A patient from a fire has severe respiratory distress, hoarseness, soot around the mouth and nares, respirations 32 and stridor. Best initial intervention?

• A. Nebulized bronchodilator
• B. Fluid resuscitation
• C. Ventilation by mouth to mask
• D. Intubation

Answer: (D)

Upper airway inhalation injury often leads to rapid swelling and obstruction. Signs like hoarseness, soot at the mouth and nares, and especially stridor with severe respiratory distress signal that the airway is narrowing from edema. In this scenario, securing the airway early with endotracheal intubation is the best initial step to prevent a cannot-ventilate situation as swelling progresses. Once a secure airway is in place, you can provide high-flow oxygen and manage secretions and edema more effectively. Nebulized bronchodilators address bronchospasm, not impending airway collapse from edema; fluid resuscitation is crucial for burn injury overall but does not solve airway obstruction, and ventilating by mask is unreliable when stridor indicates a precarious airway. Prepare for a potentially difficult airway and proceed to intubation to protect the airway now.