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Velamuri SR, Ali Y, Lanfranco J, Gupta P, Hill DM. Inhalation Injury, Respiratory Failure, and Ventilator Support in Acute Burn Care. Clin Plast Surg 2024; 51:221-232. [PMID: 38429045 DOI: 10.1016/j.cps.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
Sustaining an inhalation injury increases the risk of severe complications and mortality. Current evidential support to guide treatment of the injury or subsequent complications is lacking, as studies either exclude inhalation injury or design limit inferences that can be made. Conventional ventilator modes are most commonly used, but there is no consensus on optimal strategies. Settings should be customized to patient tolerance and response. Data for pharmacotherapy adjunctive treatments are limited.
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Affiliation(s)
- Sai R Velamuri
- Department of Surgery, College of Medicine, University of Tennessee, Health Science Center, Memphis, TN 38103, USA.
| | - Yasmin Ali
- Department of Surgery, College of Medicine, University of Tennessee Health Science Center, 910 Madison Avenue, 2nd floor Suite 217, Memphis, TN 38103, USA
| | - Julio Lanfranco
- Division of Pulmonary and Critical Care, University of Tennessee Health Science Center, 965 Court Avenue Room H316B, Memphis, TN 38103, USA
| | - Pooja Gupta
- Pulmonary and Critical Care, University of Tennessee Health Science Center, 965 court avenue, Room H316B, Memphis, TN 38103, USA
| | - David M Hill
- Department of Pharmacy, Regional One Health, University of Tennessee, 80 madison avenue, Memphis TN 38103, USA
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2
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Sultana S, Christeson S, Basiouny M, Rioux J, Veress L, Logue BA. Verification of chlorine exposure via LC-MS/MS analysis of base hydrolyzed chlorophenols from chlorotyrosine-protein adducts. J Chromatogr B Analyt Technol Biomed Life Sci 2024; 1235:124042. [PMID: 38354459 PMCID: PMC10939755 DOI: 10.1016/j.jchromb.2024.124042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/13/2024] [Accepted: 01/31/2024] [Indexed: 02/16/2024]
Abstract
Inhalation of chlorine gas, with subsequent hydrolysis in the airway and lungs to form hydrochloric acid (HCl) and hypochlorous acid (HOCl), can cause pulmonary edema (i.e., fluid build-up in the lungs), pulmonary inflammation (with or without infection), respiratory failure, and death. The HOCl produced from chlorine is known to react with tyrosine to form adducts via electrophilic aromatic substitution, resulting in 3-chlorotyrosine and 3,5-dichlorotyrosine adducts. While several analysis methods are available for determining these adducts, each method has significant disadvantages. Hence, a simple and sensitive ultra-high performance liquid chromatography-tandem mass spectroscopy (UHPLC-MS/MS) method was developed for the determination of chlorotyrosine adducts. The sample preparation involves base hydrolysis of isolated plasma proteins to form 2-chlorophenol (CP) from monochlorotyrosine adducts and 2,6-dichlorophenol (2,6-DCP), from dichlorotyrosine adducts, as markers of chlorine exposure. The chlorophenols are extracted with cyclohexane prior to UHPLC-MS/MS analysis. The method produced excellent sensitivity for 2,6-DCP with a limit of detection of 2.2 μg/kg, calibration curve linearity extending from 0.054-54 mg/kg (R2 ≥ 0.9997 and %RA > 94), and accuracy and precision of 100 ± 14 %, and <15 % relative standard deviation, respectively. The sensitivity of the method for 2-CP was relatively poor, so it was used only as a secondary marker for severe chlorine exposure. The method successfully detected elevated levels of 2,6-DCP from hypochlorite-spiked plasma protein and plasma protein isolated from chlorine-exposed rats.
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Affiliation(s)
- Sharmin Sultana
- Department of Chemistry and Biochemistry, South Dakota State University, Box 2202, Brookings, South Dakota 57007, USA
| | - Sarah Christeson
- Department of Pediatrics-Pulmonary and Sleep Medicine Section, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Mohamed Basiouny
- Department of Pediatrics-Pulmonary and Sleep Medicine Section, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Jacqueline Rioux
- Department of Pediatrics-Pulmonary and Sleep Medicine Section, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Livia Veress
- Department of Pediatrics-Pulmonary and Sleep Medicine Section, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Brian A Logue
- Department of Chemistry and Biochemistry, South Dakota State University, Box 2202, Brookings, South Dakota 57007, USA.
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3
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Liu MM, Liu JZ, Zhao CQ, Guo P, Wang Z, Wu H, Yu W, Liu R, Hai CX, Zhang XD. Protective effects of pentoxifylline against chlorine-induced acute lung injury in rats. BMC Pharmacol Toxicol 2023; 24:12. [PMID: 36850013 PMCID: PMC9969370 DOI: 10.1186/s40360-023-00645-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 01/19/2023] [Indexed: 03/01/2023] Open
Abstract
OBJECTIVE Chlorine is a chemical threat agent that can be harmful to humans. Inhalation of high levels of chlorine can lead to acute lung injury (ALI). Currently, there is no satisfactory treatment, and effective antidote is urgently needed. Pentoxifylline (PTX), a methylxanthine derivative and nonspecific phosphodiesterase inhibitor, is widely used for the treatment of vascular disorders. The present study was aimed to investigate the inhibitory effects of PTX on chlorine-induced ALI in rats. METHODS Adult male Sprague-Dawley rats were exposed to 400 ppm Cl2 for 5 min. The histopathological examination was carried out and intracellular reactive oxygen species (ROS) levels were measured by the confocal laser scanning system. Subsequently, to evaluate the effect of PTX, a dose of 100 mg/kg was administered. The activities of superoxide dismutase (SOD) and the contents of malondialdehyde (MDA), glutathione (GSH), oxidized glutathione (GSSG) and lactate dehydrogenase (LDH) were determined by using commercial kits according to the manufacturer's instructions. Western blot assay was used to detect the protein expressions of SOD1, SOD2, catalase (CAT), hypoxia-inducible factor (HIF)-1α, vascular endothelial growth factor (VEGF), occludin, E-cadherin, bcl-xl, LC 3, Beclin 1, PTEN-induced putative kinase 1 (PINK 1) and Parkin. RESULTS The histopathological examination demonstrated that chlorine could destroy the lung structure with hemorrhage, alveolar collapse, and inflammatory infiltration. ROS accumulation was significantly higher in the lungs of rats suffering from inhaling chlorine (P<0.05). PTX markedly reduced concentrations of MAD and GSSG, while increased GSH (P<0.05). The protein expression levels of SOD1 and CAT also decreased (P<0.05). Furthermore, the activity of LDH in rats treated with PTX was significantly decreased compared to those of non-treated group (P<0.05). Additionally, the results also showed that PTX exerted an inhibition effect on protein expressions of HIF-1α, VEGF and occludin, and increased the level of E-cadherin (P<0.05). While the up-regulation of Beclin 1, LC 3II/I, Bcl-xl, and Parkin both in the lung tissues and mitochondria, were found in PTX treated rats (P<0.05). The other protein levels were decreased when treated with PTX (P<0.05). CONCLUSION PTX could ameliorate chlorine-induced lung injury via inhibition effects on oxidative stress, hypoxia and autophagy, thus suggesting that PTX could serve as a potential therapeutic approach for ALI.
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Affiliation(s)
- Meng-Meng Liu
- Department of Health Service, Logistics College of Chinese People's Armed Police Force, Tianjin, 300309, China. .,Department of Toxicology, Shaanxi Key Lab of Free Radical Biology and Medicine, the Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Xi'an, 710032, China.
| | - Jiang-Zheng Liu
- Department of Toxicology, Shaanxi Key Lab of Free Radical Biology and Medicine, the Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Xi'an, 710032, China
| | - Chen-Qian Zhao
- Department of Toxicology, Shaanxi Key Lab of Free Radical Biology and Medicine, the Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Xi'an, 710032, China
| | - Peng Guo
- Department of Health Service, Logistics College of Chinese People's Armed Police Force, Tianjin, 300309, China
| | - Zhao Wang
- Department of Toxicology, Shaanxi Key Lab of Free Radical Biology and Medicine, the Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Xi'an, 710032, China
| | - Hao Wu
- Department of Toxicology, Shaanxi Key Lab of Free Radical Biology and Medicine, the Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Xi'an, 710032, China
| | - Weihua Yu
- Department of Toxicology, Shaanxi Key Lab of Free Radical Biology and Medicine, the Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Xi'an, 710032, China
| | - Rui Liu
- Department of Toxicology, Shaanxi Key Lab of Free Radical Biology and Medicine, the Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Xi'an, 710032, China
| | - Chun-Xu Hai
- Department of Toxicology, Shaanxi Key Lab of Free Radical Biology and Medicine, the Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Xi'an, 710032, China
| | - Xiao-di Zhang
- Department of Toxicology, Shaanxi Key Lab of Free Radical Biology and Medicine, the Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Xi'an, 710032, China.
