original article: 2014 aba paper

The Evaluation of Physical Exam Findings in Patients

Assessed for Suspected Burn Inhalation Injury
Jessica A. Ching, MD,* Jehan L. Shah, BS,† Cody J. Doran, BS,‡
Henian Chen, MD, PhD,§ Wyatt G. Payne, MD,*║ David J. Smith, Jr, MD*

The purpose of this investigation was to evaluate the utility of singed nasal hair (SN),
carbonaceous sputum (CS), and facial burns (FB) as indicators of burn inhalation injury,
when compared to the accepted standard of bronchoscopic diagnosis of inhalation injury. An
institutional review board approved, retrospective review was conducted. All patients were
suspected to have burn inhalation injury and subsequently underwent bronchoscopic evaluation.
Data collected included: percent burn TBSA, burn injury mechanism, admission physical exam
findings (SN, CS, FB), and bronchoscopy findings. Thirty-five males and twelve females met
inclusion criteria (n = 47). Bronchoscopy was normal in 31 patients (66%). Data were analyzed
as all patients and in subgroups according to burn TBSA and an enclosed space mechanism of
injury. Physical exam findings (SN, CS, FB) were evaluated individually and in combination.
Overall, the sensitivities, specificities, positive predictive values, and negative predictive values
calculated were poor and inconsistent, and they did not improve within subgroup analysis
or when physical findings were combined. Further statistical analysis suggested the physical
findings, whether in isolation or in combination, have poor discrimination between patients
that have and do not have inhalation injury (AUC < 0.7, P > .05) and poor agreement with
the diagnosis made by bronchoscopy (κ < 0.4, P > .05). This remained true in the subgroup
analysis as well. Our data demonstrated the findings of SN, CS, and FB are unreliable evidence
for inhalation injury, even in the context of an enclosed space mechanism of injury. Thus,
these physical findings are not absolute indicators for intubation and should be interpreted
as one component of the history and physical. (J Burn Care Res 2015;36:197–202)

Continued advancement in critical care and overall
burn management has not alleviated the increased
morbidity and mortality from burn inhalation injury
among afflicted burn patients.1,2 In burn inhalation
injury, the chemical and thermal insult suffered by the
upper and lower airways results in edema, epithelial
sloughing, increased mucus secretion, inflammation,
atelectasis, and ultimately airway obstruction.1,3–5
With the potential of airway obstruction, vigilant air-
way protection is of the utmost importance, leading
From the *Division of Plastic Surgery, University of South Florida
Morsani College of Medicine, Tampa;†University of South
Florida Morsani College of Medicine, Tampa; ‡University of
South Florida, Tampa; §Department of Epidemiology and Bio-
statistics, University of South Florida College of Public Health,
Tampa; and ║Institute for Tissue Regeneration, Bay Pines VA
Healthcare System, Florida.
Address correspondence to Jessica A. Ching, MD, Department of
Surgery-USF Health, 2 Tampa General Circle, Room 7015,
Tampa, Florida 33606.
Copyright © 2014 by the American Burn Association
1559-047X/2015
DOI: 10.1097/BCR.0000000000000175
many to emergently intubate patients with suspected
inhalation injury. This is balanced by the known
appreciable increase in ventilator-related complica-
tions in burn patients and the possibility of unnec-
essary intubation and risk.2 Although over 150,000
patients with burn injuries have presented for hospi-
tal evaluation in the last 10 years, only 7.7% of these
patients have suffered burn inhalation injury.2 Addi-
tionally, acute upper airway obstruction is estimated
to occur in one fifth to one third of patients with
inhalation injury.5,6 This means only a small fraction
of burn patients require acute intubation for airway
protection due to inhalation injury and makes the
accurate diagnosis of inhalation injury more chal-
lenging and more critical.
Inhalation injury is ideally diagnosed by bronchos-
copy.7–10 With bronchoscopy, the airway is directly
visualized, making it the accepted standard for the
diagnosis of inhalation injury.7–9,11 However, access
to urgent bronchoscopy evaluation is not feasible for
many first responders and healthcare practitioners. In
197

