Notes:

- Patients with mild symptoms of smoke inhalation injury (e.g., some cough, no respiratory distress) can be observed.
- Burns or explosions in a closed space are associated with higher risk of inhalation injury than burns occurring in open areas.
- Supraglottic airway (e.g., laryngeal mask airway [LMA], King LT [Ambu, http://www.ambuusa.com/], or Combitube [Medtronic Minimally Invasive Therapies, http://www.medtronic.com/covidien]) is not appropriate because edema will continue to increase over 48 hours and these tubes do not overcome vocal-cord edema.
- Endotracheal tube must be secured circumferentially around the neck using cotton ties or similar. Tape does not stick to the face well enough in burn patients.
- Place nasogastric (or orogastric) tube to decompress stomach in intubated patients.
- Perform frequent endotracheal suction of intubated patients to ensure tube patency and remove mucus/debris (approximately once an hour or more frequently if oxygen saturation [SpO2] drops).
- If there is evidence of inhalation injury, use 3–5mL of endotracheal saline to facilitate suctioning and prevent tube insipation and obstruction.
- Monitoring end-tidal CO2 is an important capability for all intubated patients. A rising end-tidal CO2 could indicate clogging of endotracheal tube or poor ventilation from another cause (e.g.,bronchospasm, tight eschar across chest).
- Use PEEP on all intubated patients.
- Perform a surgical escharotomy of the chest for tight, circumferential, full-thickness burns that impair breathing. Incision goes through the full thickness of the burn and into the fat (Appendix A). Expect some pain and bleeding.
- Use bronchodilators (e.g., albuterol inhaler) for intubated patients with inhalation injury, if available.
- Ventilator management of burn patients can be complicated and evolve as pulmonary conditions change due to volume overload/edema and acute respiratory distress syndrome (ARDS). Telemedicine consultation with skilled providers is recommended.