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4
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Early ECMO initiation in the emergency department for refractory hypoxemic respiratory failure caused by NaDCC intoxication. Am J Emerg Med 2022; 55:228.e1-228.e3. [PMID: 35058085 DOI: 10.1016/j.ajem.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/29/2021] [Accepted: 01/03/2022] [Indexed: 11/20/2022] Open
Abstract
We describe a case of acute respiratory failure caused by inhalation of gas formed from a reaction of intentional dissolution of sodium dichloroisocyanurate (NaDCC) tablets in water. A patient had refractory respiratory failure despite the use of conventional therapy, including lung-protective mechanical ventilation. Early veno-venous extracorporeal membrane oxygenation (VV-ECMO) support was initiated in the emergency department (ED). The patient was weaned from ECMO on hospital day 6 and discharged from the ICU on hospital day 27. Cases of severe inhalation injury with acute respiratory failure refractory to conventional treatments and mechanical ventilator support may benefit from VV-ECMO. Literature on early initiation of ED-VV-ECMO in NaDCC-induced refractory respiratory failure is rare. This case may be used as a guide in the management of subsequent cases as it shows that early initiation of ED-VV-ECMO was beneficial to the patient.
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Addis DR, Aggarwal S, Lazrak A, Jilling T, Matalon S. Halogen-Induced Chemical Injury to the Mammalian Cardiopulmonary Systems. Physiology (Bethesda) 2021; 36:272-291. [PMID: 34431415 DOI: 10.1152/physiol.00004.2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The halogens chlorine (Cl2) and bromine (Br2) are highly reactive oxidizing elements with widespread industrial applications and a history of development and use as chemical weapons. When inhaled, depending on the dose and duration of exposure, they cause acute and chronic injury to both the lungs and systemic organs that may result in the development of chronic changes (such as fibrosis) and death from cardiopulmonary failure. A number of conditions, such as viral infections, coexposure to other toxic gases, and pregnancy increase susceptibility to halogens significantly. Herein we review their danger to public health, their mechanisms of action, and the development of pharmacological agents that when administered post-exposure decrease morbidity and mortality.
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Affiliation(s)
- Dylan R Addis
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama.,Comprehensive Cardiovascular Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Saurabh Aggarwal
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular and Translational Biomedicine, University of Alabama at Birmingham, Birmingham, Alabama.,Pulmonary Injury and Repair Center, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ahmed Lazrak
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular and Translational Biomedicine, University of Alabama at Birmingham, Birmingham, Alabama.,Pulmonary Injury and Repair Center, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Tamas Jilling
- Pulmonary Injury and Repair Center, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.,Department of Pediatrics, Division of Neonatology, Children's Hospital, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sadis Matalon
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular and Translational Biomedicine, University of Alabama at Birmingham, Birmingham, Alabama.,Pulmonary Injury and Repair Center, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Abstract
Toxic inhalants include various xenobiotics. Irritants cause upper and lower respiratory tract injuries. Highly water-soluble agents injure the upper respiratory tract, while low water-soluble inhalants injure the lower track. Asphyxiants are divided into simple asphyxiants and chemical asphyxiants. Simple asphyxiants displace oxygen, causing hypoxia, while chemical asphyxiants also impair the body's ability to use oxygen. Cyanide is a classic chemical asphyxiant. Treatment includes hydroxocobalamin. Electronic cigarette or vaping use-associated lung injury (EVALI) is a relatively new illness. Patients present with respiratory symptoms and gastrointestinal distress. EVALI appears to be associated with vaping cannabinoids. Treatment is supportive and may include steroids.
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Affiliation(s)
- Evan S Schwarz
- Washington University School of Medicine, 660 South Euclid, Campus Box 8072, St Louis, MO 63110, USA.
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Ahmad I, Molyvdas A, Jian MY, Zhou T, Traylor AM, Cui H, Liu G, Song W, Agarwal A, Jilling T, Aggarwal S, Matalon S. AICAR decreases acute lung injury by phosphorylating AMPK and upregulating heme oxygenase-1. Eur Respir J 2021; 58:13993003.03694-2020. [PMID: 34049949 DOI: 10.1183/13993003.03694-2020] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 05/11/2021] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Herein we investigated the mechanisms by which 5-Aminoimidazole-4-carboxamide ribonucleotide (AICAR), an activator of adenosine monophosphate (AMP)-activated protein kinase (AMPK), administered to mice post exposure to bromine (Br2), decreases lung injury and mortality. METHODS We exposed male C57BL/6 mice as well as heme oxygenase-1 deficient (HO-1-/-) and corresponding WT littermate mice to Br2 (600 ppm for 45 or 30 min respectively) gas in environmental chambers and returned them to room air. AICAR was administered 6 h post-exposure (10 mg·kg-1, IP). We assessed survival, indices of lung injury, high mobility group box 1 (HMGB1) in the plasma, HO-1 levels in lung tissues and phosphorylation of AMPK and its upstream liver kinase B1 (LKB1). Rat lung Type II epithelial cells (L2) and human club-like epithelial cells (H441) were also exposed to Br2 (100 ppm for 10 min). Twenty-four h later we measured apoptosis and necrosis, AMPK and LKB1 phosphorylation and HO-1 expression. RESULTS There was a marked downregulation of phosphorylated AMPK and LKB1 in both lung tissues and L2 and H441 cells post-exposure. AICAR increased survival in C57BL/6 but not in HO-1-/- mice. Additionally, in WT mice AICAR decreased lung injury and restored pAMPK and pLKB1 to control levels and increased HO-1 levels in both lung tissues and cells exposed to Br2. Treatment of L2 and H441 cells with siRNAs against Nrf2 or HO-1 abrogated the protective effects of AICAR. CONCLUSIONS Our data indicate that the primary mechanism for the protective action of AICAR in toxic gas injury is by upregulating lung HO-1 levels.
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Affiliation(s)
- Israr Ahmad
- Division of Molecular and Translational Biomedicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Albama, USA.,Center for Pulmonary Injury and Repair, Birmingham, Albama, USA.,These authors contributed equally to this study
| | - Adam Molyvdas
- Division of Molecular and Translational Biomedicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Albama, USA.,Center for Pulmonary Injury and Repair, Birmingham, Albama, USA.,These authors contributed equally to this study
| | - Ming-Yuan Jian
- Division of Molecular and Translational Biomedicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Albama, USA.,Center for Pulmonary Injury and Repair, Birmingham, Albama, USA
| | - Ting Zhou
- Division of Molecular and Translational Biomedicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Albama, USA.,Center for Pulmonary Injury and Repair, Birmingham, Albama, USA
| | - Amie M Traylor
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, Albama, USA
| | - Huachun Cui
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Albama, USA
| | - Gang Liu
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Albama, USA
| | - Weifeng Song
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Albama, USA
| | - Anupam Agarwal
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, Albama, USA
| | - Tamas Jilling
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Albama, USA
| | - Saurabh Aggarwal
- Division of Molecular and Translational Biomedicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Albama, USA.,Center for Pulmonary Injury and Repair, Birmingham, Albama, USA.,These authors contributed equally as senior authors
| | - Sadis Matalon
- Division of Molecular and Translational Biomedicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Albama, USA .,Center for Pulmonary Injury and Repair, Birmingham, Albama, USA.,These authors contributed equally as senior authors
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Clinical Presentations and Outcomes of Industrial Chlorine Gas Exposure Incidence in Oman. Prehosp Disaster Med 2020; 36:18-24. [PMID: 33183378 DOI: 10.1017/s1049023x20001375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The main objective was to study different clinical presentations and outcomes of patients after acute industrial chlorine gas exposure in Oman with evaluation of overall incident management to help develop a chemical exposure incident protocol. METHODS This was a retrospective observational study of 15 patients exposed to chlorine gas after an accidental chlorine gas leak in a metal melting factory in Oman. RESULTS Six (40%) patients were admitted and nine (60%) patients were discharged from the emergency department (ED) after initial management. The important post-chlorine gas exposure clinical symptoms were eye irritation (66.6%), cough (73.3%), shortness of breath (40.0%), chest discomfort (66.6%), rhinorrhea (66.6%), dizziness (40.0%), vomiting (46.6%), sore throat (13.3%), and stridor (53.3%). Important signs included tachycardia (40.0%), tachypnea (40.0%), wheeze (20.0%), and use of accessory muscles for breathing (20.0%). Signs and symptoms of eye irritation, rhinorrhea, tachycardia, tachypnea, wheeze, and use of accessory muscles for breathing have shown significant correlation with outcome (admission) having P value of <.05. CONCLUSION In the presented acute chlorine gas exposure incidence, 15 exposed persons were brought to the ED, out of which six were admitted and nine were discharged after symptomatic treatment. Signs and symptoms of eye irritation, rhinorrhea, tachycardia, tachypnea, wheeze, and use of accessory muscles of breathing show significant relation with the outcome of admission.
