3 Airway Management

Recognize evolving airway threats

Burn-related airway problems can develop quickly, particularly after heat or smoke injures the upper airway. Swelling may progress over time and may worsen during fluid resuscitation, so an initially reassuring assessment does not remove the need for continued observation.

Assess airway and breathing early, then reassess frequently. Address immediate threats to airway patency and oxygenation before continuing a broader burn evaluation, such as estimating burn size or changing wound dressings.

Identify concerning findings

Concern for inhalation injury increases after an enclosed-space fire, particularly when there are facial or oral burns, soot around or in the mouth, voice changes, or respiratory symptoms. Hoarseness after an enclosed-space fire raises concern for upper-airway injury and evolving swelling.

Warning signs that support urgent concern include:

• Stridor with increasing work of breathing

• Progressive hoarseness or visible oral or pharyngeal swelling

• Respiratory distress or inability to clear secretions

• Altered mental status or hypoxia

Singed nasal hairs, facial burns, or soot alone do not automatically mean intubation is required. They do warrant careful assessment and repeated observation. A patient with soot in the mouth who is alert, breathing comfortably, and has no hoarseness or stridor still needs appropriate evaluation and monitoring because symptoms may evolve.

Provide oxygen and evaluate smoke exposure

When airway compromise is suspected, assess airway patency and breathing, provide oxygen, and promptly involve clinicians experienced in airway management. Give high-concentration oxygen when indicated, including when carbon monoxide exposure is suspected; do not wait for severe obstruction, cyanosis, or a falling oxygen-saturation reading before escalating care.

A standard pulse-oximeter reading can be misleading after smoke exposure because pulse oximetry may not reliably distinguish carboxyhemoglobin from oxyhemoglobin. A normal reading therefore does not rule out carbon monoxide poisoning. Assess the exposure and symptoms, arrange appropriate blood testing such as a carboxyhemoglobin measurement, and do not delay oxygen while waiting for results.

Escalate care before deterioration

Reassess frequently and seek experienced airway support and burn-care guidance early when deterioration is possible. Suspected inhalation injury warrants prompt burn-center consultation.

Increasing facial or neck swelling, anticipated fluid resuscitation, and a prolonged transfer increase concern that airway management may become more difficult. A patient who was initially speaking clearly may deteriorate; coordinate with experienced clinicians and consider securing the airway before worsening makes it more difficult. The decision to intubate depends on the patient’s findings and clinical context.

For example, stridor with increasing work of breathing supports urgent definitive airway management. By contrast, soot alone in an alert patient breathing comfortably without hoarseness or stridor calls for evaluation, appropriate oxygen, and close monitoring rather than automatic intubation. If a patient becomes less responsive and develops noisy breathing, address airway patency and oxygenation, assess breathing, and call for advanced airway assistance before continuing the secondary survey.