Differential Diagnoses

Acute Respiratory Distress Syndrome (ARDS)
Ammonia Toxicity
Asthma
Chronic Obstructive Pulmonary Disease and Emphysema
Pediatric Acute Respiratory Distress Syndrome
Pulmonary Embolism (PE)
Smoke Inhalation Injury
Toxicity, Carbon Monoxide
Toxicity, Hydrogen Sulfide
Viral Pneumonia

Workup

Hedges JR, Morrissey WL. Acute chlorine gas exposure. JACEP. 1979 Feb. 8(2):59-63. [Medline].
Zaky A, Bradley WE, Lazrak A, Zafar I, Doran S, Ahmad A, et al. Chlorine inhalation-induced myocardial depression and failure. Physiol Rep. 2015 Jun. 3 (6):[Medline].
Hemström P, Larsson A, Elfsmark L, Åstot C. l-α-Phosphatidylglycerol Chlorohydrins as Potential Biomarkers for Chlorine Gas Exposure. Anal Chem. 2016 Oct 6. [Medline]. [Full Text].
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.
Department of Homeland Security/Federal Bureau of Investigation. April 23, 2008. Potential Terrorist Attack Methods. Available at http://www.gwu.edu/~nsarchiv/nukevault/ebb388/docs/EBB015.pdf. April 23, 2008; Accessed: May 31, 2018.
Padley AP. Gas: the greatest terror of the Great War. Anaesth Intensive Care. 2016 Jul. 44 Suppl:24-30. [Medline].
[Guideline] Centers for Disease Control and Prevention, Agency for Toxic Substances and Disease Registry. Medical Management Guidelines for Chlorine. ATSDR.cdc.gov. Available at http://www.atsdr.cdc.gov/MMG/MMG.asp?id=198&tid=36. October 14, 2018; Accessed: May 31, 2018.
Nelson GD. Chloramines and Bronamines. Kirk RE, Othmer DF, eds. Concise Encyclopedia of Chemical Technology. New York: John Wiley and Sons; 1985. 256.
Centers for Disease Control and Prevention. Ocular and respiratory illness associated with an indoor swimming pool--Nebraska, 2006. MMWR Morb Mortal Wkly Rep. 2007 Sep 14. 56(36):929-32. [Medline].
Schwartz DA. Acute inhalational injury. Occup Med. 1987 Apr-Jun. 2(2):297-318. [Medline].
Jones RN, Hughes JM, Glindmeyer H, Weill H. Lung function after acute chlorine exposure. Am Rev Respir Dis. 1986 Dec. 134(6):1190-5. [Medline].
Hayaishi O. Enzymatic hydroxylation. Am Rev Biochem. 1969. 38:21-44.
Barrow CS, Alarie Y, Warrick JC, Stock MF. Comparison of the sensory irritation response in mice to chlorine and hydrogen chloride. Arch Environ Health. 1977 Mar-Apr. 32(2):68-76. [Medline].
Henderson Y, Haggard HW. Noxious Gases and the Principles of Respiration Influencing Their Action. 2nd ed. New York: Rienhold Publishing Corp; 1943. 171-3.
Das R, Blanc PD. Chlorine gas exposure and the lung: a review. Toxicol Ind Health. 1993 May-Jun. 9(3):439-55. [Medline].
Adelson L, Kaufman J. Fatal chlorine poisoning: report of two cases with clinicopathologic correlation. Am J Clin Pathol. 1971 Oct. 56(4):430-42. [Medline].
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. 1983 Apr. 54(4):1120-4. [Medline].
D'Alessandro A, Kuschner W, Wong H, Boushey HA, Blanc PD. Exaggerated responses to chlorine inhalation among persons with nonspecific airway hyperreactivity. Chest. 1996 Feb. 109(2):331-7. [Medline].
Shusterman D, Murphy MA, Balmes J. Influence of age, gender, and allergy status on nasal reactivity to inhaled chlorine. Inhal Toxicol. 2003 Oct. 15(12):1179-89. [Medline].
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. 2008 Jul-Aug. 23(4):275-80. [Medline].
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].
Wood BR, Colombo JL, Benson BE. Chlorine inhalation toxicity from vapors generated by swimming pool chlorinator tablets. Pediatrics. 1987 Mar. 79(3):427-30. [Medline].
Gummin DD, Mowry JB, Spyker DA, Brooks DE, Osterthaler KM, Banner W. 2017 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 35th Annual Report. Clin Toxicol (Phila). 2018 Dec. 56 (12):1213-1415. [Medline]. [Full Text].
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. 2009 Jan. 27(1):1-7. [Medline].
Jones R, Wills B, Kang C. Chlorine gas: an evolving hazardous material threat and unconventional weapon. West J Emerg Med. 2010 May. 11(2):151-6. [Medline]. [Full Text].
Shroff CP, Khade MV, Srinivasan M. Respiratory cytopathology in chlorine gas toxicity: a study in 28 subjects. Diagn Cytopathol. 1988 Mar. 4(1):28-32. [Medline].
