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This guidance has been developed to assist in the management of children that have suffered a burn to their airway and/or suffered smoke inhalation injuries.
This guidance should be used by the multidisciplinary team caring for children that have suffered an airway burn or smoke inhalation.
A multidisciplinary team should provide the management of the child with inhalation injury. Childhood inhalation injury mandates transfer to a PICU and if associated with burns to a paediatric burns centre.
There is insufficient data to support a treatment standard or a treatment guideline for the diagnosis of inhalation injury.
Suspect inhalation injury if:
Consultant anaesthetic staff/ PICU staff must be informed of all inhalation injuries.
No factors accurately and consistently predict the need for intubation. It is a clinical decision, ie not based on laboratory data. Drooling, stridor, hoarseness, facial or neck burn or increased work of breathing mandate intubation.
Children with lower airway injury that have required intubation should be managed in a PICU. It is possible that a child has deteriorated as lower airway injury has progressed, requiring intubation after a period of observation. These children should be referred to a PICU.
Injury may not manifest until after 48 hours. Toxins produce bronchospasm, mucosal oedema, microvascular hyperpermeability, obstructive airway casts and surfactant dysfunction.
Depressed epithelial integrity, loss of the mucocilairy clearance mechanism, migration of upper airway secretions to the lower airway and immuno-compromise predispose to bacterial colonization and translocation. Lower airway injury may progress to the acute respiratory distress syndrome. Strategies should be targeted to minimize iatrogenic ventilator induced lung injury. Intubation is as per upper airway thermal injury. (Suxamethonium can be used to facilitate intubation in the absence of a cutaneous burn injury. If there is a burn injury present then Suxamethonium can be used in the first 24 hours. Its use is contraindicated after 24 hours from a cutaneous burn).
The requirement for invasive lines can be discussed with the retrieval team. The retrieval team can site lines as indicated if the referring hospital are unable to gain access.
Cyanide toxicity is uncommon. Cyanide levels are not routinely performed by hospital biochemistry services, and have to be sent to reference laboratories. For this reason they cannot be used to influence management. The routine use of antidotes is not recommended as they have significant side effects. Priority should be given to stabilising the airway. The use of Cyanide antidotes should be discussed with a PICU consultant. Therapy will be influenced by local availability of antidotes.
Suspect Cyanide poisoning if
It is expected that the child will already be on a PICU. Bronchoscopy should not be performed by the referring hospital unless it is to assist an emergency intubation, or because the child cannot be ventilated after being intubated.
These patients are at risk of ARDS and iatrogenic ventilator induced lung injury. The standard of care for mechanical ventilation in inhalation injury has not been established. Local protocols for ventilating a patient with Acute Lung Injury should be adhered to these will be dependant on ventilator modes available. Lung protective strategies should be adopted. Any child requiring ventilation should be discussed with PICU pending transfer.
There is animal model evidence for the use of nebulised heparin and nebulised N-acetylcysteine. Whilst it is standard practice insome paediatric burn’s centres, its routine use cannot be recommended. The Shriner’s Bronchial Toilet Schedule is presented below.
The following is the Shriners policy, which can be adopted at the discretion of the PICU consultant.
Last reviewed: 01 June 2015
Next review: 10 December 2022
Author(s): Alastair Turner, Christina Harry
Document Id: 44