Mechanical ventilation strategies in inhalation injury

Overview

Inhalation injury is the respiratory companion of major burns that most often kills, and mechanical ventilation is the supportive backbone of its management. Inhalation injury occurs in roughly a quarter to a third of patients hospitalized with thermal injury, accounts for nearly 80% of non-fire-related deaths, and has become one of the most frequent causes of death in burn patients [3, 2]. The mechanism by which it kills is largely pulmonary: in a review of 529 burn patients, those with inhalation injury had a 73% incidence of respiratory failure and a 20% incidence of ARDS, versus 5% and 2% in those without ^[1]. A pooled analysis put the incidence of ARDS in burns at 24% with mortality as high as 31%, and the ARDS rate climbed to 41% when more than half the cohort had inhalation injury ^[5]. Inhalation injury is an independent predictor of moderate-to-severe ARDS ^[8]. The Berlin definition stratifies ARDS severity in burn patients better than the older AECC definition and correctly excludes minimal disease ^[7], and burn inhalation injury remains a state-of-the-science problem whose study categories span diagnosis, ventilation, systemic and inhalation therapy, mechanism, and outcomes ^[66].

This page covers how the injured lung is ventilated: conventional lung-protective ventilation, positive end-expiratory pressure and recruitment, the high-frequency percussive and oscillatory modes, airway pressure release ventilation, high-flow and noninvasive support, extracorporeal support, weaning and tracheostomy, and the outcomes and complications that follow. The defining tension of the field is that decades of work have produced many plausible modes and a great deal of physiologic data, but almost no high-quality comparative evidence: to date there are no evidence-based guidelines on ventilation strategies in ARDS after smoke inhalation, and most published evidence is graded level 3 or below for want of large human studies [12, 23]. Airway diagnosis and bronchoscopic grading, nebulized airway pharmacotherapy, carbon-monoxide and cyanide toxicity, and intubation and tracheostomy technique are covered on adjacent pages; this page stays on ventilation strategy.

Conventional and lung-protective ventilation

The default approach is conventional ventilation set to protect the lung: limit tidal volume and airway pressure, accept permissive hypercapnia, and avoid injurious inflating pressures and oxygen concentrations. Pressure support and volume assist-control were the most common initial modes used in burn patients with and without inhalation injury ^[25]. The physiologic case for restraint is direct: decreased lung compliance and increased airway resistance after inhalation injury raise airway pressures and predispose to barotrauma, so the strategy that lowers pressure lowers that risk ^[9].

The one randomized comparison of strategies in burn patients with respiratory failure pitted a high-frequency percussive ventilation strategy against a low-tidal-volume ventilation strategy and found similar ventilator-free days and similar clinical outcomes between them; the low-tidal-volume arm, however, failed to meet oxygenation or ventilation goals in a higher proportion and required rescue ventilation more often (29% vs 6%) ^[11]. That trial frames the practical reality: low-tidal-volume ventilation is the protective default, but a meaningful minority of severely injured lungs cannot be oxygenated within protective limits and escalate to another mode.

The tidal-volume question is not entirely settled in this population. A retrospective pediatric study reported that high tidal volume was associated with fewer ventilator days and a lower incidence of atelectasis and ARDS than low tidal volume, at the cost of higher peak and plateau pressures and significantly more pneumothorax ^[10]. The authors raised the possibility that higher tidal volumes might interrupt the sequence leading to lung injury in burned children, but the pneumothorax signal is a reminder that the protective rationale is built on pressure-related harm ^[10]. Variability in reported ventilator data has precluded firm conclusions about which settings drive ventilator-induced lung injury in burn patients specifically ^[20].

Positive end-expiratory pressure and recruitment

Positive end-expiratory pressure (PEEP) is foundational to oxygenating the injured lung, and it has both supportive evidence and limits. In early ovine work, positive pressure ventilation with PEEP lowered the mortality of inhalation injury ^[27]. Applied early, positive pressure ventilation with PEEP increased short-term survival and reduced tracheobronchial cast formation when started immediately after the inhalation insult, although immediate application did not prevent hypoxia and increased pleural fluid formation ^[26]. PEEP up to 20 cm H2O did not appear to cause severe reduction in airway nutritive flow or airway necrosis, supporting its safety within that range ^[31].