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Lazrak A, Song W, Zhou T, Aggarwal S, Jilling T, Garantziotis S, Matalon S. Hyaluronan and halogen-induced airway hyperresponsiveness and lung injury. Ann N Y Acad Sci 2020; 1479:29-43. [PMID: 32578230 PMCID: PMC7680259 DOI: 10.1111/nyas.14415] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 05/18/2020] [Accepted: 05/28/2020] [Indexed: 12/12/2022]
Abstract
Chlorine (Cl2 ) and bromine (Br2 ) are produced in large quantities throughout the world and used in the industry and the sanitation of water. These halogens can pose a significant threat to public health when released into the atmosphere during transportation and industrial accidents, or as acts of terrorism. In this review, we discuss the evidence showing that the activity of Cl2 and Br2 , and of products formed by their interaction with biomolecules, fragment high-molecular-weight hyaluronan (HMW-HA), a key component of the interstitial space and present in epithelial cells, to form proinflammatory, low-molecular-weight hyaluronan fragments that increase intracellular calcium (Ca2+ ) and activate RAS homolog family member A (RhoA) in airway smooth muscle and epithelial and microvascular cells. These changes result in airway hyperresponsiveness (AHR) to methacholine and increase epithelial and microvascular permeability. The increase in intracellular Ca2+ is the result of the activation of the calcium-sensing receptor by Cl2 , Br2 , and their by-products. Posthalogen administration of a commercially available form of HMW-HA to mice and to airway cells in vitro reverses the increase of Ca2+ and the activation of RhoA, and restores AHR to near-normal levels of airway function. These data have established the potential of HMW-HA to be a countermeasure against Cl2 and Br2 toxicity.
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Affiliation(s)
- Ahmed Lazrak
- Division of Molecular and Translational Biomedicine, the University of Alabama at Birmingham School of Medicine, Birmingham, AL
- Pulmonary Injury and Repair Center, Department of Anesthesiology and Perioperative Medicine, the University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Weifeng Song
- Division of Molecular and Translational Biomedicine, the University of Alabama at Birmingham School of Medicine, Birmingham, AL
- Pulmonary Injury and Repair Center, Department of Anesthesiology and Perioperative Medicine, the University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Ting Zhou
- Division of Molecular and Translational Biomedicine, the University of Alabama at Birmingham School of Medicine, Birmingham, AL
- Pulmonary Injury and Repair Center, Department of Anesthesiology and Perioperative Medicine, the University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Saurabh Aggarwal
- Division of Molecular and Translational Biomedicine, the University of Alabama at Birmingham School of Medicine, Birmingham, AL
- Pulmonary Injury and Repair Center, Department of Anesthesiology and Perioperative Medicine, the University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Tamas Jilling
- Pulmonary Injury and Repair Center, Department of Anesthesiology and Perioperative Medicine, the University of Alabama at Birmingham School of Medicine, Birmingham, AL
- Division of Neonatology, Department of Pediatrics, the University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Stavros Garantziotis
- Matrix Biology Group, Immunity, Inflammation, and Disease Laboratory, NIH/NIEHS, RTP, NC
| | - Sadis Matalon
- Division of Molecular and Translational Biomedicine, the University of Alabama at Birmingham School of Medicine, Birmingham, AL
- Pulmonary Injury and Repair Center, Department of Anesthesiology and Perioperative Medicine, the University of Alabama at Birmingham School of Medicine, Birmingham, AL
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10
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Slaughter RJ, Watts M, Vale JA, Grieve JR, Schep LJ. The clinical toxicology of sodium hypochlorite. Clin Toxicol (Phila) 2019; 57:303-311. [PMID: 30689457 DOI: 10.1080/15563650.2018.1543889] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
| | - Martin Watts
- National Poisons Centre, University of Otago, Dunedin, New Zealand
- Emergency Department, Southland Hospital, Invercargill, New Zealand
| | - J. Allister Vale
- West Midlands Poisons Unit, City Hospital, and University of Birmingham, Birmingham, UK
| | | | - Leo J. Schep
- National Poisons Centre, University of Otago, Dunedin, New Zealand
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11
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Matos AM, Oliveira RRD, Lippi MM, Takatani RR, Oliveira WD. Use of noninvasive ventilation in severe acute respiratory distress syndrome due to accidental chlorine inhalation: a case report. Rev Bras Ter Intensiva 2018; 29:105-110. [PMID: 28444079 PMCID: PMC5385992 DOI: 10.5935/0103-507x.20170015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 09/08/2016] [Indexed: 11/20/2022] Open
Abstract
Acute respiratory distress syndrome is characterized by diffuse inflammatory lung injury and is classified as mild, moderate, and severe. Clinically, hypoxemia, bilateral opacities in lung images, and decreased pulmonary compliance are observed. Sepsis is one of the most prevalent causes of this condition (30 - 50%). Among the direct causes of acute respiratory distress syndrome, chlorine inhalation is an uncommon cause, generating mucosal and airway irritation in most cases. We present a case of severe acute respiratory distress syndrome after accidental inhalation of chlorine in a swimming pool, with noninvasive ventilation used as a treatment with good response in this case. We classified severe acute respiratory distress syndrome based on an oxygen partial pressure/oxygen inspired fraction ratio <100, although the Berlin classification is limited in considering patients with severe hypoxemia managed exclusively with noninvasive ventilation. The failure rate of noninvasive ventilation in cases of acute respiratory distress syndrome is approximately 52% and is associated with higher mortality. The possible complications of using noninvasive positive-pressure mechanical ventilation in cases of acute respiratory distress syndrome include delays in orotracheal intubation, which is performed in cases of poor clinical condition and with high support pressure levels, and deep inspiratory efforts, generating high tidal volumes and excessive transpulmonary pressures, which contribute to ventilation-related lung injury. Despite these complications, some studies have shown a decrease in the rates of orotracheal intubation in patients with acute respiratory distress syndrome with low severity scores, hemodynamic stability, and the absence of other organ dysfunctions.
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Affiliation(s)
- Adriano Medina Matos
- Programa de Residência em Medicina Intensiva, Hospital Universitário Getúlio Vargas, Universidade Federal do Amazonas - Manaus (AM), Brasil.,Unidade de Terapia Intensiva, Hospital e Pronto-Socorro 28 de Agosto - Manaus (AM), Brasil
| | - Rodrigo Ribeiro de Oliveira
- Programa de Residência em Medicina Intensiva, Hospital Universitário Getúlio Vargas, Universidade Federal do Amazonas - Manaus (AM), Brasil
| | - Mauro Martins Lippi
- Programa de Residência em Medicina Intensiva, Hospital Universitário Getúlio Vargas, Universidade Federal do Amazonas - Manaus (AM), Brasil.,Unidade de Terapia Intensiva, Hospital e Pronto-Socorro 28 de Agosto - Manaus (AM), Brasil
| | - Rodrigo Ryoji Takatani
- Programa de Residência em Medicina Intensiva, Hospital Universitário Getúlio Vargas, Universidade Federal do Amazonas - Manaus (AM), Brasil.,Unidade de Terapia Intensiva, Hospital e Pronto-Socorro 28 de Agosto - Manaus (AM), Brasil
| | - Wilson de Oliveira
- Programa de Residência em Medicina Intensiva, Hospital Universitário Getúlio Vargas, Universidade Federal do Amazonas - Manaus (AM), Brasil.,Unidade de Terapia Intensiva, Hospital e Pronto-Socorro 28 de Agosto - Manaus (AM), Brasil
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12
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Uemura K, Isono M, Kagohashi K, Hasegawa R, Satoh H. Bronchial damage and diffuse alveolar hemorrhage following chlorine gas inhalation: A case report. Exp Ther Med 2017; 14:5126-5128. [PMID: 29201226 DOI: 10.3892/etm.2017.5161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 12/19/2016] [Indexed: 11/05/2022] Open
Abstract
Chlorine is a toxic inhalant and sources of exposure for individuals include accidental releases of chlorine vapor due to industrial or chemical transportation accidents. Inhalation of a large quantity of gas may cause circulatory and respiratory disorders or even mortality; however, the effects of a small amount of chlorine gas may be asymptomatic. The present case study presents a successfully treated 55-year-old male patient exposed to chlorine gas, resulting in bronchial damage and diffuse alveolar hemorrhage. Endobronchial and alveolar injuries were evaluated by direct observation using fiberoptic bronchoscopy (FB) and analyzing bronchoalveolar lavage fluid obtained by FB. Taking a precise medical history from the patient is crucial to correctly diagnose toxic gas inhalation. In addition, a timely and proper evaluation with chest imaging as well as FB may provide useful clinical information. Therefore, clinicians should consider performing FB if the circumstances permit.