Clark KA, Karmaus WJ, Mohr LC, Cai B, Balte P, Gibson JJ, et al. Lung Function before and after a Large Chlorine Gas Release in Graniteville, South Carolina. Ann Am Thorac Soc. 2016 Mar. 13 (3):356-63. [Medline]. [Full Text].
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. 1994 Oct. 150(4):1142-5. [Medline].
Francis HC, Prys-Picard CO, Fishwick D, Stenton C, Burge PS, Bradshaw LM, et al. Defining and investigating occupational asthma: a consensus approach. Occup Environ Med. 2007 Jun. 64(6):361-5. [Medline]. [Full Text].
Brooks SM, Weiss MA, Bernstein IL. Reactive airways dysfunction syndrome (RADS). Persistent asthma syndrome after high level irritant exposures. Chest. 1985 Sep. 88(3):376-84. [Medline].
Ginsberg JP, Holbrook JR, Chanda D, Bao H, Svendsen ER. Posttraumatic stress and tendency to panic in the aftermath of the chlorine gas disaster in Graniteville, South Carolina. Soc Psychiatry Psychiatr Epidemiol. 2012 Sep. 47(9):1441-8. [Medline]. [Full Text].
Szerlip HM, Singer I. Hyperchloremic metabolic acidosis after chlorine inhalation. Am J Med. 1984 Sep. 77(3):581-2. [Medline].
Kaufman J, Burkons D. Clinical, roentgenologic, and physiologic effects of acute chlorine exposure. Arch Environ Health. 1971 Jul. 23(1):29-34. [Medline].
Department of Labor: Occupational Safety and Health Administration (OSHA). General description and discussion of the levels of protection and protective gear (1910.120, App B). Available at http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=9767. August 22, 1994; Accessed: May 31, 2018.
Baxter PJ, Davies PC, Murray V. Medical planning for toxic releases into the community: the example of chlorine gas. Br J Ind Med. 1989 Apr. 46(4):277-85. [Medline]. [Full Text].
O'Malley GF, Fasano C, Dominici P, Aguilera E. Eye irrigation is more comfortable with a lidocaine: containing irrigation solution compared with normal saline. J Trauma. 2008 May. 64(5):1360-2. [Medline].
Done AK. The toxic emergency, it's a gas. Emerg Med. 1976. 305-14.
Vinsel PJ. Treatment of acute chlorine gas inhalation with nebulized sodium bicarbonate. J Emerg Med. 1990 May-Jun. 8(3):327-9. [Medline].
Cevik Y, Onay M, Akmaz I, Sezigen S. Mass casualties from acute inhalation of chlorine gas. South Med J. 2009 Dec. 102(12):1209-13. [Medline].
Nelson LS. Simple asphyxiants and pulmonary irritants. Goldfrank LR, ed. Goldfrank's Toxicologic Emergencies. 6th ed. Stanford, Conn: Appleton & Lange; 1998. 1523-38.
Aslan S, Kandis H, Akgun M, Cakir Z, Inandi T, Görgüner M. The effect of nebulized NaHCO3 treatment on "RADS" due to chlorine gas inhalation. Inhal Toxicol. 2006 Oct. 18(11):895-900. [Medline].
Kramer CG. Chlorine. J Occup Med. 1967 Apr. 9(4):193-6. [Medline].
Chester EH, Kaimal J, Payne CB Jr, Kohn PM. Pulmonary injury following exposure to chlorine gas. Possible beneficial effects of steroid treatment. Chest. 1977 Aug. 72(2):247-50. [Medline].
Akdur O, Sozuer EM, Ikizceli I, Avsarogullari L, Ozturk F, Muhtaroglu S, et al. Experimental inhalation of chlorine gas produced with a different method; effects of N-acetyl cysteine on acute pulmonary damage. Toxicol Mech Methods. 2008 Jan. 18(9):739-43. [Medline].
Fanucchi MV, Bracher A, Doran SF, Squadrito GL, Fernandez S, Postlethwait EM, et al. Post-exposure antioxidant treatment in rats decreases airway hyperplasia and hyperreactivity due to chlorine inhalation. Am J Respir Cell Mol Biol. 2012 May. 46(5):599-606. [Medline]. [Full Text].
Summerhill EM, Hoyle GW, Jordt SE, Jugg BJ, Martin JG, Matalon S, et al. An Official American Thoracic Society Workshop Report: Chemical Inhalational Disasters. Biology of Lung Injury, Development of Novel Therapeutics, and Medical Preparedness. Ann Am Thorac Soc. 2017 Jun. 14 (6):1060-1072. [Medline]. [Full Text].
Neghab M, Amiri F, Soleimani E, Hosseini SY. The Effect of Exposure to Low Levels of Chlorine Gas on the Pulmonary Function and Symptoms in a Chloralkali Unit. J Res Health Sci. 2016 Winter. 16 (1):41-5. [Medline].
Department of Labor: Occupational Safety and Health Administration (OSHA). TABLE Z-1 Limits for Air Contaminants. Available at http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=9992. January 9, 2017; Accessed: May 31, 2018.