Recruitment maneuvers and PEEP titration target the heterogeneous, dependent-lung collapse characteristic of smoke injury. After smoke inhalation the dependent lung shows a larger area of collapse and reduced filling capacity; recruitment increases ventilated volume and improves dependent-lung mechanics, though the non-dependent lung is then more prone to hyperinflation ^[32]. PEEP also redistributes bronchial blood flow, decreasing it as PEEP is applied without changing the P/F ratio in one ovine model ^[29]. In a canine smoke model, both sustained inflation and incremental-PEEP recruitment improved oxygenation and compliance ^[33]. An early-high-PEEP support strategy was suggested as potentially protective in ventilated burn patients with ARDS whose course was short and less severe than expected, and a closed-loop system that automatically raised PEEP improved lung compliance and survival in sheep with combined burn and smoke injury [41, 42]. Continuous positive airway pressure improved pulmonary function after smoke inhalation in dogs, the earliest version of this open-lung logic ^[77].

High-frequency percussive ventilation

High-frequency percussive ventilation (HFPV), delivered by the volumetric diffusive respirator (VDR), is the mode most identified with burn-center inhalation-injury care. It stacks small high-frequency subtidal breaths on a pressure-limited cycle, which in principle recruits alveoli and mobilizes secretions at lower airway pressures than conventional ventilation ^[15]. Those theoretical advantages are borne out physiologically: transition from conventional ventilation to VDR improved oxygenation and ventilation while lowering peak inspiratory pressures, and the VDR maintained gas exchange at lower airway pressures with a reduction in barotrauma [16, 15]. In stable ICU burn patients, HFPV improved gas exchange under lower peak pressures without hemodynamic compromise, an alternative open-lung recruitment method ^[14].

The clinical-outcome signal for HFPV is suggestive but inconsistent. A randomized comparison of conventional ventilation versus HFPV in 35 severely burned patients found HFPV improved blood oxygenation during the acute phase and allowed FiO2 reduction, without a difference in mortality or infectious complications ^[14]. Early work proposed that high-frequency ventilation could decrease pulmonary infection and iatrogenic barotrauma after inhalation injury, achieving adequate gas exchange where conventional ventilation could not ^[65]. Prophylactic high-frequency flow interruption in patients with bronchoscopically diagnosed inhalation injury produced a significant decrement in mortality, with significantly less parenchymal damage and a lower barotrauma index than conventional ventilation in the companion model ^[18]. Historical reports described HFPV reducing pneumonia and mortality versus conventional ventilation, and one retrospective series found lower mortality (28% vs 43%) and a significant morbidity-and-mortality reduction in the subset with 40% TBSA or less treated with HFPV ^[4]. A systematic review of seven HFPV studies found mortality and pneumonia improved in three and were unchanged in three, with no change in ventilator days or ICU stay but better oxygenation and work of breathing, supporting only a very weak recommendation that HFPV may lower mortality and pneumonia in smoke-inhalation acute lung injury ^[12]. A focused review of VAP found no significant difference in pneumonia rates between HFPV and volume-control ventilation and judged the evidence inconclusive ^[13]. The honest summary is that HFPV reliably improves oxygenation and secretion clearance and may reduce pneumonia and barotrauma, but the mortality case rests on low-quality evidence.

High-frequency oscillatory ventilation

High-frequency oscillatory ventilation (HFOV) opens and recruits the lung with very small tidal volumes around a high mean airway pressure, and the preclinical case in inhalation injury is strong. In animal models HFOV attenuated the fall in oxygenation and compliance, alleviated lung-tissue damage and the inflammatory response, and reduced markers of lung apoptosis compared with conventional ventilation, an effect amplified by adding exogenous surfactant [73, 74, 75, 76]. In a pediatric burn series, HFOV produced significant, early, and sustained improvement in oxygenation, with earlier institution associated with lower barotrauma rates ^[72].

