Smoke inhalation, defined as airway or pulmonary parenchymal injury resulting from the inhalation of toxic combustion products, presents with a wide range of severity in patients with and without skin burns. In patients with severe injuries, the diagnosis is obvious on the basis of the history and clinical presentation; in patients with less severe injuries or those in whom the clinical consequences are delayed, diagnostic precision is difficult because diagnostic clues provide only indirect information. There is no specific treatment so diagnosis is not critical for patient management. Patients at risk include 20% to 30% of flame burn victims who should receive vigorous supportive care. The mortality rate of smoke inhalation victims without a burn is < 10%. With a burn the mortality rate is 30% to 50%, suggesting that thermal injury or its treatment is responsible for further lung damage. Endotracheal intubation provides definitive treatment for obstructed or soon-to-be obstructed patients. However the diagnosis of smoke inhalation per se is not an indication for airway intubation and respiratory support; 12% of patients without a burn require intubation versus 62% of those with a burn. A translaryngeal tube can be converted to a tracheotomy safely in burn victims; tracheotomies are easier to manage if burns of the neck are excised and grafted prior to placement. Mechanical ventilation with positive end expiratory pressure (PEEP) is the treatment for the pulmonary injury. The early lesions of smoke inhalation often progress in the context of sepsis and other complications of the burn illness to a clinical state consistent with adult respiratory distress syndrome.