Nitrous Dioxide Toxicity Follow-up

  • Author: Jeffrey S Peterson, MD; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Mar 15, 2012
 

Further Inpatient Care

  • Patients presenting with hypoxemia, dyspnea, or an altered level of consciousness require observation in the hospital for a minimum of 24 hours.
  • Determine discharge decisions based on clinical improvement and resolution of hypoxemia and methemoglobinemia.
  • Patients initially asymptomatic following a known exposure should be observed for at least 8 hours for evidence of developing hypoxemia and respiratory failure. Noncardiogenic pulmonary edema may develop slowly over 48 hours after a significant exposure.
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Further Outpatient Care

  • Following a known exposure, perform complete pulmonary function tests and clinical evaluations in 3 weeks and again in 3 months.
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Inpatient & Outpatient Medications

  • Corticosteroids may need to be tapered over a long period (6-12 mo) if the development of toxic bronchiolitis obliterans is a serious concern.
  • Inhaled sympathomimetics (eg, albuterol), anticholinergics (eg, ipratropium bromide), and steroids (eg, fluticasone propionate) may be indicated for those who develop a reactive airways dysfunction syndrome (RADS) postexposure.
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Deterrence/Prevention

Working environments should be evaluated for elevated nitrous dioxide (NO2) levels and proper ventilation and protective gear, such as SCBA, should be used.

Workplace standards

American Conference of Governmental Industrial Hygienists threshold limit values (ACGIH-TLV)

  • Time weighted average (TWA) - 3 ppm
  • Short-term exposure limit (STEL) - 5 ppm

The National Institute of Occupational Safety and Health (NIOSH) values

  • Recommended exposure limit (REL) - 1 ppm
  • STEL (immediately dangerous to life or health) - 20 ppm

Labels required - Poison gas, oxidizer, corrosive

National Fire Protection Association (NFPA) hazard ratings

  • Health (Blue) - 3
  • Flammability (Red) - 0
  • Reactivity (Yellow) - 0

Respiratory recommendations - Positive-pressure SCBA (according to North American Emergency Response Guide [NAERG] 124)

Protective clothing - Chemically protective clothing as recommended by the manufacturer (according to NAERG 124)

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Prognosis

  • Overall, the long-term prognosis is good for patients who survive the initial exposure to NO2.
  • The long-term prognosis is determined by follow-up pulmonary function evaluation.
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Patient Education

  • Advise patients who have had a significant exposure to NO2 to avoid other pulmonary toxins. They should wear appropriate personal protective equipment in the workplace.
  • Advise patients that delayed symptoms, including life-threatening pulmonary edema and dyspnea caused by bronchiolitis obliterans, may result. Therefore, patients should be followed for a minimum of 2-3 months after exposure to monitor possible development of bronchiolitis obliterans.
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Contributor Information and Disclosures
Author

Jeffrey S Peterson, MD  Clinical Assistant Professor of Surgery/Emergency Medicine, Stanford University School of Medicine, Stanford University Hospital; Founder and Sports Medicine Physician, Innovative Sports Medicine

Jeffrey S Peterson, MD, is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Sports Medicine, Massachusetts Medical Society, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Suzanne M Miller, MD  Clinical Instructor, Emergency Medicine, George Washington University School of Medicine and Health Sciences; Attending Physician, Department of Emergency Medicine, INOVA Fairfax Hospital; Chief Executive Officer, MDadmit

Suzanne M Miller, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Charles B Cairns, MD  Professor and Chair, Department of Emergency Medicine, University of North Carolina School of Medicine; Consulting Faculty, Department of Emergency Medicine, Duke University Medical School and Duke Clinical Research Institute

Charles B Cairns, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Emergency Physicians, American Heart Association, American Thoracic Society, American Trauma Society, European Respiratory Society, New York Academy of Sciences, Sigma Xi, Society for Academic Emergency Medicine, and Society for Experimental Biology and Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, FACCT  Associate Clinical Professor, Department of Surgery/Emergency Medicine and Toxicology, University of Texas School of Medicine at San Antonio; Medical and Managing Director, South Texas Poison Center

Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, FACCT is a member of the following medical societies: American Academy of Emergency Medicine, American College of Clinical Toxicologists, American College of Emergency Physicians, American College of Medical Toxicology, American College of Occupational and Environmental Medicine, Society for Academic Emergency Medicine, and Texas Medical Association

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Fred Harchelroad, MD, FACMT, FAAEM, FACEP  Director of Medical Toxicology, Allegheny General Hospital

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD  Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

References

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  19. van Bree L, Rietjens I, Alink GM, et al. Biochemical and morphological changes in lung tissue and isolated lung cells of rats induced by short-term nitrogen dioxide exposure. Hum Exp Toxicol. Jul 2000;19(7):392-401. [Medline].

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Bronchiolitis obliterans following exposure to nitrogen dioxide. (Radiograph courtesy of Dr Ann Leung, Stanford University Hospital, Department of Radiology, Palo Alto, CA)
Noncardiogenic pulmonary edema following exposure to nitrogen dioxide. (Radiograph courtesy of Dr Ann Leung, Stanford University Hospital, Department of Radiology, Palo Alto, CA)
 
 
 
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