The adult clinical experience is more cautionary. Burned patients with ARDS and smoke inhalation injury did not achieve significant or eventual improvement in oxygenation index with HFOV, and there was a trend toward higher early-HFOV failure and severe hypercapnia among those with inhalation injury ^[22]. Combined with the difficulty of delivering nebulized medications during HFOV, those findings suggested HFOV may not be the optimal rescue mode when inhalation injury is present ^[22]. One review went further, holding that HFOV opens and recruits the lung effectively in trauma and ARDS but may not have a role in patients with inhalational injury ^[24]. Barotrauma occurred in 38% of patients during HFOV and severe hypercapnia in 49% in one pediatric series, underscoring that recruitment comes at a price ^[72]. HFOV is best read as a physiologically powerful rescue whose benefit is least certain in exactly the inhalation-injured lung this page concerns.

Airway pressure release ventilation

Airway pressure release ventilation (APRV) applies a high continuous pressure with brief timed releases, preserving spontaneous breathing and recruiting lung at a high mean airway pressure. It has been gaining a role in thoracic injury and may produce less physiologic trauma to mechanically ventilated patients ^[24]. Its specific evidence in early smoke inhalation is limited and mixed. In a porcine wood-smoke ARDS model, APRV-treated animals developed ARDS faster than conventional ventilation, with a lower P/F ratio at 12, 18, and 24 hours, although the difference disappeared by 48 hours and there was no difference in plateau pressures, hemodynamics, or survival ^[28]. A later porcine study likewise found smoke inhalation caused more shunt under APRV than conventional ventilation, with a lower P/F ratio at 2, 24, and 48 hours ^[30]. APRV is used in burn ARDS, but an international RAND/UCLA expert panel classified its use as an area of genuine disagreement ^[70]. The preclinical signal that APRV may worsen early oxygenation after smoke inhalation tempers enthusiasm for it as a first-line mode in this setting.

High-flow nasal cannula and noninvasive support

Noninvasive strategies have a narrow but growing place once the upper airway is secure or not threatened. High-flow nasal cannula (HFNC) was reported as a feasible alternative to invasive ventilation for initial respiratory support in burn patients with ARDS: in one comparison, mortality was numerically lower with HFNC than with mechanical ventilation (6.98% vs 13.58%) without reaching significance, and there were no differences in length of stay or cost ^[43]. High-flow nasal oxygen achieved improvement in a patient with ARDS from a 60% TBSA burn ^[44]. Noninvasive positive-pressure ventilation was shown to be as effective as conventional ventilation in improving gas exchange with fewer complications in acute hypercapnic and hypoxemic respiratory failure, and was used to support burn patients with pneumonia ^[45]. The unifying caution is that inhalation injury is progressive and threatens the airway, so these strategies presuppose an airway that does not need protecting; airway management itself is covered on an adjacent page.

Extracorporeal support and CO2 removal

When the lung cannot be oxygenated or ventilated within tolerable limits, extracorporeal support is the rescue of last resort, and it divides into full extracorporeal membrane oxygenation (ECMO) and lower-flow CO2 removal. Extracorporeal CO2 removal lets the ventilator be set far gentler: in early ovine work, arteriovenous CO2 removal allowed large reductions in minute ventilation, tidal volume, peak inspiratory pressure, respiratory rate, and FiO2 while maintaining normocapnia, and increased ventilator-free days while improving survival in a sheep ARDS model ^[34]. In a swine burn-and-smoke model, immediate post-injury extracorporeal CO2 removal reduced minute ventilation and driving pressure, delayed or prevented ARDS, and reduced its severity, prompting the proposal that proactive early CO2 removal be considered a disease-modifying approach ^[37]. Arteriovenous CO2 removal also produced higher survival than low-tidal-volume ventilation in an ovine comparison (71% vs 33% survival at 72 hours post-ARDS criteria) ^[35], and a percutaneous artificial-lung approach improved five-day survival over volume-controlled ventilation in a lethal ovine ARDS model ^[36]. Early Hemolung CO2 removal in spontaneously breathing sheep removed about 70 mL of CO2 per minute and significantly lowered PaCO2 ^[38].