198  Ching et al January/February 2015
such cases, clinical exam findings are of paramount
importance. Thus, the diagnosis of inhalation injury
is often based on the clinical exam findings of singed
nasal hair (SN), carbonaceous sputum (CS), and
facial burns (FB), especially when combined with
an enclosed space mechanism of burn injury.1,6,12 If
inhalation injury is suspected, this means the sub-
sequent decision on whether or not to intubate the
patient is biased by these same clinical findings.
With thousands of burns presenting for evaluation
each annum and only a small portion of these having
inhalation injury, it is vital that the clinical criteria for
intubation are rooted in reliable indications. Although
findings of SN, CS, and FB in combination with an
enclosed space mechanism of burn injury are com-
monly referenced as reliable evidence of inhalation
injury and the need for intubation, there are no stud-
ies which compare these exam findings to the accepted
standard of bronchoscopic diagnosis of inhalation
injury. Therefore, the purpose of this investigation was
to evaluate the utility of SN, CS, and FB as indicators
of burn inhalation injury, when compared to the direct
bronchoscopic diagnosis of inhalation injury.
METHODS
Study Location and Design
A single American Burn Association (ABA) Verified
Burn Center was the site of the study. An institutional
review board approved, retrospective chart review of
admissions from November 2011 to April 2013 was
conducted. Inclusion criteria were: a suspicion of
burn inhalation injury was present which prompted
a bronchoscopic evaluation during the admission.
Patients who were not evaluated by bronchoscopy
were excluded, as the presence or absence of inhala-
tion injury findings on bronchoscopic evaluation was
used as the accepted standard measurement. Patients
less than 18 years old were also excluded. The pri-
mary analysis examined the presence on admission
of SN, CS, and FB, along with presence or absence
of inhalation injury on bronchoscopy during the
hospitalization. The secondary analysis examined
the presence of SN, CS, and FB along with presence
or absence of inhalation injury on bronchoscopy
among subgroups of the patient population, accord-
ing to burn TBSA and burn injury mechanism. The
specific subgroups chosen for statistical analysis were
required to have a minimum of 20 patients each.
Data Collection
Patients were initially identified by codes from the
Ninth Revision of the International Classification of
Journal of Burn Care & Research
Diseases (ICD-9) associated with burn inhalation
injury or skin burns of all size, in conjunction with the
Current Procedural Terminology codes for bronchos-
copy. Charts were reviewed according to the inclusion
and exclusion criteria. Data were then collected ret-
rospectively from the qualifying patient records. Data
collected included: age, gender, past medical history,
personnel who performed the intubation, percent
burn TBSA, burn injury mechanism, admission clini-
cal exam findings (SN, CS, FB), and bronchoscopy
findings (the presence or absence of inhalation injury).
Definitions
Physical exam findings were defined as those present
on admission evaluation by the Burn Team. These
findings were analyzed in isolation and in combina-
tion for a total of seven categories: singed nasal hair
(SN), carbonaceous sputum (CS), facial burns (FB),
singed nasal hair and carbonaceous sputum (SN +
CS), singed nasal hair and facial burns (SN + FB),
carbonaceous sputum and facial burns (CS + FB),
and singed nasal hair with carbonaceous sputum and
facial burns (SN + CS + FB).
TBSA was defined by the assessment of the Burn
Physician who responded to the arrival of the patient
in the Emergency Department.
Inhalation injury was identified as present or
absent per the first bronchoscopy evaluation con-
ducted after admission. In patients who arrived intu-
bated, the airway distal to the endotracheal tube was
assessed by bronchoscopy, and in those who did not
arrive intubated, the entire upper and lower airway
was assessed by bronchoscopy. Inhalation injury was
classified as present where mucosal erythema, blis-
tering, edema, erosions, or necrosis was found in
the airways, or where particulate matter was present
in the tracheobronchial tree, as documented in the
bronchoscopy report.7 Conversely, inhalation injury
was classified as absent where none of these findings
were documented in the bronchoscopy report.
Statistical Methods
We examined data of inhalation injury according to
physical exam findings and bronchoscopy. Broncho-
scopic diagnosis was used as the accepted standard
for the diagnosis of inhalation injury. Thus, a true
positive was defined as presence of the physical exam
finding(s) when the bronchoscopic evaluation also
suggested inhalation injury, while a true negative was
defined as the absence of the physical exam finding(s)
when the bronchoscopic evaluation did not suggest
inhalation injury. For each physical exam finding
category, we assessed the sensitivity (the proportion
Journal of Burn Care & Research
Volume 36, Number 1 Ching et al  199
