eMedicine Specialties > Emergency Medicine > Warfare - Chemical, Biological, Radiological, Nuclear and Explosives

CBRNE - Lung-Damaging Agents, Phosgene: Differential Diagnoses & Workup

Author: Joy C Wethern, DO, Resident Physician PGY3, Department of Emergency Medicine, Carl R Darnall Army Medical Center, Ft Hood, Texas
Coauthor(s): Kermit D Huebner, MD, FACEP, Research Director, Carl R Darnall Army Medical Center
Contributor Information and Disclosures

Updated: May 27, 2009

Differential Diagnoses

Acute Respiratory Distress Syndrome
Pediatrics, Respiratory Distress Syndrome
Altitude Illness - Pulmonary Syndromes
Pericarditis and Cardiac Tamponade
Anaphylaxis
Pneumonia, Aspiration
Anxiety
Pneumonia, Bacterial
Asthma
Pneumonia, Immunocompromised
Bronchitis
Pneumonia, Mycoplasma
CBRNE - Lung-Damaging Agents, Chlorine
Pneumonia, Viral
CBRNE - Lung-Damaging Agents, Chloropicrin
Pneumothorax, Iatrogenic, Spontaneous and Pneumomediastinum
CBRNE - Lung-Damaging Agents, Diphosgene
Pneumothorax, Tension and Traumatic
CBRNE - Lung-Damaging Agents, Toxic Smokes: Nox, Hc, Rp, Fs, Fm, Sgf2, Teflon
Pulmonary Embolism
Hyperventilation Syndrome
Respiratory Distress Syndrome, Adult
Pediatrics, Bronchiolitis
Smoke Inhalation
Pediatrics, Croup or Laryngotracheobronchitis
Toxicity, Ammonia
Pediatrics, Epiglottitis
Toxicity, Chlorine Gas
Pediatrics, Pneumonia
Pediatrics, Reactive Airway Disease

Workup

Laboratory Studies

  • No combinations of laboratory or radiographic studies have been shown to discriminate reliably, which asymptomatic (latent phase) patients exposed to phosgene will develop life-threatening pulmonary edema.
  • Pulse oximetry measurements remain normal during the latent phase, but it is useful for following progression over several hours of observation. Increase triage priority and level of intervention if oxygen saturation begins to decline, as hypoxemia heralds onset of pulmonary edema.
  • Arterial blood gas measurements are normal during the latent phase but are useful for following progression of manifest illness after the onset of pulmonary edema. Also, arterial blood gas measurements may be useful for making adjustments in respiratory care therapy (ventilator settings). Acidosis typically occurs, initially as a respiratory acidosis, but later becomes a mixed acidosis due to anaerobic metabolism in the wake of profound tissue hypoxia.
  • CBC may reflect hemoconcentration due to third spacing of fluid into lungs once pulmonary edema has occurred, but this test is of little value prognostically.
  • A 2009 study noted that levels of secreted phospholipase A2 (sPLA-IIA) found on bronchial alveolar lavage increased markedly after phosgene exposure, peaking at 6 hours, and correlated well with severity of lung injury in the study population. While not specific for phosgene exposure, measurement of sPLA-IIA in bronchial lavage is a potential future measurement for the progression of lung injury from phosgene exposure.4

Imaging Studies

  • Chest radiograph
    • In patients without preexisting cardiac disease, the heart silhouette should be normal.
    • Chest radiograph may help exclude other possibilities in the differential diagnosis (pneumothorax, pneumonia, hemothorax, pleural effusion).
    • Early changes after phosgene exposure include hyperinflation and hilar enlargement.
    • Later changes are typical for noncardiogenic pulmonary edema: fluffy "batwing" perihilar interstitial infiltrates.
    • Radiographic findings may evolve rapidly over the first few hours after phosgene exposure and clear over several days as clinical improvement occurs.
    • Using a low-energy exposure technique (50-80 kV) may facilitate early identification of evolving pulmonary edema (as early as halfway through the latent period).


Anteroposterior portable chest radiograph in a ma...

Anteroposterior portable chest radiograph in a male patient who developed phosgene-induced adult respiratory distress syndrome. Notice the bilateral infiltrates and ground-glass appearance Image courtesy of Fred P. Harchelroad, MD, and Ferdinando L. Mirarchi, DO.

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Anteroposterior portable chest radiograph in a ma...

Anteroposterior portable chest radiograph in a male patient who developed phosgene-induced adult respiratory distress syndrome. Notice the bilateral infiltrates and ground-glass appearance Image courtesy of Fred P. Harchelroad, MD, and Ferdinando L. Mirarchi, DO.

More on CBRNE - Lung-Damaging Agents, Phosgene

Overview: CBRNE - Lung-Damaging Agents, Phosgene
Differential Diagnoses & Workup: CBRNE - Lung-Damaging Agents, Phosgene
Treatment & Medication: CBRNE - Lung-Damaging Agents, Phosgene
Follow-up: CBRNE - Lung-Damaging Agents, Phosgene
Multimedia: CBRNE - Lung-Damaging Agents, Phosgene
References
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References

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  3. Qin XJ, Li YN, Liang X, Wang P, Hai CX. The dysfunction of ATPases due to impaired mitochondrial respiration in phosgene-induced pulmonary edema. Biochem Biophys Res Commun. Feb 29 2008;367(1):150-5. [Medline].

  4. Chen HL, Hai CX, Liang X, Zhang XD, Liu R, Qin XJ. Correlation between sPLA2-IIA and phosgene-induced rat acute lung injury. Inhal Toxicol. Feb 2009;21(4):374-80. [Medline].

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Further Reading

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Keywords

phosgene, phosgene exposure, treatment, symptoms, causes, chemical weapon, CG, COCl2, carbonyl chloride, WMD, weapons of mass destruction, chemical warfare, noncardiogenic pulmonary edema, toxic inhalation, lung-damaging agents, irritant pulmonary toxin, frostbite injuries

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Contributor Information and Disclosures

Author

Joy C Wethern, DO, Resident Physician PGY3, Department of Emergency Medicine, Carl R Darnall Army Medical Center, Ft Hood, Texas
Joy C Wethern, DO is a member of the following medical societies: American College of Emergency Physicians and American Osteopathic Association
Disclosure: Nothing to disclose.

Coauthor(s)

Kermit D Huebner, MD, FACEP, Research Director, Carl R Darnall Army Medical Center
Kermit D Huebner, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, Association of Military Surgeons of the US, Society for Academic Emergency Medicine, and Society of USAF Flight Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Mark Keim, MD, Senior Science Advisor, Office of the Director, National Center for Environmental Health, Centers for Disease Control and Prevention
Mark Keim, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, 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, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

CME Editor

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

Robert G Darling, MD, FACEP, Clinical Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine; Associate Director, Center for Disaster and Humanitarian Assistance Medicine
Robert G Darling, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, and Association of Military Surgeons of the US
Disclosure: Nothing to disclose.

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