eMedicine Specialties > Pulmonology > Occupational Lung Diseases

Silo Filler's Disease: Treatment & Medication

Author: Nader Kamangar, MD, FACP, FCCP, FAASM,, Associate Professor of Clinical Medicine, Director of Hospitalist/Intensivist Program, Division of Pulmonary, Critical Care and Sleep Medicine, David Geffen School of Medicine at University of California Los Angeles; Associate Director, Combined Pulmonary and Critical Care Fellowship Program, Cedars-Sinai/Olive View-UCLA/West Los Angeles Veterans Affairs Medical Center
Coauthor(s): Lex Chen, MD, Resident Physician, Department of Internal Medicine, University of California Los Angeles, Olive View Medical Center
Contributor Information and Disclosures

Updated: Sep 17, 2009

Treatment

Medical Care

  • Prehospital care in silo filler's disease (SFD): Safely remove the patient from exposure without endangering rescuers.
  • Medical care for silo filler's disease is as follows:
    • Hospitalize the patient for 12-24 hours for observation or longer if gas exchange is compromised.
    • Administer oxygen to the patient for hypoxemia.
    • Use mechanical ventilatory support for hypoxemic or hypercapnic respiratory failure. Treat secondary infection, if present.
    • Administer volume expanders cautiously.
    • The patient may require invasive monitoring because excessive administration of volume expanders can cause hydrostatic pulmonary edema. Nitrogen dioxide forms nitric oxide, causing vasodilation and an apparent volume depletion.6
    • Monitor continuous pulse oximetry.

Consultations

  • Consult a pulmonary medicine or critical care specialist if the patient requires endotracheal intubation or hemodynamic monitoring.
  • Consult a medical toxicologist or poison control center to provide additional information and patient care guidelines.

Activity

Advise the patient to avoid exercise for 1-2 days after exposure.

Medication

Methylene blue is indicated for significant methemoglobinemia. Other possible treatments may include antibiotics if infection becomes evident, and vasopressor drugs are required to correct the normovolemic shock. Corticosteroids may be important in the prevention of bronchiolitis obliterans.

Antidotes

Methylene blue (ie, tetramethyl thionine chloride) is the recommended antidote for methemoglobinemia. It is reduced to leukomethylene blue, which is then available to reduce methemoglobin to hemoglobin.


Methylene blue (Urolene Blue)

Used if methemoglobin exceeds 30%. Administer IV.

Adult

1-2 mg/kg IV over 5 min at 1% solution; repeat dosing in 1 h if continued symptomatology or significant methemoglobinemia is present; not to exceed 7 mg/kg

Pediatric

Administer as in adults; 0.3-1.0 mg/kg IV over 5 min for neonates

Documented hypersensitivity; intraspinal administration; severe renal insufficiency; treatment of methemoglobinemia in cyanide poisoning

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

High doses (5-10 mg/kg) or rapid IV administration may induce acute hemolytic anemia or cause further methemoglobin production; patients with a glucose-6-phosphate deficiency may not benefit from this treatment; toxic effects include dyspnea, precordial pain, restlessness, apprehension, a sense of oppression, and tremors

Corticosteroids

These agents do not benefit the patient during the acute phase, but they are effective in treating bronchiolitis obliterans. Because not all patients with acute lung injury develop bronchiolitis, judge the risk factors and choose between prescribing the patient corticosteroids as prevention and monitoring the patient for clinical or radiographic evidence of bronchiolitis obliterans.


Methylprednisolone (Adlone, Solu-Medrol, Depo-Medrol)

Reduces inflammatory response of bronchiolitis obliterans and can be tapered over 8 wk, adjusting the dose based on clinical symptoms, radiographs, and spirometry.

Adult

125 mg IV q6h initially; follow with 40 mg/d PO, tapering to 20 mg/d over the first mo, then gradually wean off over the next mo

Pediatric

Not to exceed 30 mg/kg IV

Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels of methylprednisolone; phenobarbital, phenytoin, and rifampin may decrease levels of methylprednisolone (adjust dose); monitor patients for hypokalemia when taking medication concurrently with diuretics

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications of glucocorticoid use

Inhalational agents

One case report described a patient with ARDS secondary to silo filler’s disease who required nitric oxide (NO) therapy because of worsening oxygenation. Great care should be instituted with nitric oxide therapy because of the possibility of worsening pulmonary damage and methemoglobinemia, which are already present in silo filler’s disease.


Nitric oxide (INOmax)

Produced endogenously from action of enzyme NO synthetase on arginine; relaxes vascular smooth muscle by binding to heme moiety of cytosolic guanylate cyclase, activating guanylate cyclase and increasing intracellular levels of cGMP, which then leads to vasodilation; when inhaled, NO decreases pulmonary vascular resistance and improves lung blood flow.

Adult

20 ppm via respirator initially; not to exceed 80 ppm; effect of pulmonary vasodilatation may still be observed at 5 ppm; deliver by system that measures concentrations of NO in breathing gas with constant concentration throughout respiratory cycle; deliver by system that does not cause generation of excessive inhaled nitrogen dioxide

Pediatric

20 ppm via respirator initially; not to exceed 80 ppm; most children respond at 20 ppm and can be weaned to lower doses; effect of pulmonary vasodilatation may still be observed at 5 ppm; deliver by system that measures concentrations of NO in breathing gas with constant concentration throughout respiratory cycle; deliver by system that does not cause generation of excessive inhaled nitrogen dioxide

Concomitant administration with NO donor compounds (eg, nitroprusside, nitroglycerin) may have additive effects and may increase risk of methemoglobinemia

Right to left shunting of blood; methemoglobin reductase deficiency

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Abrupt discontinuation of NO may lead to worsening oxygenation and increasing PAP; toxic effects include methemoglobinemia and pulmonary inflammation resulting from reactive nitrogen intermediates; caution in thrombocytopenia, anemia, leukopenia, or bleeding disorders; monitor for PaO2, methemoglobin, and NO2; abrupt withdrawal causes rebound pulmonary hypertension

More on Silo Filler's Disease

Overview: Silo Filler's Disease
Differential Diagnoses & Workup: Silo Filler's Disease
Treatment & Medication: Silo Filler's Disease
Follow-up: Silo Filler's Disease
References
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References

  1. Klonoff-Cohen H, Lam PK, Lewis A. Outdoor carbon monoxide, nitrogen dioxide, and sudden infant death syndrome. Arch Dis Child. Jul 2005;90(7):750-3. [Medline].