that the physical exam findings correctly identified
inhalation injury out of the total who had inhalation
injury by bronchoscopy) and specificity (the propor-
tion that the absence of the physical exam findings
correctly identified a no inhalation injury out of all
those who had no inhalation injury by bronchoscopic
evaluation). For adjunctive analysis of each physi-
cal exam category, the positive predictive value (the
proportion of true positives to total positives of the
physical exam findings) and negative predictive value
(the proportion of true negatives to total negatives of
the physical exam findings) were calculated as well.
We also used receiver operating characteristic (ROC)
analysis methods, based on the sensitivity and specific-
ity, to evaluate how well the presence or absence of
the physical exam finding(s) discriminated between a
patient that had inhalation injury according to bron-
choscopy and a patient that did not have inhalation
injury on bronchoscopy. Analysis of the ROC provides
a precise and valid measure of diagnostic accuracy unin-
fluenced by prior probabilities. The area under the ROC
curve (AUC) was then compared to standard statisti-
cal guidelines, where AUC ≤ 0.5 is no discrimination,
0.5 < AUC ≤ 0.7 is poor discrimination, 0.7 < AUC
≤ 0.8 is acceptable discrimination, 0.8 < AUC ≤0.9 is
excellent discrimination, and AUC > 0.9 is outstand-
ing discrimination.13 Thus, the minimum threshold
for acceptable discrimination is an AUC of 0.7. Sta-
tistical significance was indicated when the associated
P value was less than .05.
Agreement between the assessed physical findings
and bronchoscopy was also evaluated using Cohen’s
kappa (κ), which is based on the number of true posi-
tives and true negatives of the physical exam findings.
This assessed the degree to which the presence or
absence of the physical exam finding(s) agreed with
the presence or absence of inhalation injury accord-
ing to bronchoscopy. Excellent agreement was indi-
cated when κ ≥ 0.75, while 0.4 < κ < 0.75 indicated
fair to good agreement, and κ ≤ 0.4 indicated poor
agreement. Statistical significance was indicated when
the associated P value was less than .05.
All analyses were performed with the use of SAS,
version 9.3 (SAS Institute, Inc., Cary, NC). A two-
sided P value of less than .05 was considered to indi-
cate statistical significance.
RESULTS
Patients
A total of 47 patients met criteria for inclusion in
the study. This included 35 male and 12 female
patients. Patient age ranged from 18 years old
to 78 years old (mean = 51.7 years, median = 54
years, SD = 14.2 years). TBSA ranged from 1% to
97% (mean = 29.6%, median = 23%, SD = 27.9%).
All patients either arrived intubated or were intu-
bated at some point during the hospital admission.
The majority of intubations were performed prior
to evaluation by our Burn Team; such intubations
were executed by first responders or an outside
hospital provider (66%) and our emergency depart-
ment physicians (11%). According to burn injury
mechanism, the largest subgroup was the enclosed
space mechanism of injury (n = 20), followed by an
open space injury (n = 10), an explosion (n = 10),
and a flash flame injury from home oxygen use
while smoking (n = 7).
Bronchoscopy Comparison
Bronchoscopy was normal in 31 patients (66%), and
it was consistent with inhalation injury in 16 patients
(34%). Bronchoscopic evaluation for inhalation injury
was performed within 24 hours of admission in 44
patients. The remaining three patients were closely
monitored for suspected inhalation injury and under-
went bronchoscopy on hospital day 3, 5, or 6 due to
changes in respiratory status or persistent concerns
for inhalation injury. Of these three patients, only the
patient who underwent bronchoscopy on hospital day
6 had findings consistent with inhalation injury, while
the other two patients had normal airway findings.
Group analysis was initially performed for all
patients collectively (n = 47). Then further sub-
group analysis of the physical exam findings was
performed to distinguish if the subgroup classifi-
cation impacted statistical analysis, positively or
negatively. The subgroups chosen for more specific
analysis were: those patients injured in an enclosed
space (n = 20), those patients with burn TBSA
greater than 20% (n = 26), and those patients with
burn TBSA less than 20% (n = 21). These specific
subgroups were chosen for statistical analysis as
each contained a minimum of 20 patients. Addi-
tional subgroups according to TBSA or other injury
mechanisms could not be reliably analyzed as they
contained less than 20 patients each.
Overall, SN or FB possessed the greatest sensitiv-
ity of 0.82 in burns greater than 20% TBSA, while
FB alone also demonstrated a sensitivity of 0.75 in
all patients and those injured in an enclosed space.
The combination of CS + FB possessed the highest
specificities of 0.74 for all patients and 0.8 for burns
greater than 20% TBSA, while the combination of
SN + CS + FB also had a specificity of 0.71 for all
patients and 0.8 for burns greater than 20% TBSA.

