Significant morbidity and mortality from smoke inhalation occurs in victims of fire. Lung injury can be caused by chemical and thermal insults. A variety of noxious gases, irritants and asphyxiants are generated depending on the material burnt. Carbon monoxide is the predominant cause of death among fire victims. Treatment should be directed at reversing hypoxaemia as a result of asphyxia or carbon monoxide poisoning. There is no evidence that the routine use of corticosteroids or prophylactic antibiotics is beneficial. Through a better understanding of the pathophysiology of smoke-induced lung injury, the effects of exogenous surfactant, leukotriene inhibitors, antioxidants, nitric oxide synthase inhibitors and fibrinolytics suggest that these compounds may have a future therapeutic role in smoke-induced injury. Studies are needed to evaluate the safety and efficacy of these potential therapies before they are used clinically.