by the process of breathing which involves the muscles of respiration.

<span class="mw-page-title-main">Trachea</span> Cartilaginous tube that connects the pharynx and larynx to the lungs

The trachea, also known as the windpipe, is a cartilaginous tube that connects the larynx to the bronchi of the lungs, allowing the passage of air, and so is present in almost all animals with lungs. The trachea extends from the larynx and branches into the two primary bronchi. At the top of the trachea the cricoid cartilage attaches it to the larynx. The trachea is formed by a number of horseshoe-shaped rings, joined together vertically by overlying ligaments, and by the trachealis muscle at their ends. The epiglottis closes the opening to the larynx during swallowing.

Diffusing capacity of the lung (DL) measures the transfer of gas from air in the lung, to the red blood cells in lung blood vessels. It is part of a comprehensive series of pulmonary function tests to determine the overall ability of the lung to transport gas into and out of the blood. DL, especially DLCO, is reduced in certain diseases of the lung and heart. DLCO measurement has been standardized according to a position paper by a task force of the European Respiratory and American Thoracic Societies.

<span class="mw-page-title-main">Respiratory tract</span> Organs involved in transmission of air to and from the point where gases diffuse into tissue

The respiratory tract is the subdivision of the respiratory system involved with the process of respiration in mammals. The respiratory tract is lined with respiratory epithelium as respiratory mucosa.

<span class="mw-page-title-main">Pulmonary aspiration</span> Entry of materials into the larynx (voice box) and lower respiratory tract

Pulmonary aspiration is the entry of material such as pharyngeal secretions, food or drink, or stomach contents from the oropharynx or gastrointestinal tract, into the larynx and lower respiratory tract, the portions of the respiratory system from the trachea (windpipe) to the lungs. A person may inhale the material, or it may be delivered into the tracheobronchial tree during positive pressure ventilation. When pulmonary aspiration occurs during eating and drinking, the aspirated material is often colloquially referred to as "going down the wrong pipe".

<span class="mw-page-title-main">Inhalation</span> Flow of the respiratory current into an organism

Inhalation is the process of drawing air or other gases into the respiratory tract, primarily for the purpose of breathing and oxygen exchange within the body. It is a fundamental physiological function in humans and many other organisms, essential for sustaining life. Inhalation is the first phase of respiration, allowing the exchange of oxygen and carbon dioxide between the body and the environment, vital for the body's metabolic processes. This article delves into the mechanics of inhalation, its significance in various contexts, and its potential impact on health.

<span class="mw-page-title-main">Carbon monoxide poisoning</span> Toxic effects of carbon monoxide

Carbon monoxide poisoning typically occurs from breathing in carbon monoxide (CO) at excessive levels. Symptoms are often described as "flu-like" and commonly include headache, dizziness, weakness, vomiting, chest pain, and confusion. Large exposures can result in loss of consciousness, arrhythmias, seizures, or death. The classically described "cherry red skin" rarely occurs. Long-term complications may include chronic fatigue, trouble with memory, and movement problems.

In physiology, respiration is the movement of oxygen from the outside environment to the cells within tissues, and the removal of carbon dioxide in the opposite direction to the surrounding environment.

<span class="mw-page-title-main">Oxygen therapy</span> Use of oxygen as a medical treatment

Oxygen therapy, also referred to as supplemental oxygen, is the use of oxygen as medical treatment. Supplemental oxygen can also refer to the use of oxygen enriched air at altitude. Acute indications for therapy include hypoxemia, carbon monoxide toxicity and cluster headache. It may also be prophylactically given to maintain blood oxygen levels during the induction of anesthesia. Oxygen therapy is often useful in chronic hypoxemia caused by conditions such as severe COPD or cystic fibrosis. Oxygen can be delivered via nasal cannula, face mask, or endotracheal intubation at normal atmospheric pressure, or in a hyperbaric chamber. It can also be given through bypassing the airway, such as in ECMO therapy.

<span class="mw-page-title-main">Injury in humans</span> Physiological wound caused by an external source

An injury is any physiological damage to living tissue caused by immediate physical stress. Injuries to humans can occur intentionally or unintentionally and may be caused by blunt trauma, penetrating trauma, burning, toxic exposure, asphyxiation, or overexertion. Injuries can occur in any part of the body, and different symptoms are associated with different injuries.

<span class="mw-page-title-main">Respiratory arrest</span> Medical condition

Respiratory arrest is a serious medical condition caused by apnea or respiratory dysfunction severe enough that it will not sustain the body. Prolonged apnea refers to a patient who has stopped breathing for a long period of time. If the heart muscle contraction is intact, the condition is known as respiratory arrest. An abrupt stop of pulmonary gas exchange lasting for more than five minutes may permanently damage vital organs, especially the brain. Lack of oxygen to the brain causes loss of consciousness. Brain injury is likely if respiratory arrest goes untreated for more than three minutes, and death is almost certain if more than five minutes.

A blood agent is a toxic chemical agent that affects the body by being absorbed into the blood. Blood agents are fast-acting, potentially lethal poisons that typically manifest at room temperature as volatile colorless gases with a faint odor. They are either cyanide- or arsenic-based.

