The Pulmonary Sequelae Associated
with
Accidental Inhalation of Chlorine Gas*
David
A. Schwartz,
Sambasiva
M.D.
Twenty
subject
exposed
occasions
was
of a low
volume
accidentally
12 years.
years
gas
can
interstitial
cause
tract
can
quantity,
On average,
and
high
Over
13 of the
20
due
to) progressive
have
been
animals
experimentally
exposed
if
the
rapid
exposed
chlorine
gas
during
World
the
editorial
comment
see
page
ual
I,
among
individuals
noxious
gas.
chlorine
is
The
‘“
acute
and
by
is thought
oxygen
injury
extensive
to be
radicals
to
and
induced
by
epithelial
mediated
generated
by
the
the
acute
manifestations
subjects
high-dose
single
mnented,
exposure
the long-tern
(11) studies
o)fVok)rld
that
o)fthe
l’
tiian’
asthnia,
(lata
‘ear
bronchitis,
after
to) stiggest
(leveloping
effects
\Var
survivo)rs
rt’ports’#{176}#{176}’’’’’t1iat
one
that
been
reniain
gas
The
were
subse(luentlv
tip individuals
filloved
these
eXpO)stlre,
in(lividuals
m’t’s)iI’atory
this
docu-
may
had
We
were
investigated
six
at risk
fromn
1)isvaso
I)ivision,
University
of loeva,
these
follow-up
for
report
the occurrence
shortly
was
of residual
volume
with
value
have
the
inhala-
followed
six
by a
of the
volume
two
is particularly
years
after
the
since
reported
in
concentrations
11
below
interesting
been
to high
of airflow
after
a residual
predicted
individ-
earlier
however,
the
l)een
of
their
other
of chlorine
consequences
the
to chlorine
these
association
to) high
Pulmonary
On
woorkers
accident
were
this
toook
17,
I)iace
197.5,
to) high
at
a
from
Inhalation
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21610/ on 06/18/2017
we
(within
24
higher
long-
risk
group
postexposure
series
represents
for
chlorine
persons
gas.
lOI)S
Cloaraeteri.s’ties
20
pres’ioumsly
Wilile
the
healthy
comistrimction
o)f chlorine
c(oncemltratio)ns
I)m011) fllill
of Chlorine
a high
adverse
l)erio(l
of
ooff-loaoledf’ronld railroad car otmtside
Sequelae
case
concentrations
exposed
had
i mnn)e(liate
folhw-up
070(1 I’Xp0507’(’
Decemuher
persistent
In addition,
and
ifa
the
ME’I’I
Population
earlier.
if the
a
early
findings
knowledge,
reported
12 years
individuals
l)etWeen
in
exposure
of workers
was
to) determine
Iosva
Stmulq
gas
airxvays.
o)I)jective
Vt) our
longest
gas
in determining
volume
whether
ideuitified
to determine
in a cohort
interested
hyperreactive
the
be
function
residual
also
O)f
was
of chlorine
lung
exposed
term
setting.
investigation
particularly
ofexposure)
Cotil(l
( itv (I)r. So’iosvartz);
tiso’ l)ivisiomo
of Pulmiomoarv
Diseases
amid
( ritio’al
( ,oi’(’. t1m,iersit
oof \Lsilimogtoon
(I)rs.
Sm1litil
an(I Lakshmuimooro’amo); aml(1 Seattle
Veteramis
Adnlinistratioml
I Ioosl)itdl
(I)m’.
I.aksiumuinaravan).
Seattle.
Nlamlmls(-ril)t
roceiveol
Jmmno 22; ro’visio)mI d(l’t’1)t0ol
Auguist
S.
Reprint
re(ju(’sts:
!)r. Selmmcartz,
tnirersiti,
of lomt’a C3.3 GH, Iomva
(:it,1 .52242
820
97:820-25)
prognosis
An
of
following
1990;
This,
o)f this
hours
exposed
*Fro)mll tho’ PImlm110)narv
air
airways
observed
from
consequences
and
disabled
the
was
(Chest
trapping
low
prevalemice
for at least
be
who
finding
0)111%’ t\x0)#{176}t’ 1)mo)\’ide
1)r0)l)lt’I1s
purpose
long-term
indicate
Of
that
reactive
gassings.
volumes
abnormally
Follow-
victims
and
and
development
of
air
exposed
by reevaluating
unclear.