  2. Belanger K, Gent JF, Triche EW, Bracken MB, Leaderer BP. Association of indoor nitrogen dioxide exposure with respiratory symptoms in children with asthma. Am J Respir Crit Care Med. Feb 1 2006;173(3):297-303. [Medline].

  3. Stieb DM, Szyszkowicz M, Rowe BH, Leech JA. Air pollution and emergency department visits for cardiac and respiratory conditions: a multi-city time-series analysis. Environ Health. Jun 10 2009;8:25. [Medline].

  4. MMWR. Silo-Filler's disease in rural New York. MMWR Morb Mortal Wkly Rep. Jul 23 1982;31(28):389-91. [Medline].

  5. Zwemer FL Jr, Pratt DS, May JJ. Silo filler's disease in New York State. Am Rev Respir Dis. Sep 1992;146(3):650-3. [Medline].

  6. Ichinose F, Roberts JD Jr, Zapol WM. Inhaled nitric oxide: a selective pulmonary vasodilator: current uses and therapeutic potential. Circulation. Jun 29 2004;109(25):3106-11. [Medline].

  7. do Pico GA. Lung (agricultural/rural). Otolaryngol Head Neck Surg. Feb 1996;114(2):212-6. [Medline].

  8. Douglas WW, Hepper NG, Colby TV. Silo-filler's disease. Mayo Clin Proc. Mar 1989;64(3):291-304. [Medline].

  9. Goldstein E, Peek NF, Parks NJ, Hines HH, Steffey EP, Tarkington B. Fate and distribution of inhaled nitrogen dioxide in rhesus monkeys. Am Rev Respir Dis. Mar 1977;115(3):403-12. [Medline].

  10. Gurney JW, Unger JM, Dorby CA, Mitby JK, Von Essen SG. Agricultural disorders of the lung. Radiographics. Jul 1991;11(4):625-34. [Medline].

  11. Leavey JF, Dubin RL, Singh N, Kaminsky DA. Silo-Filler's disease, the acute respiratory distress syndrome, and oxides of nitrogen. Ann Intern Med. Sep 7 2004;141(5):410-1. [Medline].

  12. Maurer WJ. Silo-filler's disease. A historical perspective and report of a case. Wis Med J. Aug 1985;84(8):13-6. [Medline].

  13. Ramirez J, Dowell AR. Silo-filler's disease: nitrogen dioxide-induced lung injury. Long-term follow-up and review of the literature. Ann Intern Med. Apr 1971;74(4):569-76. [Medline].

  14. Robinson DM, Yu ML, Prakash UB. 60-year-old man with respiratory distress and confusion. Mayo Clin Proc. Aug 1996;71(8):813-6. [Medline].

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Further Reading

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Keywords

silo filler’s disease, silo filler disease, silo unloader disease, nitrogen dioxide poisoning, SFD, silo-filler's disease, proliferative pulmonary disease, pulmonary edema, bronchiolitis obliterans, asphyxiation, methemoglobinemia, chemical pneumonitis, acute respiratory distress syndrome, ARDS, acute lung injury, nitrogen oxides, bronchioles lung injury, alveoli lung injury, arterial blood gas, ABG, methemoglobin, MHb, methemoglobinemia

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Contributor Information and Disclosures

Author

Nader Kamangar, MD, FACP, FCCP, FAASM,, Associate Professor of Clinical Medicine, Director of Hospitalist/Intensivist Program, Division of Pulmonary, Critical Care and Sleep Medicine, David Geffen School of Medicine at University of California Los Angeles; Associate Director, Combined Pulmonary and Critical Care Fellowship Program, Cedars-Sinai/Olive View-UCLA/West Los Angeles Veterans Affairs Medical Center
Nader Kamangar, MD, FACP, FCCP, FAASM, is a member of the following medical societies: American Academy of Sleep Medicine, American Association of Bronchology, American College of Chest Physicians, American College of Physicians, American Lung Association, American Medical Association, American Thoracic Society, California Thoracic Society, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Lex Chen, MD, Resident Physician, Department of Internal Medicine, University of California Los Angeles, Olive View Medical Center
Lex Chen, MD is a member of the following medical societies: American College of Physicians
Disclosure: Nothing to disclose.

Medical Editor

Gregory Tino, MD, Director of Pulmonary Outpatient Practices, Associate Professor, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania Medical Center and Hospital
Gregory Tino, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Gregg T Anders, DO, Medical Director, Great Plains Regional Medical Command , Brook Army Medical Center; Clinical Associate Professor, Department of Internal Medicine, Division of Pulmonary Disease, University of Texas Health Science Center at San Antonio
Gregg T Anders, DO is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society
Disclosure: Nothing to disclose.

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD, Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center; Professor of Medicine, David Geffen School of Medicine at UCLA
Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society
Disclosure: Nothing to disclose.

 
 
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