Diving disorders, or diving related medical conditions, are conditions associated with underwater diving, and include both conditions unique to underwater diving, and those that also occur during other activities. This second group further divides into conditions caused by exposure to ambient pressures significantly different from surface atmospheric pressure, and a range of conditions caused by general environment and equipment associated with diving activities.

Occupational lung diseases comprise a broad group of diseases, including occupational asthma, industrial bronchitis, chronic obstructive pulmonary disease (COPD), bronchiolitis obliterans, inhalation injury, interstitial lung diseases, infections, lung cancer and mesothelioma. These can be caused directly or due to immunological response to an exposure to a variety of dusts, chemicals, proteins or organisms. Occupational cases of interstitial lung disease may be misdiagnosed as COPD, idiopathic pulmonary fibrosis, or a myriad of other diseases; leading to a delay in identification of the causative agent.

<span class="mw-page-title-main">Dimethylzinc</span> Chemical compound

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<span class="mw-page-title-main">Tracheobronchial injury</span> Damage to the tracheobronchial tree

Tracheobronchial injury is damage to the tracheobronchial tree. It can result from blunt or penetrating trauma to the neck or chest, inhalation of harmful fumes or smoke, or aspiration of liquids or objects.

<span class="mw-page-title-main">Lithium tetrachloroaluminate</span> Chemical compound

Lithium tetrachloroaluminate is an inorganic compound with the formula Li[AlCl4]. It consists of lithium cations Li+ and tetrahedral tetrachloroaluminate anions [AlCl4]−.

Acute inhalation injury may result from frequent and widespread use of household cleaning agents and industrial gases. The airways and lungs receive continuous first-pass exposure to non-toxic and irritant or toxic gases via inhalation. Irritant gases are those that, on inhalation, dissolve in the water of the respiratory tract mucosa and provoke an inflammatory response, usually from the release of acidic or alkaline radicals. Smoke, chlorine, phosgene, sulfur dioxide, hydrogen chloride, hydrogen sulfide, nitrogen dioxide, ozone, and ammonia are common irritants.

<span class="mw-page-title-main">Hydrofluoric acid burn</span> Medical condition

A hydrofluoric acid burn is a chemical burn from hydrofluoric acid. Where it contacts the skin it results in significant pain, swelling, redness, and skin breakdown. If the fumes are breathed in swelling of the upper airway and bleeding may occur. Complications can include electrolyte, heart, lung, kidney, and neurological problems.

References

  1. ↑ "Smoke inhalation definition and meaning | Collins English Dictionary". www.collinsdictionary.com. Retrieved 2021-11-10.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Shubert, James; Sharma, Sandeep (2022). "Inhalation Injury". StatPearls. PMID   30020633. NBK513261.
  3. 1 2 3 4 5 6 7 8 9 Enkhbaatar, Perenlei (2015). "Chapter 94: Thermal Lung Injury and Acute Smoke Inhalation". Fishman's Pulmonary Diseases and Disorders (5 ed.). New York: McGraw-Hill Education. Retrieved November 5, 2021.
  4. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Gill, Preea; Martin, Rebecca V (June 2015). "Smoke inhalation injury". BJA Education. 15 (3): 143–148. doi: 10.1093/bjaceaccp/mku017 .
  5. 1 2 3 4 5 6 7 8 Smoke Inhalation Injury. Elsevier Clinical Key[ verification needed ]
  6. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Rehberg, Sebastian; Maybauer, Marc O; Enkhbaatar, Perenlei; Maybauer, Dirk M; Yamamoto, Yusuke; Traber, Daniel L (June 2009). "Pathophysiology, management and treatment of smoke inhalation injury". Expert Review of Respiratory Medicine. 3 (3): 283–297. doi:10.1586/ERS.09.21. PMC   2722076 . PMID   20161170.
  7. 1 2 3 4 "U.S. fire statistics". U.S. Fire Administration. 2021-11-02. Retrieved 2021-11-05.
  8. ↑ "Fire Death and Injury Risk". U.S. Fire Administration. Retrieved 2023-12-28.
  9. ↑ Peterson, Molly (2022-08-09). "Does Wildfire Smoke Cause Lung Cancer?". The New York Times. ISSN   0362-4331 . Retrieved 2023-12-28.
  10. ↑ Gorguner, Metin; Akgun, Metin (2010). "Acute Inhalation Injury". The Eurasian Journal of Medicine. 42 (1): 28–35. doi:10.5152/eajm.2010.09. PMC   4261306 . PMID   25610115.
  11. ↑ "Physiology, Oxygen Transport And Carbon Dioxide Dissociation Curve".
  12. ↑ Mondal, Antu; Chattopadhyay, Shyamal Kumar (15 November 2022). "Selective Turn-On Fluorescence Sensing of Cyanide Using the Pyridoxal Platform of a Ni(II) Complex". ACS Omega. 7 (45): 40941–40949. doi:10.1021/acsomega.2c04063. PMC   9670700 . PMID   36406569.
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