200  Ching et al January/February 2015
The highest positive predictive value of 0.57
occurred in the categories of CS + FB and CS + FB +
SN in burns greater than 20% TBSA; all other posi-
tive predictive values were less than 0.57. For the
all patients group, CS exhibited a negative predic-
tive value greater than 0.7, while FB had a negative
predictive value greater than 0.7 for burns greater
than 20% TBSA. In those patients with burns less
than 20% TBSA, CS, SN + CS, CS + FB, and the
combination of SN + CS + FB, all had a negative pre-
dictive value greater than 0.7. For the enclosed space
subgroup, no positive predictive values or negative
predictive values were greater than 0.7, and 86% of
those calculated for the subgroup were less than or
equal to 0.5.
The majority of sensitivities, specificities, posi-
tive predictive values, and negative predictive values
calculated were less than 0.7 and did not increase
appreciably when multiple physical exam findings
were combined. Of the all the sensitivities, speci-
ficities, positive predictive values, and negative pre-
dictive values calculated, 59% were 0.5 or less and
86.7% were less than 0.7. No physical exam finding
category exhibited sensitivities, specificities, posi-
tive predictive values, and negative predictive values
greater than 0.7 consistently across all groups ana-
lyzed. A summation of the sensitivities, specificities,
positive predictive values, and negative predictive
values for all patients (Table 1) and for those with
an enclosed space mechanism of injury (Table 2) are
included for reference.
ROC analysis was performed to assess the abil-
ity of the presence or absence of the physical exam
finding(s), individually or in combination to dis-
criminate between a patient that had inhalation
injury according to bronchoscopy and a patient that
did not have inhalation injury on bronchoscopy. The
ROC analysis was completed for all physical find-
ing categories in the context of all patients, those
patients injured in an enclosed space, those patients
with burn TBSA greater than 20%, and those
patients with burn TBSA less than 20%. All physical
exam finding categories suggest no discrimination or
Table 1. Analysis of the predictive ability of physical characteristics compared to fiberoptic bronchoscopy for the diagnosis
of smoke inhalation injury, utilizing sensitivities, specificities, positive predictive values, and negative predictive values for all
patients (n = 47)
SN CS
Sensitivity 0.69 0.50
Specificity 0.16 0.65
Positive predictive value 0.30 0.42
Negative predictive value 0.50 0.71
SN, singed nasal hair; CS, carbonaceous sputum; FB, facial burns.
Journal of Burn Care & Research
poor discrimination in determining the presence or
absence of inhalation injury on bronchoscopy, with
all patients combined or in any subgroup analysis
(AUC range, 0.325–0.613). The AUC values for all
patients and subgroups, when physical findings were
isolated and combined, did not reach statistical sig-
nificance (P > .05).
Agreement analysis utilizing Cohen’s kappa (κ)
yielded values below 0.4 for all patients and all sub-
groups (enclosed space mechanism, burn TBSA
greater than 20%, and burn TBSA less than 20%),
which denotes poor agreement between exam find-
ings and the presence or absence of inhalation injury
on bronchoscopy. Additionally, all kappa values were
nonsignificant (P > .05) for all categories of exam
findings with all patients combined as well as for
each subgroup. Summations of the ROC (Table 3)
and kappa (Table 4) statistical analyses for all patients
and all subgroups are included for reference.
DISCUSSION
The purpose of our retrospective study was to evalu-
ate the utility of SN, CS, and FB as indicators of
burn inhalation injury, with bronchoscopic diag-
nosis of inhalation injury as the standard of com-
parison. Our data demonstrated the inconsistency
of SN, CS, and FB, whether occurring individually
or in combination, across all burn patients in our
sample, burn injuries greater than 20% TBSA, burn
injuries less than 20% TBSA, and an enclosed space
mechanism of burn injury. In comparison with the
objective diagnosis of inhalation injury by bron-
choscopy, the present statistical analysis yielded no
evidence for the use of these physical findings to
discriminate between patients that have and do not
have inhalation injury, nor did our analysis show
adequate agreement between these physical findings
and the diagnosis made by bronchoscopy. The lack
of reliability of SN, CS, and FB in indicating inha-
lation injury imparts significant clinical application
for those evaluating burn patients without access to
urgent fiberoptic bronchoscopy.
FB SN+CS SN+FB CS+FB SN+CS+FB
0.75 0.38 0.63 0.38 0.31
0.29 0.65 0.42 0.74 0.71
0.35 0.35 0.36 0.43 0.38
0.69 0.67 0.68 0.70 0.65
Journal of Burn Care & Research
Volume 36, Number 1 Ching et al  201