Full ECMO is used for refractory hypoxemia, with outcomes that are reasonable but selection-dependent. A meta-analysis of ECMO for burn-and-smoke ARDS reported pooled survival of 54%, with survival associated with younger age, and noted that patients with refractory ARDS on ECMO survive at this rate ^[39]. In pediatric burns, venovenous ECMO showed the best survival of all configurations, similar to non-burned patients, while prolonged mechanical ventilation before ECMO decreased survival ^[40]. The early enthusiasm is tempered by historical concern: a sheep study suggested ECMO may potentiate the pathophysiology of smoke inhalation injury and account for initial deterioration in native lung function after cannulation, and some reports recommended against ECMO in critically ill burn patients [46, 47]. An ovine study did show ECMO conferred a survival advantage over inhalation injury alone ^[48]. ECMO and its anticoagulation, cannulation, and program-volume considerations belong to a dedicated topic; here it functions as the final tier of ventilatory rescue.

Weaning, extubation, and tracheostomy

Getting the patient off the ventilator is as important as the mode that kept them on it, and the burn-specific data favor protocolized, lighter sedation. Implementation of a combined spontaneous awakening and breathing protocol in a burn ICU was accompanied by significantly shorter ICU stay, fewer ventilator days, and lower pneumonia incidence, including in the inhalation-injury subgroup, and was judged safe ^[78]. A short course of propofol facilitated smooth extubation in ventilated burned children, 82% of whom were successfully extubated on the first attempt ^[54]. Classic extubation criteria do not predict extubation outcomes well in burn patients, where the presence of inhalation injury was actually associated with extubation success and higher heart rate and lower pH predicted failure ^[53]. Noninvasive positive-pressure ventilation supported respiratory function and allowed endotracheal intubation to be avoided in most burn patients with acute respiratory failure, a cohort in which pneumonia was common ^[45].

Tracheostomy timing is a recurring decision. Early tracheostomy in severely burned children was safe and improved ventilator mechanics, with lower peak inspiratory pressures, higher ventilatory volumes, and better compliance after conversion ^[50]. Converting the airway to tracheostomy before postburn day 10 was associated with a significantly lower incidence of subglottic stenosis, and keeping airway pressures below 50 cm H2O was advised to prevent late complications ^[51]. A randomized trial of early tracheostomy in patients with a high probability of prolonged ventilator dependence improved P/F ratios after the procedure but did not improve ventilator support, length of stay, pneumonia, or survival, and a quarter of conventionally managed patients were successfully extubated without ever needing tracheostomy ^[49]. In large databases, early tracheostomy decreased discharge to long-term care but was not associated with VAP ^[52]. The weight of evidence is that routine early tracheostomy does not improve outcomes, while selective early conversion protects the airway in those who clearly need prolonged support.

Ventilation-related outcomes and complications

The complications of ventilating the inhalation-injured lung are what the protective strategies are designed to prevent. Barotrauma is the canonical pressure-related harm: it was reported in 45% of studies in one systematic review, ranged from 0 to 29% of patients, and was more frequent at higher airway pressures ^[20]. Severe barotrauma with pneumothorax, pneumomediastinum, and subcutaneous emphysema can follow smoke and toxic-gas inhalation and intensify during positive-pressure ventilation ^[55]. In children, pulmonary barotrauma is a frequent, life-threatening complication of mechanical ventilation, and reducing it is a stated advantage of percussive and oscillatory modes ^[15].

Pneumonia is the dominant infectious complication and the leading cause of death in this group. VAP incidence was significantly higher in patients with inhalation injury than without (relative risk 2.1), a difference that persisted after adjustment for age, burn size, and ventilation duration, and inhalation injury also raised reintubation and tracheostomy rates ^[21]. Burn patients who developed VAP had larger burns, more inhalation injuries, longer ventilation, and higher mortality (34% vs 19%); TBSA and ventilator days were independent VAP risk factors ^[56]. High-grade inhalation injury roughly doubled the hazard of nosocomial pneumonia compared with low-grade injury ^[57]. The clinical chain is explicit: pneumonia independently increases burn mortality, and the combination of inhalation injury and pneumonia compounds it ^[2]. Inhalation injury creates a damaged tracheobronchial mucosa, and early intubation provides a portal for bacterial contamination, which is why intubation that is not needed is itself a harm ^[3].