I chlorine
0.004)
0.03)
to the
optimistic
finding
residual
hydration
well
amid emnphvsemna.5.m2
aCCi(lemital
ChrO)IliC
have
led
presence
results
their
O)f
the
with
(p
(>15
Those
following
the exposure.
to high concentrations
of
demonstrating
This
by highly
associated
13 subjects
gas.3’6
cell
o)f chlorine.2
While
of
gas.
loss
individuals
this
(p
documented
of chlorine
exposure.
exposed
cytotoxic
manifested
sloughing”
reactive
accidentally
older
chlorine
group2
our
study
773
the
a very
of acute
pro)gressive
sol-
were
exposure
Otherwise,
cases
low
and
five
obstruction
immediately
that exposure
or
provide
80 percent
For
that
airways
accounted
for the air trapping
the exposure
to chlorine
gas.
tion
War
found
airflow
chlorine
obstruction
These
gas,7
reactive
reactivity
from
in laboratory
to chlorine
also
chlorine
gas may result in long-term
pulmonary
complications that are characterized
by a reduced
residual
volume.
Unfortunately,
these
data
preclude
us from
determining
studies
of
failure.I,16
with
marked
more
exposures.
sufficient
edema,3#{176}’ and
to) occur
individuals
airway
to) the
in
We
had
whether
the
development
respiratory
documented
to
injury
inhaled
ptmhnonary
‘ .2
during
value.
trapping
(p = 0.03)
These
data suggest
prevalence
of
the ensuing
increased
immediate
in
1)neumonia,
changes
and
tested
at year 12 had an increase
in airway
reactivity
percent
decline
in FEy)
to inhaled
methacholine.
at year 12, 67 percent
of
below 80 percent
of their
and,
result
F.C.C.?;
,
predicted
following
the expoone day following
consistently
(p<O.OOL)
and
residual
volumes
re5)iratory
diers
the next
up for 8.5
most notable
for the
and air trapping.
residual
hlorine
death
M.D.
airflow
obstruction
persisted;
however,
the high
ofair trapping
resolved.
Ofnote,
the prevalence
follow-up
period
those tested had
C
were
tested
12 years
function
tests obtained
Pulmonary
Smith,
D.
of chlorine
gas in 1975.
performed
on these individ-
were
the accident
were
airflow
obstruction
years,
the
prevalence
over
followed
persons
sure.
individuals
to high concentrations
function
tests were
uals on several
Dorsett
Al. D. , F. C. C. P
healthy
previously
exposed
Pulmonary
each
, MPH.;
Liikslinzinarayan,
liojuid
chlorine
i)mmilding
Gas (Schwartz,
Smith,
gas.
was
to a hoddimig
Lakshmiroara
The
being
tank
yen)
Table
1 -Clinical
the
Characteristics*
ofExposed
Workers
ofExposure
by Length
of Follow-up
Time
at
and
the
onset
dosimeter
(ie,
diluent
Follow-up
Time,
yr
All Workers
(N=20)
Age
at exposure,
Smoking
37.8±9.5
yr
history,
12(N=13)
<12(N=7)
39.4±
10.3
7.5
(%)
No.
Never
2 (10)
1 (8)
1 (14)
Ex
4 (20)
3 (23)
1 (14)
14 (70)
9 (69)
5 (71)
Current
Day
1 CXR,
No.
Day
5 (25)
3 (23)
FEVNC
ratio
VC
81.3±21.9
82.4±25.7
68.8±
11.3
69. 1
18.2
96.9±
96.3
±
79.2±
68.3±
95. 1
RV
139.4±43.6
147.6±50.3
124.0±23.3
106.7±19.4
109.6±22.7
101.1±10.3
FRC
107.1
110.8
19.9
19.9
±
test
equal
to
1 mg/mI
variables
categonc
are
variables
expressed
are expressed
the
baseline
by the
Statistical
Anal
as
the
mean
19.5
SD
±
baseline
coompletion
breath
unit
measures
interval
between
had
reached,
the
concentration
in FEy,
FEy,
is
woro’
mnethacholine
i)eeml
At each
premethacholimle
o)f
obtained
abbreviated
the
(one
fall iou FEy,
ofcilange
to diluent)
lowest
at
Spirometric
termimlated.