Table 2. Analysis of the predictive ability of physical characteristics compared to fiberoptic bronchoscopy for the diagnosis
of smoke inhalation injury, utilizing sensitivities, specificities, positive predictive values, and negative predictive values for
patients with a history of a burn in an enclosed space (n = 20)
SN CS FB SN+CS SN+FB CS+FB SN+CS+FB

Sensitivity 0.63 0.63 0.75 0.38 0.50 0.50 0.38

Specificity 0.08 0.50 0.33 0.08 0 0.17 0
Positive predictive value 0.31 0.45 0.43 0.33 0.33 0.50 0.43
Negative predictive value 0.25 0.67 0.67 0.09 0 0.17 0

SN, singed nasal hair; CS, carbonaceous sputum; FB, facial burns.

The distrust of clinical exam findings or mecha- result of carbon deposits in the upper airways rather
nism of burn injury to indicate inhalation injury is than the lower airways.6 CS also does not necessar-
longstanding, while quantification of the perceived ily indicate high-temperature smoke exposure.6,10
inconsistency is lacking. Frequently referenced land- Thermal injury to the airway results when air in
mark studies include Moylan et al and Moylan and excess of 150 degrees Celsius is inhaled.1 Normally,
Chan.14,15 In 1972, Moylan et al15 found FB, CS, the hot air is cooled by the pharynx and very rarely
hoarseness, and wheezing to have unreliable value continues into the lower airways at these high tem-
in comparison to an abnormal 133Xenon lung scan; peratures.10,16 SN and FB are indicators of thermal
however, only five of these patients underwent damage prior to air passage into the pharynx and,
bronchoscopy for definitive diagnosis of inhalation thus, do not equate to upper airway thermal injury
injury. It was echoed by Moylan and Chan soon after or acute airway compromise.
with added reservation regarding the association of The inconsistency of SN, CS, and FB indicated
enclosed space accidents with inhalation injury.14 As by the present data should invoke caution to use of
such the inconsistency of FB, CS, and an enclosed these findings alone in diagnosing inhalation injury
space mechanism of injury in indicating inhalation and determining the need for intubation. These
injury has been questioned for some time. clinical findings, by the current analysis, are nearly
The unreliability of the physical findings assessed equivalent to flipping a coin. It is possible that with
in the present study may be partially due to the two- additional burn and patient variables not included in
fold mechanism of inhalation injury: chemical and the present study, these clinical findings could prove
thermal injury. Chemical burns can occur from the more accurate.
inhalation of toxic gases throughout the tracheo- It should be noted there are a multitude of physi-
bronchial tree and particulate matter deposition in cal exam findings not studied in our data, includ-
