Toxicity, Chlorine Gas Follow-up

  • Author: Eli Segal, MD, CM, FRCP; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Jan 11, 2010
 

Further Inpatient Care

  • Consider hospitalization to observe and treat the patient with chlorine gas exposure in a highly monitored setting in any of the following cases:
    • Symptoms persist after 6 hours.
    • Patient was severely exposed.
    • Child was exposed.
    • Patient has a history of underlying respiratory or cardiovascular disease.
  • Some authors suggest observation for a minimum of 24 hours because pulmonary edema may occur for 24 hours after exposure. Pulmonary edema occasionally may induce severe hypoxemia in minutes.
  • Patients who are asymptomatic 24 hours after exposure may be discharged from hospital.[35]
  • For a severe reaction, follow up with a pulmonologist.
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Further Outpatient Care

  • No hospitalization is required for mild chlorine exposure or for patients who remain asymptomatic.
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Transfer

  • Transfer, as necessary, if local resources (eg, critical care, toxicologist, pulmonologist) are not available.
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Deterrence/Prevention

  • Deterrence may decrease the number of accidental exposures to chlorine gas. Proper descriptions on swimming pool chlorinator solutions with detailed warnings to avoid mixing solutions would prevent a great number of accidents.
  • As accidental occupational exposures to chlorine gas comprise a significant percentage of severe exposures, proper methods of training and supervision are beneficial. Proper enforcement of regulations covering these work situations should be helpful.
  • Long-term exposure to smaller amounts of chlorine gas may contribute to pulmonary disease.
  • The current US legal limit for occupational exposure to chlorine gas enforceable by the Occupational Safety and Health Administration (OSHA) is 0.5 ppm averaged over an 8-hour day, not to exceed 1.0 ppm for more than 15 minutes at a time.[36]
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Complications

  • Short-term effects of acute exposures of chlorine gas
    • Smokers and those with asthma are most likely to demonstrate persistence of obstructive pulmonary defects.[3]
    • Within 3-5 days, after the sloughing off of the mucosa, oozing areas become covered with mucopurulent exudate. This can result in chemical pneumonitis, often complicated by secondary bacterial invasion.
  • Residual effects following acute exposures of chlorine gas
    • Long-term follow-up studies of acute human exposures to chlorine gas provide conflicting data on the potential for long-term adverse effects from short-term chlorine exposure.
    • In one study, after 2 years of follow-up, research subjects displayed decreased vital capacity, diffusing capacity, and total lung capacity with a trend towards higher airway resistance.[37] This suggests that persistent dose-related lung function deficits may occur following acute chlorine gas exposure.
    • Other studies demonstrated no consistent pattern of pulmonary function deficits following acute exposure.[38, 26, 39, 40]
    • Jones et al found that long-term sequelae after acute chlorine gas exposure were more affected by cigarette smoking than by the chlorine gas exposure.[3]
    • Although no definite conclusion can be drawn concerning the long-term effects of an acute chlorine gas exposure, findings point to an increased nonspecific airway responsiveness that may persist. Following an acute exposure, some patients displayed eventual repair of injured pulmonary epithelium with fibrosis.[41]Bronchiolitis obliterans and emphysema have been described in patients following acute exposures.
  • Reactive airway dysfunction syndrome (RADS), or irritant-induced asthma, is a variant of occupational asthma that occurs in individuals who are acutely exposed to high concentrations of an irritant product and develop respiratory symptoms in the minutes or hours that follow. They develop persistent bronchial hyperresponsiveness after the inhalational incident.[42] A similar pathology may occur with repeated exposures.[43]
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Prognosis

  • Resolution of pulmonary abnormalities in most individuals occurs over the course of one week to one month following exposure.
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Patient Education

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Contributor Information and Disclosures
Author

Eli Segal, MD, CM, FRCP  Assistant Professor, Department of Family Medicine, McGill University; Attending Physician, Department of Emergency Medicine, Jewish General Hospital

Eli Segal, MD, CM, FRCP, is a member of the following medical societies: American College of Emergency Physicians and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Coauthor(s)

Eddy S Lang, MDCM, CCFP(EM), CSPQ  Associate Professor, Senior Researcher, Division of Emergency Medicine, Department of Family Medicine, University of Calgary; Assistant Professor, Department of Family Medicine, McGill University

Eddy S Lang, MDCM, CCFP(EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians, Canadian Association of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Peter MC DeBlieux, MD  Professor of Clinical Medicine and Pediatrics, Section of Pulmonary and Critical Care Medicine, Program Director, Department of Emergency Medicine, Louisiana State University School of Medicine in New Orleans

Peter MC DeBlieux, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Radiological Society of North America, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart & 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.