percentage
exposure
divided
was
the
methacholine
in the
methachooline
five-minute
a 20 percent
was
too this,
of methacholine
units
challenge
lowest
A
100.3±
as the frequency
the
Whemi
following
of
s after
a solutiorn
spirometry
as outlined
oof methacholine).
during
test
0)1
calcumlato’d
was
(either
as
ha.selino’
mimlus
the
postmethacholimie
FEy,,
and
all multiplied
oor
FE’O.
by
1(X).
yin
with
used
to test
while
Students
Yates’
coorrectio)n
differences
in the
two-tailed
too coompare
*Continumous
inhalation
150 breath
was
inhaled
Subsequent
doses
for 0.6
first
and
inhalatiorn.
tootal
solution
11.3
±
TLC
±
o)f the
the
9.8
12.4
21.4
±
in increasing
The
the
subject
solution)
this
methacholine,
13.4
saline
administered
methachoiine
1 PFTst
FEV,
each
was
inhalations.
2 (29)
to deliver
at 180 5 following
o)btained
(%)
Infiltrates
set
Briefly,
buffered
pr(oto)col.’
34.8±
was
0)f inhalation.
factor
t test
continuous
and
a Fisher
prevalence
and
exact
test
of categoric
analysis
were
variai)les,
of variance
were
use(l
varlai)les!’
while
(percent
of total
RESULTS
sui)jects).
Of
tPFTs:
individual
measures
ofpulmonary
functioon
are all expressed
as percent
predicted
except
for the FEV,/VC
ratioo.
in the
the
pulp
mill.
The
holding
tank
became
chlorine
flexible
collected
under
was
temperature
gas rose
along
outer
cloud
were
actively
working
were
exposed
to chlorine
were
However,
infiltrates
local
Pulmonary
Pulmonary
within
days,
treated
with
tests
were
(Dco).
standard
were
values
and Becklake’
gas.
used.
who
were
A dosimeter
The
sui)jects
the
two)
workers
problems.
20
had
were
were
orne
too a
period
sented
workers
years,
of
Table
1 . At
ranging
from
were
exposure
and
trates.
the
and
seven
testing
individuals
(Table
1).
2 and
volumes
were
3 show
during
the
had
of 37.8
workers
time
an
(70
of
initial
the
chest
infil12 years
representative
differ
of
significantly
not
the
change
12-year
prethe
age
reexamined
were
the
are
pulmonary
were
not
who
the
mean
exposure
Most
transient
who
did
the
a mean
at
individuals
exposure
group
the
with
smokers
13 workers
worker
after
subjects
of
26 to 61 years.
five
entire
study
young
active
one
years
workers,
time
showing
The
and
followed
8 . 5 years.
the
the
relatively
percent)
nine
each
subject
ears,
Table
2-Spirometry
available
the
from
the
for repeated
in spirometry
period
and
of observation.
(Mean ± SD)
of Observation
Values
Period
and
During
12-Year
using
et
and
Tilt’
functioonal
equipnlemlt
predicted
no)rnlal
Gooldnlan
et al’s for the
testing,
performned
(Noo.
Doo.
an abhrtvi-
FEV,/VC
N
FEVI*
to chloorine
42 DeVilbiss)
capacity
was
(FRC)
VC*
Ratio
FEF25-75’
18
82.5±21.3
97.6±17.5
67.9±11.8
79.4±37.1
20
96.3±21.0
106.3±17.1
73.4±9.7
95.0±40.6
I)ay4()
17
99.9±25.5
110.3±22.7
72.7±9.4
96.5±40.9
1 yr
15
91.4±
70.7±9.1
84.2±29.7
2yr
13
92.4±18.2
106.6±16.1
70.3±11.1
S().9±27.4
9vr
6
86.6±32.4
110.7±26.9
63.5±22.1
74.3±42.3
13
86.4±24.7
99.3±12.8
68.0±15.8
74.0±39.5
0.31
0.38
0.53
0.52
I)ay
10
l2yo’
ton all exposed
the exposure
residual
Expoosumre
Day!
losing
spiron1etr)
fumiction
was
monoxide
perfornled
Van Canse
to a nebulizer
from
were
for
following
After
wasil000t
for carbon
interval.