the lower airways.1 CS may evince smoke exposure ing hoarseness, stridor, tachypnea, increased work
and inhaled particulate matter, but it may also be the of breathing, and shortness of breath, which war-
rant further study to assess their utility in diagnos-
Table 3. The receiver operating characteristic ing burn inhalation injury and its associated airway
discrimination analysis for all patients (n = 47), the compromise. Unfortunately, the majority of patients
enclosed space subgroup (n = 20), the burn TBSA included in the study arrived intubated, making it
< 20% subgroup (n = 21), and the burn TBSA ≥ 20% difficult to accurately assess many of the aforemen-
subgroup (n = 26) tioned additional physical findings.
All Enclosed TBSA TBSA
As a retrospective chart review, data collection
Patients* Space* < 20%* ≥ 20%* inherently relied on the accuracy of health provider
documentation. This potential for error could be
SN 0.424 0.354 0.325 0.442
minimized and the study design strengthened with
CS 0.573 0.563 0.613 0.561
FB 0.520 0.542 0.394 0.609
a subsequent prospective study. Also, only patients
SN + CS 0.510 0.438 0.413 0.561 with suspected burn inhalation injury underwent
SN + FB 0.522 0.521 0.388 0.597 bronchoscopic evaluation. Although future research
CS + FB 0.558 0.583 0.544 0.582 with bronchoscopic evaluation of all patients, both
SN + CS + FB 0.527 0.521 0.444 0.582 with and without suspected burn inhalation injury,
would provide more robust data regarding physical
SN, singed nasal hair; CS, carbonaceous sputum; FB, facial burns.
Values less than 0.7 indicate poor discrimination, and values less than 0.5
exam findings, the procedural risks and healthcare
indicate no discrimination. costs associated with bronchoscopy in the absence of
*P > .05. suspected burn inhalation injury should be heavily
 Journal of Burn Care & Research
202  Ching et al January/February 2015

Table 4. The Cohen’s kappa agreement analysis for all CONCLUSION

patients (n = 47), the enclosed space subgroup (n = 20),
the burn TBSA < 20% subgroup (n = 21), and the burn Contrary to the classic tenet that SN, CS, and FB
TBSA ≥ 20% subgroup (n = 26) consistently indicate the presence of inhalation
All Enclosed TBSA TBSA
injury, especially in an enclosed space burn injury,
Patients* Space* < 20%* ≥ 20%* our data suggest these findings have poor discrimi-
nation ability and poor agreement with the bron-
SN 0.12 0.25 0.22 0.10
choscopic diagnosis of inhalation injury. Thus, these
CS 0.14 0.12 0.18 0.12
FB 0.03 0.07 0.12 0.20
findings should not be interpreted in isolation but as
SN + CS 0.02 0.12 0.15 0.12 one component of the history and physical to avoid
SN + FB 0.04 0.04 0.15 0.18 unnecessary intubation and risk.
CS + FB 0.12 0.17 0.08 0.17
SN + CS + FB 0.06 0.04 0.11 0.17
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