John G Benitez, MD, MPH, FACMT, FAACT, FACPM, FAAEM,  Associate Professor, Department of Medicine, Medical Toxicology, Vanderbilt University Medical Center; Managing Director, Tennessee Poison Center

John G Benitez, MD, MPH, FACMT, FAACT, FACPM, FAAEM, is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, and Wilderness Medical Society

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

  1. Gilchrist HL, Matz PB. The residual effects of warfare gases: the use of chlorine gas, with report of cases. Med Bull Vet Adminis. 1933;9:229-270.

  2. Schwartz DA. Acute inhalational injury. Occup Med. Apr-Jun 1987;2(2):297-318. [Medline].

  3. Jones RN, Hughes JM, Glindmeyer H, Weill H. Lung function after acute chlorine exposure. Am Rev Respir Dis. Dec 1986;134(6):1190-5. [Medline].

  4. Hayaishi O. Enzymatic hydroxylation. Am Rev Biochem. 1969;38:21-44.

  5. Barrow CS, Alarie Y, Warrick JC, Stock MF. Comparison of the sensory irritation response in mice to chlorine and hydrogen chloride. Arch Environ Health. Mar-Apr 1977;32(2):68-76. [Medline].

  6. Henderson Y, Haggard HW. Noxious Gases and the Principles of Respiration Influencing Their Action. 2nd ed. New York: Rienhold Publishing Corp; 1943:171-3.

  7. Das R, Blanc PD. Chlorine gas exposure and the lung: a review. Toxicol Ind Health. May-Jun 1993;9(3):439-55. [Medline].

  8. Nelson GD. Chloramines and Bronamines. In: Kirk RE, Othmer DF, eds. Concise Encyclopedia of Chemical Technology. New York: John Wiley and Sons; 1985:256.

  9. Hedges JR, Morrissey WL. Acute chlorine gas exposure. JACEP. Feb 1979;8(2):59-63. [Medline].

  10. Adelson L, Kaufman J. Fatal chlorine poisoning: report of two cases with clinicopathologic correlation. Am J Clin Pathol. Oct 1971;56(4):430-42. [Medline].

  11. Rotman HH, Fliegelman MJ, Moore T, Smith RG, Anglen DM, Kowalski CJ, et al. Effects of low concentrations of chlorine on pulmonary function in humans. J Appl Physiol. Apr 1983;54(4):1120-4. [Medline].

  12. D'Alessandro A, Kuschner W, Wong H, et al. Exaggerated responses to chlorine inhalation among persons with nonspecific airway hyperreactivity. Chest. Feb 1996;109(2):331-7. [Medline].

  13. Shusterman D, Murphy MA, Balmes J. Influence of age, gender, and allergy status on nasal reactivity to inhaled chlorine. Inhal Toxicol. Oct 2003;15(12):1179-89. [Medline].

  14. National Institute for Occupational Health and Safety. National occupational exposure survey (1981-83). Unpublished provisional data; Cincinnati, Ohio: U.S. Department of Health and Human Services; NIOSH Division of Surveillance, Hazard Evaluation and Field Studies, Surveillance Branch, Hazard Division.

  15. Blanc PD, Galbo M, Hiatt P, Olson KR. Morbidity following acute irritant inhalation in a population based study. JAMA. 1991;266:664-9. [Medline].

  16. Davis DS, Dewolf GB, Ferland KA, et al. Accidental Release of Air Toxins. Park Ridge, New Jersey: NDC; 1989:6-9.

  17. Litovitz TL, Schmitz BF, Holm KC. 1988 annual report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med. Sep 1989;7(5):495-545. [Medline].

  18. Litovitz TL, Schmitz BF, Bailey KM. 1989 annual report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med. Sep 1990;8(5):394-442. [Medline].

  19. Litovitz TL, Bailey KM, Schmitz BF, Holm KC, Klein-Schwartz W. 1990 annual report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med. Sep 1991;9(5):461-509. [Medline].

  20. Litovitz TL, Holm KC, Bailey KM, Schmitz BF. 1991 annual report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med. Sep 1992;10(5):452-505. [Medline].

  21. Litovitz TL, Holm KC, Clancy C, Schmitz BF, Clark LR, Oderda GM. 1992 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 1993;11(5):494-555. [Medline].