and
tesP
nitrogen
administratioon
Moorris
12 years
the
capacity
test
Time
spirometry
(hewlett-Packard),
fumlction
pulnlo)flary
challenge
imihaled
was
follow-
only
ten
all exposed
characteristics
were
exposure
carcinoma
of observation
in
lung
subjects
the
were
foollowing
years,
oof standard
spiroometer
volumes,
connected
twoo
consisted
study
of
tested
ear,
20
pooints
after
to chlorine
12 years
individuals
Considering
following
transient
supplemental
19 of the
time
too contact
lung
the
tile
thoose
on
days
roentgenogram
workers
admitted
given
several
volumes
of
too standard
methacholine
wowkers
At
diffusing
and
foor lung
Imo addition
ated
lung
over
were
and
and also developed
individuals
perfoormed
calibrated
pro)tocols”
used
of
(mean,
Two
exposed
reexamined
tests.
measurememits
consistent
time
coorticoosteroids.
tests
and a single-breath
The
and throat
made
function
of static
method,
all
most
40 days,
fsmnctiorn
measurement
exposure,
Five
exposure.
electronically
an
of
cardiac
ten
workers
were
of hepatocellular
Tables
were
pulmonary
usimlg
all
All workers
to two
days,
pulmonary
The
nose,
at the
or
for
The
and
smokers
15 pack-years),
exposure,
the
eyes,
12 years-attempts
perform
of age
up
workers
building
current
respiratory
tightness.
of the
the exposure-ten
and
the
chlorine
of time.
61 years
exposure.
exposure.
as a yelloow-
constrtmctioon
percent)
the
died
ambient
the
settled
with
20 construction
13 (65
ing
Testing
function
24 hours
to
the
particular
(mean,
roentgenogram.
Functkm
and
14 were
following
was
mill
20
25 and
without
chest
none
Since
mill was heated,
of this
and
Prior
for one
and
car.
pulp
exsmokers
ofthe
with
on chest
o)xygen,
of liquid
rOO)f
white;
healthy
hospital
car
voiume
gas for a briefpenod
were
burning
cough
railroad
a large
Unfortunately,
immediately
experienced
ofthe
on the
smokers.
be
the
and
railroad
between
four
to
a dry
roof.
were
never
claimed
the
all were
43 pack-years),
the
wall
green
Ofl
connecting
1#{176}C
and the pulp
-
the
The workers
the exposure;
hose
disconnected
the
gas,
1)V1l1m0t
*percem,t
tCalculated
17.4
1()8.9±
14.4
predicted.
using
analysis
ofsariance.
CHEST
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21610/ on 06/18/2017
I 97
I 4 I APRIL,
1990
821
Table
(Mean
3-Lung
Volumes
± SD)
and
Diffusing
12-Year
During
Capacity*
Period
pulmonary
of Observation
Tinie
In
After
Expoosure
N
TLC
RV
FRC
DCO)
19
108.2±19.6
141.6±45.0
108.5±19.5
.
.
I)ay 10
20
110.3±15.4
124.1±30.9
106.9±25.3
.
.
Day
17
108.7
1 yr
15
102.7±14.8
2vr
13
1
Day
40
9 yr
101.8±
13
108. 1
19.0
99.4
20.2
±
94.6
FEy1
18.3
±
90.3±20.6
94.5±26.1
88.2±24.4
90.8±18.0
90.4±15.5
100.8±31.7
82.3±39.2
0.0001
16.9
tosing
amialysis
the
50 breath
units
In
to
less
after
the
vo)lume
exception
that
years
I where
vC
the
ratio
during
subjects
percent
predicted)
percent
and
residual
0
in
was
probably
smoking
the high
In
the
(<80
residual
percent
period
of observation,
in
no)t the
workers.
of
that
exposure
cause
of the
the
the
only
notable
a
a
mean
to
airflow
high
25
chlorine
findings
in
least
80 percent
cation
at
normal
from
the
residual
volumes
12 years
any
(Table
contrast,
who
had
meant
12 years
clinical
following
true
compared
methacholine
80%
expo-
that
not
that
gas
when
we
year
(data
with
exposed
challenge
Predicted
as-
associated
expressed
FEV iNC Ratio < 65%
RV> 120%
Predicted
<
we
with
the
chlorine
even
per
that
SO
predicted)
were
were
exposure
examined
in terms
not
shown).
workers
tests
(N
0
80
0
U)
I-.