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Affiliation(s)
- Kosuke Uemura
- Division of General Medicine, Mito Medical Center, University of Tsukuba, Mito, Ibaraki 310-0015, Japan
| | - Momoko Isono
- Division of General Medicine, Mito Medical Center, University of Tsukuba, Mito, Ibaraki 310-0015, Japan
| | - Katsunori Kagohashi
- Division of Respiratory Medicine, Mito Medical Center, University of Tsukuba, Mito, Ibaraki 310-0015, Japan
| | - Ryuichi Hasegawa
- Division of Intensive Care Medicine, Mito Medical Center, University of Tsukuba, Mito, Ibaraki 310-0015, Japan
| | - Hiroaki Satoh
- Division of Respiratory Medicine, Mito Medical Center, University of Tsukuba, Mito, Ibaraki 310-0015, Japan
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13
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Shin HJ, Chang JS, Ahn S, Kim TO, Park CK, Lim JH, Oh IJ, Kim YI, Lim SC, Kim YC, Kwon YS. Acute respiratory distress syndrome and chemical burns after exposure to chlorine-containing bleach: a case report. J Thorac Dis 2017; 9:E17-E20. [PMID: 28203432 DOI: 10.21037/jtd.2017.01.45] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Chlorine-containing bleach can cause acute respiratory distress syndrome (ARDS) and chemical burns. However, simultaneous occurrence of the two conditions caused by this agent is very rare. We describe the case of a 74-year-old female who presented with shortness of breath and hemoptysis following accidental exposure to chlorine-containing bleach. She had second- to third-degree chemical burns on both buttocks and thighs, and received mechanical ventilation because of the development of ARDS. Mechanical ventilation was discontinued on day 6 of hospitalization because of the rapid improvement of hypoxemia, and the patient was transferred to another hospital for further management of the chemical burns on day 18.
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Affiliation(s)
- Hong-Joon Shin
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Jin-Sun Chang
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Seong Ahn
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Tae-Ok Kim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Cheol-Kyu Park
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Jung-Hwan Lim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - In-Jae Oh
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Yu-Il Kim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Sung-Chul Lim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Young-Chul Kim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Yong-Soo Kwon
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
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14
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Matos AM, Oliveira RRD, Lippi MM, Takatani RR, Oliveira WD. Use of noninvasive ventilation in severe acute respiratory distress syndrome due to accidental chlorine inhalation: a case report. Rev Bras Ter Intensiva 2017. [PMID: 28444079 DOI: 10.5935/0103-507x.201700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Acute respiratory distress syndrome is characterized by diffuse inflammatory lung injury and is classified as mild, moderate, and severe. Clinically, hypoxemia, bilateral opacities in lung images, and decreased pulmonary compliance are observed. Sepsis is one of the most prevalent causes of this condition (30 - 50%). Among the direct causes of acute respiratory distress syndrome, chlorine inhalation is an uncommon cause, generating mucosal and airway irritation in most cases. We present a case of severe acute respiratory distress syndrome after accidental inhalation of chlorine in a swimming pool, with noninvasive ventilation used as a treatment with good response in this case. We classified severe acute respiratory distress syndrome based on an oxygen partial pressure/oxygen inspired fraction ratio <100, although the Berlin classification is limited in considering patients with severe hypoxemia managed exclusively with noninvasive ventilation. The failure rate of noninvasive ventilation in cases of acute respiratory distress syndrome is approximately 52% and is associated with higher mortality. The possible complications of using noninvasive positive-pressure mechanical ventilation in cases of acute respiratory distress syndrome include delays in orotracheal intubation, which is performed in cases of poor clinical condition and with high support pressure levels, and deep inspiratory efforts, generating high tidal volumes and excessive transpulmonary pressures, which contribute to ventilation-related lung injury. Despite these complications, some studies have shown a decrease in the rates of orotracheal intubation in patients with acute respiratory distress syndrome with low severity scores, hemodynamic stability, and the absence of other organ dysfunctions.
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Affiliation(s)
- Adriano Medina Matos
- Programa de Residência em Medicina Intensiva, Hospital Universitário Getúlio Vargas, Universidade Federal do Amazonas - Manaus (AM), Brasil.,Unidade de Terapia Intensiva, Hospital e Pronto-Socorro 28 de Agosto - Manaus (AM), Brasil
| | - Rodrigo Ribeiro de Oliveira
- Programa de Residência em Medicina Intensiva, Hospital Universitário Getúlio Vargas, Universidade Federal do Amazonas - Manaus (AM), Brasil
| | - Mauro Martins Lippi
- Programa de Residência em Medicina Intensiva, Hospital Universitário Getúlio Vargas, Universidade Federal do Amazonas - Manaus (AM), Brasil.,Unidade de Terapia Intensiva, Hospital e Pronto-Socorro 28 de Agosto - Manaus (AM), Brasil
| | - Rodrigo Ryoji Takatani
- Programa de Residência em Medicina Intensiva, Hospital Universitário Getúlio Vargas, Universidade Federal do Amazonas - Manaus (AM), Brasil.,Unidade de Terapia Intensiva, Hospital e Pronto-Socorro 28 de Agosto - Manaus (AM), Brasil
| | - Wilson de Oliveira
- Programa de Residência em Medicina Intensiva, Hospital Universitário Getúlio Vargas, Universidade Federal do Amazonas - Manaus (AM), Brasil.,Unidade de Terapia Intensiva, Hospital e Pronto-Socorro 28 de Agosto - Manaus (AM), Brasil
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15
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Carlisle M, Lam A, Svendsen ER, Aggarwal S, Matalon S. Chlorine-induced cardiopulmonary injury. Ann N Y Acad Sci 2016; 1374:159-67. [PMID: 27303906 DOI: 10.1111/nyas.13091] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Chlorine (Cl2 ) is utilized worldwide for a diverse range of industrial applications, including pulp bleaching, sanitation, and pharmaceutical development. Though Cl2 has widespread use, little is known regarding the mechanisms of toxicity associated with Cl2 exposure, which occurs during industrial accidents or acts of terrorism. Previous instances of Cl2 exposure have led to reported episodes of respiratory distress that result in high morbidity and mortality. Furthermore, studies suggest that acute Cl2 exposure also results in systemic vascular injury and subsequent myocardial contractile dysfunction. Here, we review both lung and cardiac pathology associated with acute Cl2 inhalation and discuss recently published data that suggest that mitochondrial dysfunction underlies the pathogenesis of Cl2 -induced toxicity. Last, we discuss our findings that suggest that upregulation of autophagy protects against Cl2 -induced lung inflammation and can be a potential therapeutic target for ameliorating the toxic effects of Cl2 exposure.
