Smoke inhalation injury in children still represents a significant cause of pulmonary disease and mortality. Carbon monoxide and other toxic products of combustion are major determinants of severity. Early hypoxemia is a contributor to over 50% of deaths. There are several clinical entities: upper airway obstruction, bronchospasm, consolidation, pulmonary edema, ARDS, and late pneumonia. Intensive care has improved outcome from burns, but pulmonary injury is still an important cause of mortality. New therapies such as high frequency ventilation may improve the outcome. Primary prevention is the most important way to reduce the poor outcome from significant exposure.