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Inhalation injury is a broad term that includes pulmonary exposure to a wide range of chemicals in various forms, including smoke, gases, vapors, fumes, aerosols, or dust.1,2 Toxic chemical exposure can be a consequence of an industrial disaster, occupational exposure, recreational mishap, natural catastrophe, chemical warfare, or acts of terrorism.3 The consequences of such exposure include direct injury to the upper respiratory tract and lung parenchyma, as well as systemic toxicity. The manifestation and severity of such injuries depend upon chemical characteristics (e.g., solubility, particle size, composition, etc.), the amount of toxic compound or compounds inhaled, and patient characteristics (e.g., age, premorbid conditions, etc.).

Inhalation injury can be classified according to cause: asphyxiants, choline esterase inhibitors, respiratory tract irritants, and vesicants (further elaborated in Table 36-1).3 Chemical inhalation injury may be accompanied by thermal injury, as often happens with smoke inhalation.


Real-time identification of specific chemicals is difficult and many a times not feasible. Symptom onset and progression may be latent but are typically rapid, and the window for effective therapy is often narrow. Therefore, prompt, empirical therapy of casualties suffering from inhalation injury is required. Ending the exposure by evacuation and decontamination is invaluable in treating such casualties. Extrication of casualties from a contaminated zone is best performed by emergency personnel using adequate protective gear. Importantly, when a traumatic injury is suspected (i.e., following an explosion or a terror attack), emergency medical personnel should treat life-threatening situations according to trauma care guidelines.

This chapter presents an overview of some of the leading agents that are involved in inhalation injuries. It will discuss their history, epidemiology, properties, clinical manifestation, treatments, and long-term effects.


Smoke inhalation is one of the most commonly encountered inhalation injuries. It involves the exposure of a casualty’s respiratory system to toxic chemicals released during material combustion and, not necessarily, to direct heat that causes thermal injury. Common toxic compounds that are found in smoke include carbon monoxide, ammonia, carbon dioxide, hydrogen cyanide, aldehydes, sulfur dioxides, and nitrogen dioxide.1 In the United States, fire departments responded to a total of 1,291,500 fires that resulted in approximately 3,700 fatalities and 16,600 injured casualties in 2019.4 Respiratory failure remains the leading cause of death from fire injuries, and smoke inhalation injuries affect up to one-third of all burn injury victims.1

The upper respiratory tract is more prone to thermal injury, whereas chemical ...

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