Media Gallery

Chest radiograph of a 36-year-old chemical worker 2 hours postexposure to chlorine inhalant. She had severe resting dyspnea during the second hour, diffuse crackles/rhonchi on auscultation, and a partial pressure of oxygen of 32 mm Hg breathing room air. The radiograph shows diffuse pulmonary edema without significant cardiomegaly. Used with permission from Medical Aspects of Chemical and Biological Warfare, Textbook of Military Medicine. 1997: 256.
A section from a lung biopsy (hematoxylin and eosin stain; original magnification X 100) from a 36-year-old chemical worker taken 6 weeks postexposure to chlorine. At that time, the patient had no clinical abnormalities and a partial pressure of oxygen of 80 mm Hg breathing room air. The section shows normal lung tissues without evidence of interstitial fibrosis and/or inflammation. Used with permission from Medical Aspects of Chemical and Biological Warfare, Textbook of Military Medicine. 1997: 256.

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Author

Gerald F O'Malley, DO Clinical Associate Professor of Emergency Medicine, Albert Einstein Medical Center

Gerald F O'Malley, DO is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, American College of Osteopathic Emergency Physicians, American Osteopathic Association, Society for Academic Emergency Medicine

Disclosure: Received consulting fee from McNeil Pharmaceuticals for speaking and teaching.

Coauthor(s)

Robert Bassett, DO, FAAEM Fellow in Medical Toxicology, Department of Emergency Medicine, Einstein Medical Center; Clinical Assistant Professor of Emergency Medicine, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Robert Bassett, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

William J Boroughf, DO Fellow in Medical Toxicology, Attending Physician, Department of Emergency Medicine, Einstein Medical Center

William J Boroughf, DO is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology

Disclosure: Nothing to disclose.

Chief Editor

Zygmunt F Dembek, PhD, MPH, MS, LHD Associate Professor, Department of Military and Emergency Medicine, Adjunct Assistant Professor, Department of Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine

Zygmunt F Dembek, PhD, MPH, MS, LHD is a member of the following medical societies: American Chemical Society, New York Academy of Sciences

Disclosure: Nothing to disclose.

Acknowledgements

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

John G Benitez, MD, MPH 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