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Affiliation(s)
- Matthew Carlisle
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Molecular and Translational Biomedicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Adam Lam
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Molecular and Translational Biomedicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Erik R Svendsen
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina.,Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Saurabh Aggarwal
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Molecular and Translational Biomedicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sadis Matalon
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Molecular and Translational Biomedicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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16
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McGovern TK, Goldberger M, Allard B, Farahnak S, Hamamoto Y, O'Sullivan M, Hirota N, Martel G, Rousseau S, Martin JG. Neutrophils mediate airway hyperresponsiveness after chlorine-induced airway injury in the mouse. Am J Respir Cell Mol Biol 2016; 52:513-22. [PMID: 25192041 DOI: 10.1165/rcmb.2013-0430oc] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Chlorine gas (Cl2) inhalation causes oxidative stress, airway epithelial damage, airway hyperresponsiveness (AHR), and neutrophilia. We evaluated the effect of neutrophil depletion on Cl2-induced AHR and its effect on the endogenous antioxidant response, and if eosinophils or macrophages influence Cl2-induced AHR. We exposed male Balb/C mice to 100 ppm Cl2 for 5 minutes. We quantified inflammatory cell populations in bronchoalveolar lavage (BAL), the antioxidant response in lung tissue by quantitative PCR, and nuclear factor (erythroid-derived 2)-like 2 (NRF2) nuclear translocation by immunofluorescence. In vitro, NRF2 nuclear translocation in response to exogenous hypochlorite was assessed using a luciferase assay. Anti-granulocyte receptor-1 antibody or anti-Ly6G was used to deplete neutrophils. The effects of neutrophil depletion on IL-13 and IL-17 were measured by ELISA. Eosinophils and macrophages were depleted using TRFK5 or clodronate-loaded liposomes, respectively. AHR was evaluated with the constant-phase model in response to inhaled aerosolized methacholine. Our results show that Cl2 exposure induced neutrophilia and increased expression of NRF2 mRNA, superoxide dismutase-1, and heme-oxygenase 1. Neutrophil depletion abolished Cl2-induced AHR in large conducting airways and prevented increases in antioxidant gene expression and NRF2 nuclear translocation. Exogenous hypochlorite administration resulted in increased NRF2 nuclear translocation in vitro. After Cl2 exposure, neutrophils occupied 22 ± 7% of the luminal space in large airways. IL-17 in BAL was increased after Cl2, although this effect was not prevented by neutrophil depletion. Neither depletion of eosinophils nor macrophages prevented Cl2-induced AHR. Our data suggest the ability of neutrophils to promote Cl2-induced AHR is dependent on increases in oxidative stress and occupation of luminal space in large airways.
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Affiliation(s)
- Toby K McGovern
- Meakins-Christie Laboratories, Department of Medicine, McGill University, Montreal, Quebec, Canada
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17
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Soares C, Bastos JCSC, Wiggers VR, Decker RK, Noriler D, Meier HF. Experimental and Numerical Investigation of a Reactive Absorption Column for Chlorine Gas Mitigation. CHEM ENG COMMUN 2015. [DOI: 10.1080/00986445.2015.1126582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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18
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Management of chlorine gas-related injuries from the Graniteville, South Carolina, train derailment. Disaster Med Public Health Prep 2014; 8:411-6. [PMID: 25225966 DOI: 10.1017/dmp.2014.81] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A widely produced chemical, chlorine is used in various industries including automotive, electronics, disinfectants, metal production, and many others. Chlorine is usually produced and transported as a pressurized liquid; however, as a gas it is a significant pulmonary irritant. Thousands of people are exposed to chlorine gas every year, and while large-scale exposures are uncommon, they are not rare. Symptoms are usually related to the concentration and length of exposure, and although treatment is largely supportive, certain specific therapies have yet to be validated with randomized controlled trials. The majority of those exposed completely recover with supportive care; however, studies have shown the potential for persistent inflammation and chronic hyperreactivity. This case report describes an incident that occurred in Graniteville, South Carolina, when a train derailment exposed hundreds of people to chlorine gas. This report reviews the events of January 6, 2005, and the current treatment options for chlorine gas exposure.(Disaster Med Public Health Preparedness. 2014;0:1-6).
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19
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Case files of the University of California San Francisco Medical Toxicology Fellowship: acute chlorine gas inhalation and the utility of nebulized sodium bicarbonate. J Med Toxicol 2014; 9:259-65. [PMID: 23719961 DOI: 10.1007/s13181-013-0309-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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20
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Oktay C, Sayrac AV, Isik S, Sayrac N, Senay E, Kavasoglu ME. Personnel response during an internal emergency-unexpected release of an irritant gas in a hospital. Workplace Health Saf 2013; 61:381-3. [PMID: 23991704 DOI: 10.3928/21650799-20130827-51] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Internal emergencies can occur at any time and location in a hospital. Planning, training, and exercises can prepare personnel to respond effectively to internal emergency situations. All hospital staff should be trained to recognize an internal incident and activate the hospital emergency management system. Maintaining the health and safety of patients, employees, and visitors is paramount. Training and exercises also encourage staff to act with competence and confidence during an untoward incident to mitigate or avert possible catastrophe. This article describes an incident in which 12 hospital employees presented to the emergency department after exposure to a potent pulmonary irritant gas, chlorine, following an unfortunate accident. These cases are used to illustrate how planning, training, and exercises assisted health care personnel in responding to a potentially catastrophic internal emergency.
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21
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Chang H, Cui L, Li X, Shen J, Wei W, Kou Z. Preparation and characterization of surface modified powder of calcium hydroxide used as chlorine scavenger. J Loss Prev Process Ind 2012. [DOI: 10.1016/j.jlp.2012.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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22
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Editorial Comments–Acute Stress Symptoms, Dissociation, and Depression Among Rescue Personnel 24 Hours after the Bet-Yehoshua Train Disaster: The Effect of Exposure to Dead Bodies. Prehosp Disaster Med 2012. [DOI: 10.1017/s1049023x0000621x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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23
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McGovern T, Day BJ, White CW, Powell WS, Martin JG. AEOL10150: a novel therapeutic for rescue treatment after toxic gas lung injury. Free Radic Biol Med 2011; 50:602-8. [PMID: 21156205 PMCID: PMC4026011 DOI: 10.1016/j.freeradbiomed.2010.12.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Revised: 11/22/2010] [Accepted: 12/01/2010] [Indexed: 12/15/2022]
Abstract
New therapeutics designed as rescue treatments after toxic gas injury such as from chlorine (Cl(2)) are an emerging area of interest. We tested the effects of the metalloporphyrin catalytic antioxidant AEOL10150, a compound that scavenges peroxynitrite, inhibits lipid peroxidation, and has SOD and catalase-like activities, on Cl(2)-induced airway injury. Balb/C mice received 100ppm Cl(2) gas for 5 min. Four groups were studied: Cl(2) only, Cl(2) followed by AEOL10150 1 and 9 h after exposure, AEOL10150 only, and control. Twenty-four hours after Cl(2) gas exposure airway responsiveness to aerosolized methacholine (6.25-50mg/ml) was measured using a small-animal ventilator. Bronchoalveolar lavage (BAL) was performed to assess airway inflammation and protein. Whole lung tissue was assayed for 4-hydroxynonenal. In separate groups, lungs were collected at 72 h after Cl(2) injury to evaluate epithelial cell proliferation. Mice exposed to Cl(2) showed a significantly higher airway resistance compared to control, Cl(2)/AEOL10150, or AEOL10150-only treated animals in response to methacholine challenge. Eosinophils, neutrophils, and macrophages were elevated in BAL of Cl(2)-exposed mice. AEOL10150 attenuated the increases in neutrophils and macrophages. AEOL10150 prevented Cl(2)-induced increase in BAL fluid protein. Chlorine induced an increase in the number of proliferating airway epithelial cells, an effect AEOL10150 attenuated. 4-Hydroxynonenal levels in the lung were increased after Cl(2) and this effect was prevented with AEOL10150. AEOL10150 is an effective rescue treatment for Cl(2)-induced airway hyperresponsiveness, airway inflammation, injury-induced airway epithelial cell regeneration, and oxidative stress.
