Early intubation decisions in burn-related inhalation injury: a systematic review of the utility of physical findings in rural and low-resource healthcare settings

Background Bronchoscopy is the gold standard for diagnosing inhalation injury in burn patients. However, its availability remains limited even in major cities such as Jakarta. This lack of access presents significant diagnostic challenges, particularly in rural and resource-limited areas across Indonesia. This paper aims to review physical findings for the early diagnosis of inhalation injury in burn patients and to identify indicators for early intubation in settings where bronchoscopy is limited or unavailable. Methods A literature review was conducted using the keywords “inhalation injury,” “burns,” and “intubation,” with PubMed, Cochrane, and ScienceDirect as the primary databases. The inclusion criteria for this review consisted of trials that evaluated physical findings as diagnostic tools for inhalation injury, with bronchoscopy serving as the gold standard. Study selection followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, with two independent reviewers assessing eligibility. Risk of bias was evaluated using the Quality Assessment of Diagnostic Accuracy Studies 2 tool for diagnostic accuracy studies. Pooled sensitivity, specificity, and diagnostic ORs (DORs), along with 95% CIs, were calculated for individual physical findings and clinical decision aids. Results Ten physical findings for inhalation injury were analyzed and ranked by DORs. Most findings showed high specificity and low sensitivity. The pooled DOR ranged from 0.93 to 7.50. Dyspnea had the highest DOR of 7.50 (95% CI 0.48 to 119.17), while singed nasal hair had the lowest DOR of 0.93 (95% CI 0.09 to 9.71). Dyspnea, stridor, and hoarseness exhibited the highest DOR among other physical findings. Conclusion Physical examination remains essential where bronchoscopy is unavailable, although most findings have limited sensitivity. Physical signs with the highest diagnostic accuracy, especially dyspnea, stridor, and hoarseness, may help guide early intubation in resource-limited settings. PROSPERO registration number CRD420250651230.