  22. Gapany-Gapanavicius M, Yellin A, Almog S, Tirosh M. Pneumomediastinum. A complication of chlorine exposure from mixing household cleaning agents. JAMA. Jul 16 1982;248(3):349-50. [Medline].

  23. Babu RV, Cardenas V, Sharma G. Acute respiratory distress syndrome from chlorine inhalation during a swimming pool accident: a case report and review of the literature. J Intensive Care Med. Jul-Aug 2008;23(4):275-80. [Medline].

  24. Szerlip HM, Singer I. Hyperchloremic metabolic acidosis after chlorine inhalation. Am J Med. Sep 1984;77(3):581-2. [Medline].

  25. Van Sickle D, Wenck MA, Belflower A, Drociuk D, Ferdinands J, Holguin F, et al. Acute health effects after exposure to chlorine gas released after a train derailment. Am J Emerg Med. Jan 2009;27(1):1-7. [Medline].

  26. Kaufman J, Burkons D. Clinical, roentgenologic, and physiologic effects of acute chlorine exposure. Arch Environ Health. Jul 1971;23(1):29-34. [Medline].

  27. Martinez TT, Long C. Explosion risk from swimming pool chlorinators and review of chlorine toxicity. J Toxicol Clin Toxicol. 1995;33(4):349-54. [Medline].

  28. Done AK. The toxic emergency, it's a gas. Emerg Med. 1976;305-14.

  29. Vinsel PJ. Treatment of acute chlorine gas inhalation with nebulized sodium bicarbonate. J Emerg Med. May-Jun 1990;8(3):327-9. [Medline].

  30. Nelson LS. Simple asphyxiants and pulmonary irritants. In: Goldfrank LR, ed. Goldfrank's Toxicologic Emergencies. 6th ed. Stanford, Conn: Appleton & Lange; 1998:1523-38.

  31. Wood BR, Colombo JL, Benson BE. Chlorine inhalation toxicity from vapors generated by swimming pool chlorinator tablets. Pediatrics. Mar 1987;79(3):427-30. [Medline].

  32. Aslan S, Kandis H, Akgun M, et al. The effect of nebulized NaHCO3 treatment on "RADS" due to chlorine gas inhalation. Inhal Toxicol. Oct 2006;18(11):895-900. [Medline].

  33. Kramer CG. Chlorine. J Occup Med. Apr 1967;9(4):193-6. [Medline].

  34. Chester EH, Kaimal J, Payne CB Jr, Kohn PM. Pulmonary injury following exposure to chlorine gas. Possible beneficial effects of steroid treatment. Chest. Aug 1977;72(2):247-50. [Medline].

  35. Baxter PJ, Davies PC, Murray V. Medical planning for toxic releases into the community: the example of chlorine gas. Br J Ind Med. Apr 1989;46(4):277-85. [Medline].

  36. Occupational Safety and Health Administration. Air contaminants-Permissible exposure limits. Title 29 Code of Federal Regulations, Part 1910.1000. U.S. Department of Labor, OSHA 3112. 1989.

  37. Kowitz TA, Reba RC, Parker RT, Spicer WS Jr. Effects of chlorine gas upon respiratory function. Arch Environ Health. Apr 1967;14(4):545-58. [Medline].

  38. Weill H, George R, Schwarz M, Ziskind M. Late evaluation of pulmonary function after acute exposure to chlorine gas. Am Rev Respir Dis. Mar 1969;99(3):374-9. [Medline].

  39. Jones AT. Noxious gases and fumes. Proc R Soc Med. Sep 1952;45(9):609-10. [Medline].

  40. Lawson JJ. Chlorine exposure: a challenge to the physician. Am Fam Physician. Jan 1981;23(1):135-8. [Medline].

  41. Shroff CP, Khade MV, Srinivasan M. Respiratory cytopathology in chlorine gas toxicity: a study in 28 subjects. Diagn Cytopathol. Mar 1988;4(1):28-32. [Medline].

  42. Brooks SM, Weiss MA, Bernstein IL. Reactive airways dysfunction syndrome (RADS). Persistent asthma syndrome after high level irritant exposures. Chest. Sep 1985;88(3):376-84. [Medline].

  43. Malo JL, Cartier A, Boulet LP, L'Archeveque J, Saint-Denis F, Bherer L, et al. Bronchial hyperresponsiveness can improve while spirometry plateaus two to three years after repeated exposure to chlorine causing respiratory symptoms. Am J Respir Crit Care Med. Oct 1994;150(4):1142-5. [Medline].