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Affiliation(s)
- Toby McGovern
- Meakins Christie Laboratories, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Brian J. Day
- Department of Pediatrics, National Jewish Health, Denver, Colorado, USA
| | - Carl W. White
- Department of Pediatrics, National Jewish Health, Denver, Colorado, USA
| | - William S. Powell
- Meakins Christie Laboratories, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - James G. Martin
- Meakins Christie Laboratories, Department of Medicine, McGill University, Montreal, Quebec, Canada
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24
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Pneumomediastinum from acute inhalation of chlorine gas in 2 young patients. Am J Emerg Med 2011; 29:357.e1-4. [DOI: 10.1016/j.ajem.2010.04.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Accepted: 04/16/2010] [Indexed: 11/15/2022] Open
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25
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Yadav AK, Doran SF, Samal AA, Sharma R, Vedagiri K, Postlethwait EM, Squadrito GL, Fanucchi MV, Roberts LJ, Patel RP, Matalon S. Mitigation of chlorine gas lung injury in rats by postexposure administration of sodium nitrite. Am J Physiol Lung Cell Mol Physiol 2010; 300:L362-9. [PMID: 21148791 DOI: 10.1152/ajplung.00278.2010] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Nitrite (NO(2)(-)) has been shown to limit injury to the heart, liver, and kidneys in various models of ischemia-reperfusion injury. Potential protective effects of systemic NO(2)(-) in limiting lung injury or enhancing repair have not been documented. We assessed the efficacy and mechanisms by which postexposure intraperitoneal injections of NO(2)(-) mitigate chlorine (Cl(2))-induced lung injury in rats. Rats were exposed to Cl(2) (400 ppm) for 30 min and returned to room air. NO(2)(-) (1 mg/kg) or saline was administered intraperitoneally at 10 min and 2, 4, and 6 h after exposure. Rats were killed at 6 or 24 h. Injury to airway and alveolar epithelia was assessed by quantitative morphology, protein concentrations, number of cells in bronchoalveolar lavage (BAL), and wet-to-dry lung weight ratio. Lipid peroxidation was assessed by measurement of lung F(2)-isoprostanes. Rats developed severe, but transient, hypoxemia. A significant increase of protein concentration, neutrophil numbers, airway epithelia in the BAL, and lung wet-to-dry weight ratio was evident at 6 h after Cl(2) exposure. Quantitative morphology revealed extensive lung injury in the upper airways. Airway epithelial cells stained positive for terminal deoxynucleotidyl-mediated dUTP nick end labeling (TUNEL), but not caspase-3. Administration of NO(2)(-) resulted in lower BAL protein levels, significant reduction in the intensity of the TUNEL-positive cells, and normal lung wet-to-dry weight ratios. F(2)-isoprostane levels increased at 6 and 24 h after Cl(2) exposure in NO(2)(-)- and saline-injected rats. This is the first demonstration that systemic NO(2)(-) administration mitigates airway and epithelial injury.
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Affiliation(s)
- Amit K Yadav
- Departments of Environmental Health Sciences, Schools of Public Health and Medicine, University of Alabama at Birmingham, USA
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26
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Mechanisms and modification of chlorine-induced lung injury in animals. Ann Am Thorac Soc 2010; 7:278-83. [PMID: 20601632 DOI: 10.1513/pats.201001-009sm] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Chlorine (Cl(2)) is a reactive oxidant gas used extensively in industrial processes. Exposure of both humans and animals to high concentrations of Cl(2) results in acute lung injury, which may resolve spontaneously or progress to acute respiratory failure. Injury to airway and alveolar epithelium may result from chemical reactions of Cl(2), from HOCl (the hydrolysis product of Cl(2)), and/or from the various reaction products, such as chloramines, that are formed from the reactions of these chlorinating species with biological molecules. Subsequent reactions may initiate self-propagating reactions and induce the production of inflammatory mediators compounding injury to pulmonary surfactant, ion channels, and components of lung epithelial and airway cells. Low-molecular-weight antioxidants, such as ascorbate, glutathione, and urate, present in the lung epithelial lining fluid and tissue, remove Cl(2) and HOCl and thus decrease injury to critical target biological targets. However, levels of lung antioxidants of animals exposed to Cl(2) in concentrations likely to be encountered in the vicinity of industrial accidents decrease rapidly and irreversibly. Our measurements show that prophylactic administration of a mixture containing ascorbate and desferal N-acetyl-cysteine, a precursor of reduced glutathione, prevents Cl(2)-induced injury to the alveolar epithelium of rats exposed to Cl(2). The clinical challenge is to deliver sufficient quantities of antioxidants noninvasively, after Cl(2) exposure, to decrease morbidity and mortality.
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27
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Sever M, Mordeniz C, Sever F, Dokur M. Accidental chlorine gas intoxication: evaluation of 39 patients. J Clin Med Res 2009; 1:274-9. [PMID: 22481989 PMCID: PMC3311442 DOI: 10.4021/jocmr2009.12.1283] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2009] [Indexed: 11/16/2022] Open
Abstract
Background Chlorine is a known pulmonary irritant gas that may cause acute damage in the respiratory system. In this paper, the socio-demographic and clinical characteristics of 39 accidentally exposed patients to chlorine gas are reported and different emergency treatment modalities are also discussed. Methods Two emergency departments applications were retrospectively analyzed for evaluation of accidental chlorine gas exposure for year 2007. Patients were classified into 3 groups according to severity of clinical and laboratory findings based on the literature and duration of land of stay in the emergency department. The first group was slightly exposed (discharged within 6 hours), second group moderately exposed (treated and observed for 24 hours), and third group was severely exposed (hospitalized). Most of the patients were initially treated with a combination of humidified oxygen, corticosteroids, and bronchodilators. Results The average age was 17.03 ± 16.01 years (95% CI). Seven (17.9%) of them were female and 29 (74.4%) were children. Twenty-four patients (61.5%) were included in the first, nine (23.1%) were in second and six (15.4%) were in the third group. The presenting symptoms were cough, nausea, and vomiting and conjunctiva hyperemia for the first group, first groups symptoms plus dyspnea for the second group. Second groups symptoms plus palpitation, weakness and chest tightness were for the third group. Cough and dyspnea were seen in 64.1% and 30.8% of the patients respectively. No patients died. Conclusions The authors recommend that non symptomatic or slightly exposed patients do not need any specific treatment or symptomatic treatment is sufficient. Keywords Accidental; Chlorine exposure; Chlorine gas; Chlorine intoxication; Emergency department
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Affiliation(s)
- Mustafa Sever
- Department of Emergency Medicine, Harran University School of Medicine, Sanliurfa, Turkey
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28
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Yigit O, Soyuncu S, Eray O, Enver S. Inhalational and dermal injury due to explosion of calcium hypochlorite. Cutan Ocul Toxicol 2009; 28:37-40. [DOI: 10.1080/15569520802636132] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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29
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Acute health effects after exposure to chlorine gas released after a train derailment. Am J Emerg Med 2009; 27:1-7. [PMID: 19041527 DOI: 10.1016/j.ajem.2007.12.006] [Citation(s) in RCA: 126] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2007] [Revised: 12/05/2007] [Accepted: 12/08/2007] [Indexed: 11/22/2022] Open
Abstract
In January 2005, a train derailment on the premises of a textile mill in South Carolina released 42 to 60 tons of chlorine gas in the middle of a small town. Medical records and autopsy reports were reviewed to describe the clinical presentation, hospital course, and pathology observed in persons hospitalized or deceased as a result of chlorine gas exposure. Eight persons died before reaching medical care; of the 71 persons hospitalized for acute health effects as a result of chlorine exposure, 1 died in the hospital. The mean age of the hospitalized persons was 40 years (range, 4 months-76 years); 87% were male. The median duration of hospitalization was 4 days (range, 1-29 days). Twenty-five (35%) persons were admitted to the intensive care unit; the median length of stay was 3 days. Many surviving victims developed significant pulmonary signs and severe airway inflammation; 41 (58%) hospitalized persons met PO2/FiO2 criteria for acute respiratory distress syndrome or acute lung injury. During their hospitalization, 40 (57%) developed abnormal x-ray findings, 74% of those within the first day. Hypoxia on room air and PO2/FiO2 ratio predicted severity of outcome as assessed by the duration of hospitalization and the need for intensive care support. This community release of chlorine gas caused widespread exposure and resulted in significant acute health effects and substantial health care requirements. Pulse oximetry and arterial blood gas analysis provided early indications of outcome severity.
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30
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Leustik M, Doran S, Bracher A, Williams S, Squadrito GL, Schoeb TR, Postlethwait E, Matalon S. Mitigation of chlorine-induced lung injury by low-molecular-weight antioxidants. Am J Physiol Lung Cell Mol Physiol 2008; 295:L733-43. [PMID: 18708632 DOI: 10.1152/ajplung.90240.2008] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Chlorine (Cl(2)) is a highly reactive oxidant gas used extensively in a number of industrial processes. Exposure to high concentrations of Cl(2) results in acute lung injury that may either resolve spontaneously or progress to acute respiratory failure. Presently, the pathophysiological sequelae associated with Cl(2)-induced acute lung injury in conscious animals, as well as the cellular and biochemical mechanisms involved, have not been elucidated. We exposed conscious Sprague-Dawley rats to Cl(2) gas (184 or 400 ppm) for 30 min in environmental chambers and then returned them to room air. At 1 h after exposure, rats showed evidence of arterial hypoxemia, respiratory acidosis, increased levels of albumin, IgG, and IgM in bronchoalveolar lavage fluid (BALF), increased BALF surfactant surface tension, and significant histological injury to airway and alveolar epithelia. These changes were more pronounced in the 400-ppm-exposed rats. Concomitant decreases of ascorbate (AA) and reduced glutathione (GSH) were also detected in both BALF and lung tissues. In contrast, heart tissue AA and GSH content remained unchanged. These abnormalities persisted 24 h after exposure in rats exposed to 400 ppm Cl(2). Rats injected systemically with a mixture of AA, deferoxamine, and N-acetyl-L-cysteine before exposure to 184 ppm Cl(2) had normal levels of AA, lower levels of BALF albumin and normal arterial Po(2) and Pco(2) values. These findings suggest that Cl(2) inhalation damages both airway and alveolar epithelial tissues and that resulting effects were ameliorated by prophylactic administration of low-molecular-weight antioxidants.