Mortality and ventilator-burden outcomes track injury severity more than mode. Pediatric inhalation injury carried 16.4% mortality with a mean of 15.2 ventilator days in one large series, and is associated with significant morbidity and mortality in children ^[58]. A care system emphasizing precise fluid repletion, early excision, and avoidance of injurious inflating pressures and oxygen concentrations produced a low rate of respiratory death, which the authors read as evidence that the strategy minimized ventilator-induced lung injury ^[59]. Adjunctive measures interact with ventilation: inhaled nitric oxide gave a modest, transient P/F improvement in burn patients failing conventional support ^[60], goal-directed fluid management shortened ventilation time in severe inhalation injury ^[61], and a low-tidal-volume protective strategy with recruitment was held to be beneficial ^[62]. None of these displaces the central finding that severity, not ventilator brand, dominates outcome.

Special populations

Children are the population where mode choice has the clearest physiologic payoff. In children with bronchoscopically identified inhalation injury, HFPV produced a significant decrease in the work of breathing compared with conventional ventilation ^[9]. HFPV reduced pulmonary morbidity in pediatric inhalation injury, with no cases of pneumonia, better P/F ratios, lower peak pressures, and less work of breathing than conventional ventilation in one comparison ^[19]. The VDR was a safe and effective method of ventilation for pediatric burn patients offering advantages over conventional ventilation ^[17]. Early tracheostomy was safe and improved ventilator management in severely burned children ^[50], and high survival can be expected in young children with large burns and inhalation injury managed with protective ventilation ^[59]. The literature cautions against over-intubating: Goh and colleagues note that endotracheal intubation is essential where upper-airway obstruction may occur but is not warranted prophylactically in all cases of inhalation injury ^[63], and one comparison found surgical providers with acute-care-surgery training manage burn airways as well as burn specialists ^[64]. Adult and pediatric airways differ in their tolerance of cuffed tubes and tracheostomy timing, which is why pediatric ventilation pathways diverge from adult ones.

Controversies and Evidence Gaps

• No high-quality mode comparison and no guideline. To date there are no evidence-based guidelines on ventilation strategies in ARDS after smoke inhalation, the absence of good-quality evidence has precluded meta-analysis, and published inhalation-injury evidence is mostly level 3 or below [12, 23]. There is no consensus among leading burn centers on inhalation-injury management ^[71].
• HFPV benefit rests on weak evidence. The mortality and pneumonia signal for HFPV is supported only by low-quality data and a very weak recommendation, and the literature explicitly calls for randomized trials to define its role [12, 4].
• HFOV may not help the inhalation-injured lung. Adult burn patients with inhalation injury did not improve their oxygenation index on HFOV and trended toward higher failure and hypercapnia, and one review held HFOV may have no role in inhalational injury [22, 24].
• APRV is genuinely contested. Preclinical models show APRV may worsen early oxygenation after smoke inhalation, and an international expert panel listed APRV use among the statements on which experts disagreed [28, 70].
• Tracheostomy timing is unsettled. Routine early tracheostomy did not improve outcomes or yield earlier extubation in a randomized trial, yet selective early conversion before postburn day 10 lowers subglottic stenosis; the ideal timing in inhalation injury has not been determined [49, 51, 69].
• Prophylactic intubation and over-ventilation are real harms. Prophylactic mechanical ventilation may represent unnecessary intubations, and raising awareness of the risks and consequences of mechanical ventilation has been urged ^[64].
• The mainstay adjuncts have not moved mortality. A 2025 retrospective found a nebulized inhalation protocol did not shorten ventilator days or improve survival in grade II-III injuries, reinforcing that ventilatory support, not adjunctive pharmacotherapy, remains the backbone ^[67].
• Burn-specific ARDS physiology complicates diagnosis. Stress-index and electrical-impedance work shows ventilation shifts from the dependent to the independent lung after smoke exposure, with a rising stress index, complicating both diagnosis and trial design ^[68].

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