Despite ubiquitous use of high-volume–low-pressure cuffs, overinflation of the endotracheal cuff is the most common cause of injury secondary to endotracheal intubation. High cuff pressures can cause ischemia of the contiguous airway wall in as short as 4 hours. Prolonged overinflation can lead to scarring and stenosis; full-thickness injury can result in fistulae between the innominate artery anteriorly and the esophagus posteriorly. Avoidance requires careful cuff management to keep pressures as low as possible; in circumstances of prolonged ventilatory support and high airway pressure, cuff pressure monitoring (to maintain pressures <20 mmHg) is advisable.

Early diagnosis is critical to avoid subsequent complications, including respiratory infection and tracheal stenosis.

Management of smoke commonly supportive; use of antibiotics, respiratory support, and airway clearance with flexible bronchoscopy as dictated by the patient’s condition. In rare circumstances, extracorporeal membrane oxygenation is required if there is associated injury to the more distal airways and lung parenchyma.