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Affiliation(s)
- Martin Leustik
- Department of Anesthesiology, University of Alabama at Birmingham, 901 19th Street South, Birmingham, AL 35205-3703, USA
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Abstract
INTRODUCTION An incident involving the release of chlorine gas from the pump room at a local swimming pool resulted in 54 patients seeking treatment in the emergency departments (EDs) of two local, tertiary-level hospitals in Singapore. The hospital hazardous materials (HAZMAT) disaster plan was activated. This report describes how one of the EDs organized in response to the disaster. EVENT Of the 54 people seeking treatment, 36 were treated in the ED at the Singapore General Hospital. The patients were decontaminated at shower facilities prior to entering the ED. The ED was reorganized to cope with existing patients, as well as the large influx of patients from the event site. A protocol was established in coordination with the local drug and poison information center to manage the patients who suffered from chlorine inhalation. Most patients were observed in the ED and subsequently discharged. Outpatient review appointments were scheduled. INJURIES Acute respiratory symptoms were the most common symptoms., Four children and four adults were admitted to the hospital, and the other patients were discharged from the ED after observation. All of the chest x-rays were normal on the day of the chlorine inhalation. There were no mortalities or significant morbidities, even up to six months after the incident. CONCLUSIONS Although this chlorine HAZMAT incident did not cause severe injuries, and only a limited number of persons required admission to the hospital, some valuable lessons were learned.
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Affiliation(s)
- Adeline Ngo
- Department of Emergency Medicine, Singapore General Hospital, Singhealth, Singapore.
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Dandrieux A, Dimbour J, Dusserre G. Are dispersion models suitable for simulating small gaseous chlorine releases? J Loss Prev Process Ind 2006. [DOI: 10.1016/j.jlp.2006.04.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Aslan S, Kandiş H, Akgun M, Cakir Z, Inandi T, Görgüner M. The effect of nebulized NaHCO3 treatment on "RADS" due to chlorine gas inhalation. Inhal Toxicol 2006; 18:895-900. [PMID: 16864407 DOI: 10.1080/08958370600822615] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Chlorine is one of the most common substances involved in toxic inhalation. As with all irritant gases, the airway injuries caused by chlorine gas may result in clinical manifestations similar to those of asthma. In this study, we investigated the effect of nebulized sodium bicarbonate (NSB) on the treatment and quality of life (QoL) of victims exposed to chlorine gas. Forty-four consecutive patients with reactive airways dysfunction syndrome (RADS) due to chlorine inhalation (40 females and 4 males, age range 17-56 yr) were included in this study. Patients were placed in control and treatment groups in a sequential odd-even fashion based on their order of presentation. Treatment of all patients included corticosteroids and nebulized short-acting beta2-agonists. Then the control group (n = 22) received nebulized placebo (NP), and the NSB group (n = 22) received NSB treatment (4 cm3 of 4.20% sodium bicarbonate solution). A quality of life (QoL) questionnaire and pulmonary function tests (PFTs) were performed before and after treatments in both groups. The most common symptoms were dyspnea (82%) and chest tightness (82%). Baseline characteristics of both groups were similar. Compared to the placebo group, the NSB group had significantly higher FEV1 values at 120 and 240 min (p < .05). Significantly more improvement in QoL questionnaire scores occurred in the NSB group compared to the NP group (p < .001). Thus, NSB is a clinically useful treatment, as tested by PFTs and QoL questionnaire, for patients with RADS caused by exposure to chlorine gas.
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Affiliation(s)
- Sahin Aslan
- Department of Emergency Medicine, School of Medicine, Atatürk University, Erzurum, Turkey
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Batchinsky AI, Martini DK, Jordan BS, Dick EJ, Fudge J, Baird CA, Hardin DE, Cancio LC. Acute respiratory distress syndrome secondary to inhalation of chlorine gas in sheep. ACTA ACUST UNITED AC 2006; 60:944-56; discussion 956-7. [PMID: 16688054 DOI: 10.1097/01.ta.0000205862.57701.48] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Toxic industrial chemicals (TICs) are potential terrorist weapons. Several TICs, such as chlorine, act primarily on the respiratory tract, but knowledge of the pathophysiology and treatment of these injuries is inadequate. This study aims to characterize the acute respiratory distress syndrome (ARDS) caused by chlorine gas (Cl2) inhalation in a large-animal model. METHODS Anesthetized female sheep were ventilated with 300 L of a Cl2/air/oxygen mixture for 30 minutes. In phase 1 (n = 35), doses were 0 ppm (Group 1, n = 6); 120 ppm (Group 2, n = 6); 240 to 350 ppm (Group 3, n = 11); and 400 to 500 ppm (Group 4, n = 12). In phase 2 (n = 17), doses were 0 ppm (Group 5, n = 5); 60 ppm (Group 6, n = 5); and 90 ppm (Group 7, n = 7), and the multiple inert gas elimination technique (MIGET) was used to characterize the etiology of hypoxemia. Computed tomography (CT) scans were performed daily for all animals. RESULTS In Phase 1, lung function was well maintained in Group 1; Cl2 caused immediate and sustained acute lung injury (PaO2-to-FiO2 ratio, PFR<3.0) in Group 2 and ARDS (PFR<2.0) in Groups 3 and 4. All animals in Groups 1 and 2 survived 96 hours. Kaplan-Meier analysis showed dose-related differences in survival (log-rank test, p < 0.0001). Logistic regression identified 280 ppm as the lethal dose 50%. CT and histopathology demonstrated lesions of both small airways and alveoli. In Phase 2, MIGET showed diversion of blood flow from normal to true-shunt lung compartments and, transiently, to poorly ventilated compartments. CONCLUSIONS Cl2 causes severe, dose-related lung injury, with features seen in both smoke inhalation and in ARDS secondary to systemic disease. This model will be used to test new therapeutic modalities.
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Affiliation(s)
- Andriy I Batchinsky
- US Army Institute of Surgical Research, Fort Sam Houston, Texas 78234-6315, USA
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Bonetto G, Corradi M, Carraro S, Zanconato S, Alinovi R, Folesani G, Da Dalt L, Mutti A, Baraldi E. Longitudinal monitoring of lung injury in children after acute chlorine exposure in a swimming pool. Am J Respir Crit Care Med 2006; 174:545-9. [PMID: 16763216 PMCID: PMC1555620 DOI: 10.1164/rccm.200509-1392oc] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Acute exposure to chlorine gas results in respiratory impairment, but few data are available on the pathobiology of the underlying lung damage. OBJECTIVES To assess lung function and potential lung damage pathways in the acute phase and longitudinally over a 15-mo follow-up after acute chlorine exposure. METHODS Ten previously healthy children were accidentally exposed to chlorine gas at a swimming pool because of an erroneous servicing procedure. The fraction of nitric oxide in exhaled air (Fe(NO)), exhaled breath condensate compounds, and serum Clara cell-specific protein CC16 were repeatedly measured. MAIN RESULTS In the acute phase, all patients had respiratory distress (one child required mechanical ventilation) and reduced lung function (median and interquartile range: FVC, 51 [43-60]% predicted; FEV(1), 51 [46-60]% predicted). This was accompanied by low Fe(NO) (4.7 [3.9-7.9] ppb), high exhaled breath condensate leukotriene B(4) (LTB(4)) levels (24.4 [22.5-24.9] pg/ml), and increased serum CC16 levels (mean +/- SEM, 23.4 +/- 2.5 microg/L). Lung function returned to normal in 15 d (FVC, 97% predicted [82-108], and FEV(1), 92% predicted [77-102]). Fe(NO) reached normal values after 2 mo (12.6 [11.4-15] ppb), whereas LTB(4) levels were still increased (12 [9.3-17.1] pg/ml). CONCLUSION Children acutely exposed to chlorine in a swimming pool presented a substantial lung function impairment associated with biochemical exhaled breath alterations, represented mainly by an increase in LTB(4) and a reduction in Fe(NO). Although lung function and Fe(NO) improved within a few weeks, the increased levels of exhaled LTB(4) persisted for several months.
