Nitrous Dioxide Toxicity Medication

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

Medication Summary

High-dose corticosteroids are suggested in the treatment of pulmonary manifestations, but data on their prophylactic use after nitrous dioxide (NO2) exposure are anecdotal.

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Corticosteroids

Class Summary

These agents reduce the inflammatory response. Whether early administration can prevent development of noncardiogenic pulmonary edema is unknown. The decision to administer corticosteroids must be made on clinical grounds.

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Methylprednisolone (Solu-Medrol)

 

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

Consider tapering if prolonged dosing (>14 d) is required.

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Antidotes

Class Summary

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

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Methylene blue

 

DOC if patient is cyanotic from methemoglobinemia and symptomatic or if methemoglobin level is >30%. Alters pulse oximetry readings. Available as 1% solution (10 mg/mL) in 10 mL ampules.

The FDA warns against the concurrent use of methylene blue with serotonergic psychiatric drugs, unless indicated for life-threatening or urgent conditions. Methylene blue may increase serotonin CNS levels as a result of MAO-A inhibition, increasing the risk of serotonin syndrome.[7]

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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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  2. Jarvis DL, Leaderer BP, Chinn S, Burney PG. Indoor nitrous acid and respiratory symptoms and lung function in adults. Thorax. Jun 2005;60(6):474-9. [Medline].

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  5. van Strien RT, Gent JF, Belanger K, et al. Exposure to NO2 and nitrous acid and respiratory symptoms in the first year of life. Epidemiology. Jul 2004;15(4):471-8. [Medline].

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  7. US Food and Drug Administration. FDA Drug Safety Communication: Serious CNS reactions possible when methylene blue is given to patients taking certain psychiatric medications. Available at http://www.fda.gov/Drugs/DrugSafety/ucm263190.htm. Accessed July 27, 2011.

  8. Becker S, Soukup JM. Effect of nitrogen dioxide on respiratory viral infection in airway epithelial cells. Envir Res. 1999;81(2):159-66. [Medline].

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  15. Mayorga MA. Overview of nitrogen dioxide effects on the lung with emphasis on military relevance. Toxicology. May 20 1994;89(3):175-92. [Medline].

  16. Papi A, Amadesi S, Chitano P, et al. Bronchopulmonary inflammation and airway smooth muscle hyperresponsiveness induced by nitrogen dioxide in guinea pigs. Eur J Pharmacol. Jun 18 1999;374(2):241-7. [Medline].

  17. Prutz WA, Monig H, Butler J, Land EJ. Reactions of nitrogen dioxide in aqueous model systems: oxidation of tyrosine units in peptides and proteins. Arch Biochem Biophys. Nov 15 1985;243(1):125-34. [Medline].

  18. Sagai M, Ichinose T. Lipid peroxidation and antioxidative protection mechanism in rat lungs upon acute and chronic exposure to nitrogen dioxide. Environ Health Perspect. Aug 1987;73:179-89. [Medline].

  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].

  20. Veeramachaneni NK, Harken AH, Cairns CB. Clinical implications of hemoglobin as a nitric oxide carrier. Arch Surg. Apr 1999;134(4):434-7. [Medline].

  21. Weller BL, Witschi H, Pinkerton KE. Quantitation and localization of pulmonary manganese superoxide dismutase and tumor necrosis factor alpha following exposure to ozone and nitrogen dioxide. Toxicol Sci. Apr 2000;54(2):452-61. [Medline].

  22. World Health Organization. Nitrogen oxides. In: Recommended Health-Based Occupation Exposure Limits for Respiratory Irritants. 1984:73-114.

 
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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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