Early Flexible Bronchoscopy in Pediatric Inhalation Injury with Minimal Cutaneous Burns: Diagnostic and Therapeutic Implications from Two Cases

Background: Inhalation airway injury is a major cause of increased morbidity and mortality in pediatric burn patients. Flexible bronchoscopy (FB) is the diagnostic gold standard and also has therapeutic value. However, deciding the right timing for FB is challenging, especially in children exposed to smoke with minimal or no skin burns. Case presentation: We report two pediatric patients with severe inhalation injury but minimal or absent cutaneous burns. In both cases, initial clinical findings and chest X-rays were non-specific, which could have delayed diagnosis. Timely FB revealed extensive airway damage, including airway edema and carbonaceous deposits. Patient 1 demonstrated AIS Grade 4 injury, while Patient 2 had AIS Grade 3 injury on bronchoscopic assessment. Both patients underwent bronchoalveolar lavage (BAL), with removal of carbonaceous debris and airway secretions, which was temporally associated with subsequent improvement in oxygenation, followed by early extubation with favorable short-term outcomes. Conclusion: Our two cases indicate that significant inhalation injury can occur in children, even without major skin burns or obvious early radiographic findings. Early flexible bronchoscopy—when clinically feasible—may facilitate definitive diagnosis and therapeutic airway clearance in selected patients. Improvements in oxygenation were temporally associated with BAL; however, causal inference cannot be established in the absence of comparative data.