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Affiliation(s)
- Gea Bonetto
- Department of Pediatrics, University of Padua, Via Giustiniani 3, 35128 Padua, Italy.
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Russell D, Blain PG, Rice P. Clinical management of casualties exposed to lung damaging agents: a critical review. Emerg Med J 2006; 23:421-4. [PMID: 16714497 PMCID: PMC2564332 DOI: 10.1136/emj.2003.011775] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2005] [Indexed: 11/03/2022]
Abstract
There is no specific antidote for the treatment of casualties exposed to chlorine, phosgene, or mustards; therefore, management is largely supportive. Corticosteroid treatment has been given to casualties accidentally exposed to chlorine. Clinical data on efficacy are inconclusive as the numbers given steroids have been small and the indications for administration unclear. There have been no clinical controlled studies. There is a stronger evidence base from animal studies, particularly from porcine and rodent models. Lung injury induced by phosgene and mustard appears to be mediated by glutathione depletion, lipid peroxidation, free radical generation, and subsequent cellular toxicity. There is limited evidence to suggest that repletion of glutathione reduces and/or prevents lung damage by these agents. This may provide an opportunity for therapeutic intervention.
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Affiliation(s)
- D Russell
- Health Protection Agency, Chemical Hazards and Poisons Division, Cardiff, UK.
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A simple model for calculating chlorine concentrations behind a water spray in case of small releases. J Loss Prev Process Ind 2005. [DOI: 10.1016/j.jlp.2005.06.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Wang J, Zhang L, Walther SM. Administration of Aerosolized Terbutaline and Budesonide Reduces Chlorine Gas–Induced Acute Lung Injury. ACTA ACUST UNITED AC 2004; 56:850-62. [PMID: 15187753 DOI: 10.1097/01.ta.0000078689.45384.8b] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The pathophysiology and treatment of chlorine gas-induced acute lung injury is poorly characterized and based on anecdotal data. This study aimed to assess the effects of aerosolized beta-2 adrenergic agonist and corticosteroid therapy on chlorine gas-induced lung injury. METHODS Anesthetized, ventilated pigs were exposed to chlorine gas (400 parts per million for 20 minutes), then assigned randomly 30 minutes later to receive aerosolized terbutaline, budesonide, terbutaline followed by budesonide or placebo (6 pigs in each group). Hemodynamics, gas exchange, and lung mechanics were evaluated for another 5 hours. RESULTS All the animals demonstrated an immediate increase in airway and pulmonary artery pressure as well as sharp drops in arterial oxygen tension (PaO2) and lung compliance (CL). Recovery of PaO2 and CL was greatest in the terbutaline plus budesonide group, but therapy with terbutaline and budesonide alone also was associated with significant improvement in PaO2 and CL, as compared with placebo. CONCLUSIONS Treatment of acute chlorine gas lung injury with aerosolized terbutaline followed by aerosolized budesonide improved lung function. Combined treatment was more effective than treatment with either drug alone.
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Affiliation(s)
- Jianpu Wang
- Section of Disaster Medicine, Department of Biomedicine and Surgery, Faculty of Health Sciences, University of Linköping, Linköping, Sweden.
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Affiliation(s)
- Stefanos N Kales
- Cambridge Health Alliance, Department of Medicine, Occupational and Environmental Health, Harvard Medical School, Cambridge, Mass 02139, USA.
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The use of water sprays for mitigating chlorine gaseous releases escaping from a storage shed. J Loss Prev Process Ind 2003. [DOI: 10.1016/s0950-4230(03)00038-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Güloğlu C, Kara IH, Erten PG. Acute accidental exposure to chlorine gas in the Southeast of Turkey: a study of 106 cases. ENVIRONMENTAL RESEARCH 2002; 88:89-93. [PMID: 11908933 DOI: 10.1006/enrs.2001.4324] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
The present study reports a thorough investigation of the sociodemographic characteristics, clinical findings, and treatment of persons affected acutely by chlorine gas exposure from a chlorine tank belonging to the municipality of Diyarbakir. One hundred six persons were assessed. In this cross-sectional study, 58 patients were male and 48 were female. Children and adolescents younger than 18 years constituted more than half of the patients (60 cases, 56.6%). The age of patients ranged between 3 months and 75 years. Among the cases evaluated in emergency rooms, 7 patients had mild poisoning and were discharged after first examinations and symptomatic treatments, 62 patients were moderately affected and were taken under observation, and the remaining 37 were severely affected and were hospitalized. In physical examinations, 29 patients had expiratory wheezing, and 1 had tachycardia and extrasystoles. There were no deaths among these patients, acute chlorine intoxication affected mostly children. Respiratory tract findings were predominant in most of the patients. Steroid and bicarbonate applications were inadequate supportive therapies. Humidified O(2) and beta-agonist applications were most useful in the therapy of acute chlorine intoxication.
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Affiliation(s)
- Cahfer Güloğlu
- Department of Family Medicine, Dicle University Faculty of Medicine, Diyarbakir, 21280, Turkey
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Dandrieux A, Dusserre G, Ollivier J. Small scale field experiments of chlorine dispersion. J Loss Prev Process Ind 2002. [DOI: 10.1016/s0950-4230(01)00019-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Agabiti N, Ancona C, Forastiere F, Di Napoli A, Lo Presti E, Corbo GM, D'Orsi F, Perucci CA. Short term respiratory effects of acute exposure to chlorine due to a swimming pool accident. Occup Environ Med 2001; 58:399-404. [PMID: 11351056 PMCID: PMC1740147 DOI: 10.1136/oem.58.6.399] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Acute exposure to chlorine causes lung damage, and recovery may proceed slowly for several weeks. The short term respiratory effects of acute chlorine inhalation during a swimming pool accident were examined. METHODS A total of 282 subjects (134 children, aged <14 years) inhaled hydrogen chloride and sodium hypochlorite during an accident caused by a malfunction of the water chlorinating system in a community pool in Rome in 1998. Most people received bronchodilators and cortisone at the emergency room; five children were admitted to hospital. A total of 260 subjects (92.2%) were interviewed about duration of exposure (<3, 3--5, >5 minutes), intensity of exposure (not at all or a little, a moderate amount, a lot), and respiratory symptoms. Lung function was measured in 184 people (82 children) after 15--30 days. The effects of exposure to chlorine were analysed through multiple linear regression, separately in adults and in children. RESULTS Acute respiratory symptoms occurred among 66.7% of adults and 71.6% of children. The incidences were highest among those who had chronic respiratory disease and had a longer duration of exposure. In about 30% of the subjects, respiratory symptoms persisted for 15--30 days after the accident. Lung function levels were lower in those who reported a high intensity of exposure than in those who reported low exposure, both in children and in adults (mean (95% confidence interval (95% CI)) differences in forced expiratory volume in 1 second (FEV(1,)) were -109 (-310 to 93) ml, and -275 (-510 to -40) ml, respectively). CONCLUSION Persistent symptoms and lung function impairment were found up to 1 month after the incident. Although community pool accidents happen rarely, the medical community needs to be alerted to the possible clinical and physiological sequelae, especially among susceptible people.
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Affiliation(s)
- N Agabiti
- Agency for Public Health, Lazio, Via S Costanza 53, 00198 Rome, Italy.
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Abstract
Chlorine is a reactive gas used by humanity for over two centuries. Exposure to chlorine has occurred in a number of situations, including as a chemical warfare agent, in industrial and domestic exposures, and as a result of accidents and spills. The toxicology of chlorine is related almost entirely to effects in the respiratory system. A consistent symptomology occurs in both animals and humans. This ranges from sensory irritation, to irritation and bronchospasm, to cellular changes to bronchioles and alveoli, to development of pulmonary disease. While full recovery from such injuries remains the most likely outcome, there is little doubt that permanent loss of function is possible in severe cases. In all industrial applications of chlorine, occupational exposures to chlorine should be controlled to at least the recommended exposure standard. However, a focus of activity on ensuring that excursions (such as leaks or "gassing" incidents) above these values do not occur is likely to be more beneficial. Treatment of chlorine exposure is essentially symptomatic, with the efficacy of some treatments (such as corticosteroid therapy) still not well established.
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Affiliation(s)
- C Winder
- School of Safety Science, University of New South Wales, Sydney, NSW, 2052, Australia.
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Affiliation(s)
- J B Leiken
- Rush-Presbyterian-St Luke's Medical Center, Chicago, Illinois, USA
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