  44. Academy of Health Sciences, US Army. First aid in toxic environments. In: First Aid for Soldiers, Virtual Naval Hospital. Available at: http://www.vnh.org/FirstAidForSoldiers/fm2111.html. Accessed November 8, 2004; 1988.

  45. Bosse GM. Nebulized sodium bicarbonate in the treatment of chlorine gas inhalation. J Toxicol Clin Toxicol. 1994;32(3):233-41. [Medline].

  46. Chisholm CD, Singleton EM, Okerberg CV. Inhaled sodium bicarbonate therapy for chlorine inhalation injuries. Ann Emerg Med. 1989;18:466.

  47. Douidar SM. Nebulized sodium bicarbonate in acute chlorine inhalation. Pediatr Emerg Care. Dec 1997;13(6):406-7. [Medline].

  48. Gorguner M, Aslan S, Inandi T, Cakir Z. Reactive airways dysfunction syndrome in housewives due to a bleach-hydrochloric acid mixture. Inhal Toxicol. Feb 2004;16(2):87-91. [Medline].

  49. Guloglu C, Kara IH, Erten PG. Acute accidental exposure to chlorine gas in the Southeast of Turkey: a study of 106 cases. Environ Res. Feb 2002;88(2):89-93. [Medline].

  50. Gunnarsson M, Walther SM, Seidal T, Lennquist S. Effects of inhalation of corticosteroids immediately after experimental chlorine gas lung injury. J Trauma. Jan 2000;48(1):101-7. [Medline].

  51. Heidemann SM, Goetting MG. Treatment of acute hypoxemic respiratory failure caused by chlorine exposure. Pediatr Emerg Care. Apr 1991;7(2):87-8. [Medline].

  52. Horton DK, Berkowitz Z, Kaye WE. The public health consequences from acute chlorine releases, 1993-2000. J Occup Environ Med. Oct 2002;44(10):906-13. [Medline].

  53. Karellas NS, Chen QF, De Brou GB, Milburn RK. Real time air monitoring of hydrogen chloride and chlorine gas during a chemical fire. J Hazard Mater. Aug 15 2003;102(1):105-20. [Medline].

  54. Parimon T, Kanne JP, Pierson DJ. Acute inhalation injury with evidence of diffuse bronchiolitis following chlorine gas exposure at a swimming pool. Respir Care. Mar 2004;49(3):291-4. [Medline].

  55. Patil LR, Smith RG, Vorwald AJ, Mooney TF Jr. The health of diaphragm cell workers exposed to chlorine. Am Ind Hyg Assoc J. Nov-Dec 1970;31(6):678-86. [Medline].

  56. Pereira WE, Hoyano Y, Summons RE, Bacon VA, Duffield AM. Chlorination studies. II. The reaction of aqueous hypochlorous acid with alpha-amino acids and dipeptides. Biochim Biophys Acta. Jun 20 1973;313(1):170-80. [Medline].

  57. Roberge RJ, Martin TP. Relief of cough. Postgrad Med. 1997;101:46.

  58. Sexton JD, Pronchik DJ. Chlorine inhalation: the big picture. J Toxicol Clin Toxicol. 1998;36(1-2):87-93. [Medline].

  59. Shusterman D, Balmes J, Avila PC, et al. Chlorine inhalation produces nasal congestion in allergic rhinitics without mast cell degranulation. Eur Respir J. Apr 2003;21(4):652-7. [Medline].

  60. Tarlo SM, Broder I. Irritant-induced occupational asthma. Chest. Aug 1989;96(2):297-300. [Medline].

  61. Traub SJ, Hoffman RS, Nelson LS. Case report and literature review of chlorine gas toxicity. Vet Hum Toxicol. Aug 2002;44(4):235-9. [Medline].

  62. United States Army Medical Research Institute of Chemical Defense. Introduction, pulmonary agents. In: Medical Management of Chemical Casualties Handbook. 3rd ed.

  63. Wang J, Abu-Zidan FM, Walther SM. Effects of prone and supine posture on cardiopulmonary function after experimental chlorine gas lung injury. Acta Anaesthesiol Scand. Oct 2002;46(9):1094-102. [Medline].

  64. Wang J, Zhang L, Walther SM. Administration of aerosolized terbutaline and budesonide reduces chlorine gas-induced acute lung injury. J Trauma. Apr 2004;56(4):850-62. [Medline].

  65. Wang J, Zhang L, Walther SM. Inhaled budesonide in experimental chlorine gas lung injury: influence of time interval between injury and treatment. Intensive Care Med. Mar 2002;28(3):352-7. [Medline].

 
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