smoke-inhalationby James Hubbard, MD, MPH

The recent train disaster in Washington, D.C., reminded me that I haven’t covered smoke inhalation in my posts.

Picture this. You’re on a subway going through a tunnel when you hear a loud pop. The train stops, the lights go out, and the air starts filling with smoke. And it’s getting worse.

A voice comes over the intercom. “The train is not on fire. Please, everyone, sit on the floor and wait for help.” The voice orders you not to open the doors. You’re trapped.

In the D.C. event, which resulted in one woman dying and dozens being hospitalized, I don’t know why they weren’t allowed to evacuate. Perhaps because no one knew exactly what had happened and how safe it was to go out.

About 35 minutes later, emergency help arrived. But that means that in a major metropolitan city, all these people were trapped for over half an hour with no help. It’s a tragic example of not always being able to predict when or where an emergency will happen.

Many of the passengers probably thought they were just making a quick trip out. I mean, I’m guessing no one had their gas mask with them. But what they seemed to do so well is stay calm enough to think and use the knowledge they had to do the best they could.

What Smoke Inhalation Does to You

In most fire deaths, it’s not the flames that got the person, it’s the smoke inhalation.

Smoke does two main things to you:

  1. It irritates your lungs, triggering mucous production and possible bronchoconstriction (asthma) if you’re prone to that.
  2. It poisons the air you breathe because the smoke is filled with soot, other debris, and gases.

While you’re breathing this toxic air, if there’s also a fire, it eats up precious oxygen and produces carbon dioxide along with other gases that take the oxygen’s place. Depending on what is burning, other very toxic fumes are also produced—carbon monoxide, cyanide, hydrogen sulfate.

So when you’re trapped in a smoky room, you’re dealing with irritation of the airways, less and less oxygen, and poisonous gases. That’s why the number-one, most important advice for dealing with smoke inhalation is get out of there.

And it’s why answering questions about the D.C. smoke situation is difficult. They couldn’t get out. They were trapped. But most managed to survive.

What Do You Do When You’re Trapped?

I’ve been asked a few questions about the Washington event. The answers are also applicable to the more likely smoke inhalation scenarios from a house fire, wildfire, in a car, in a plane, you name it.

Q: The Washington Post reports that while trapped, one woman collapsed. Passengers took turns giving her CPR. I know you don’t know the details, but thinking about a similar, imagined scenario, here are my questions:
Assuming a woman who collapsed from smoke inhalation had no signs of life, would you do Hands-Only CPR or CPR with breaths? I know Hands-Only is the way to go normally these days, but is smoke inhalation an exception?

A: All you can do is what you think best, with the knowledge you have and the situation at hand.

You’re right that there exceptions to the Hands-Only rule. If you think the collapse was primarily caused by trouble breathing, the American Heart association recommends adding the artificial respirations. This cause is specifically suspected in someone who has drowned and in prepubescent children.

In the case of a woman who collapses on a smoke-filled train, it could be presumed that the collapse was from breathing problems. If there’s no sign of life, chest compressions and artificial respirations are certainly appropriate.

But this scenario is more complicated than the typical one. With the horrible air everyone, including you, is breathing, how much oxygen are your really giving her?

So I don’t think there is a good answer to this question. Unless you have supplemental oxygen, it’s a no-win situation.

Plus, you must consider your own health. Chest compressions take a lot of exertion, which means whoever is doing them, even in a normal situation, is going to require even more oxygen than usual. And here, we’re talking about an environment where breathing faster only means you’re getting more toxic fumes. The worst thing you can do is end up passing out also.

In this specific train case, the passengers took turns doing CPR. It seems to me that this was a wise and valid compromise.

Unfortunately, this woman showed no signs of life for 25 minutes in an oxygen-deprived environment. Her chances were very dire no matter what was done.

Q: Some passengers shared inhalers (I assume for asthma?) with people who were having trouble breathing, according to The Washington Post. Does that help with smoke inhalation? How?

A: Some people’s airways constrict when exposed to smoke. They may have asthma, another lung disease, or just sensitive airways. Others are not so prone.

It seems to me an albuterol inhaler (the type used for asthma) is worth a try, especially with wheezing. But do remember, asthma medicine has its own risks. It can increase your heart rate and blood pressure and could actually make someone with heart disease worse.

And never, ever take more than a couple of puffs. If that doesn’t help, neither will more, and people die each year from overdosing.

Q: One picture showed people sitting on the floor. Would it be even better to lie on the floor if there’s room?

A: Well, you could do that, or just lower your head. Hot smoke and many gases rise. But with time and more smoke, at some point, the entire room top to bottom will be saturated. So getting down may bide you time, but getting out of the smoke as soon as possible is essential.

Q: In the picture, people are covering their faces with jackets and such. If you had water, would it be better to wet the material to cover your face?

A: Yes. At least it’s worth a try.

For a makeshift mask, with our without water I’d use something with loose fiber so you can seal around your whole mouth and nose but still breathe through it. Covering your face and breathing the air that comes around the edges is not nearly as effective because that allows debris through.

The water will absorb some of the water-soluble toxins, such as cyanide. Again, though, you’re going to have to be able to breathe through the wet material.

But even a gas mask is not going to help you get more oxygen. For that, you’ll need a supplement or some way to get fresh air.

Q: In a video by passenger Jonathan Rogers of the rescue, shared by The Washington Post, you can hear someone asking for water. Is there a medical reason to give water after smoke inhalation even if someone doesn’t ask for it?

A: You can wash out the debris from your mouth and nose by swishing some around in your mouth and spitting, and by irrigating. Also, your breathing passages work much better when they’re moist. Drinking water will help supply your body so it can produce moisture in these airways.

Q: What else should you do after smoke inhalation if you can’t get to a hospital?
  1. Fresh air is a must. It’s key. Of course supplement oxygen is great if available.
  2. Get rest and plenty of fluids.
  3. Use an albuterol inhaler as directed if you have it and you’re wheezing.
  4. You could also consider oral or inhaled steroids early on if they’re available.
  5. Some people can seem perfectly fine. Then, a few hours later, the airway linings start to swell, which can lead to severe respiratory distress. So if you’ve inhaled a lot of smoke, you should be heading for medical help if possible (or it should be coming to you). Meantime, your best bet is rest, fluids, and oxygen.

What about you? Have you ever experienced smoke inhalation? How did it affect you? What did you do?

If you work in a field where you have to deal with this danger, I’m sure you could add valuable insight, that might very well save a life of reader. What about it?

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Top photo: Flickr/Boby, via CC BY-SA 2.0.