U,
60
/
40
/
C
0)
U)
0.
0
20
r
0
1
Day 1
I
Day 10
7
/
/
‘/
Day 40
Time
FOGURE
I
predicted),
dumring the
822
.
The prevalence
of a low FEV1NC
and low residual
volume
(<80
period
of 1(0110w-up.
1 Year
Since
9 Years
rL
12 Years
Exposure
ratio (<65 percent),
percent
predicted)
Pulmonary
2 Years
Sequelae
elevated
residual
is presented
for
from Inhalation
volume
(> 120 percent
each
observation
point
of Chlorine
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21610/ on 06/18/2017
Gas (Schwartz,
Smith,
at
distinguish
demonstrated
volume
milliliters
RV
demar-
characteristics
in residual
negative
The
following
exposure
remained
preof
to
percent
the
with
their
be associated
analysis
(<80
the
when
might
expo-
volumes
value.
performed
the
the
of
not
on
those
percent
residual
that
to a
analysis,
following
groups:
was
day
-
tendency
airways
but
of
of loss
exposure
ofthe
was
one
4). This
In
80
Our
after
reduction
of rate
than
volume
lower
obtained
two)
factors
residual
the
predicted
percent
100
#{149}0
to
o)htalned
the
purposes
with
abnormal
gas.
with
resting
80
factors
12 years
of their
to chlorine
gas
for
13
response
predict
into)
those
sure
the
Of
airways
or hyperreactive
less
and
analyze
mll
of
account
obstruction.
value
sessed
obstruction
therapy.
following
For the
separated
dicted
loss
prevalence
of methacholine
clinical
would
volume
volumes
a lower
high
FEy1
baseline
hyperreactive
hours)
examined
were
could
observed
expected
among
our study
subjects
may
“baseline”
prevalence
ofairfiow
summary,
with
increases
the
an
to 8
subjects
was
excess
Moreover,
(>120
61 percent
Although
obstruction
not
prevalence
predicted)
percent.
residual
volume
from
airflow
suggests
the
of study
to) 67
This
these
a high
prevalence
O)f
FEy1
h7
was
the
volume
throughout
while
(FEy3!
the
intermediate
the
examination.
subjects
sure
in
methacho-
their
units
had
an
24
of these
residual
study
Figure
constant
had
(within
reduced
volumes
in
of
three
examined
if any
follow-up
lung
relatively
diminishes
percent
prevalence
remains
with
or
depicted
to see
the
percent
1)ronchodilator
subjects
then
in either
obstruction
ofobservation,
of those
from
2)
of airflow
percent)
perio)d
apparent
is also
prevalence
residual
throughout
are
(Table
relationship
<65
the
low
changes
measures
3). This
mean
diminishes
few
spirometry
(Table
high
subjects,
of
decline
ofinhaled
study
150 breath
tested,
dose
percent
methacholine.
We
initially
progressively
of follow-up,
the
in
of an
85
after
immediately
With
than
and
provocative
or less
other
inhaling
subjects
two
two
in resid-
a progressive
volume.
a 20
2).
elevation
by
caused
study
oof variance.
initial
subjects,
improved
inhaled
an
that
and
and
0.82
predicted.
tCalculated
was
dropped
105.6±23.0
0.12
study
(Fig
values
110.8±
93.9±23.1
three
line
were
that was followed
loss O)f residual
lung
methacholine
98.9±28.6
0.48
Percent
25.8
±
83.9±37.2
102.5±12.9
pvaluet
*
16.6
99.9±15.3
6
12r
±
function
ual volume
persistent
Lakshminarayan)
8),
100
w
z
1
Lu
(1)
80
>
LU
LI.
FIo:oIOF: 2. Percentage
)i)so-rved
soit Io tiot-
60
airway
Baseline
25
5
CUMULATIVE
those
with
po)siti\’e
(N = 5)
tended
strated
airflow
trapping
(p
tests
5). After
was
airway
to) be
on
within
directly
among
time
of the
limited
age,
initial
who)
we
that
of
(data
to
nar
function
than
expected
values
hensive
sttidy’5
to) date
residual
\‘O)ltlfllC
(
shown).
a formal
analysis.
peno)d.
13
The
However,
the
found
inconsistency
tho’
most
the
ofour
lower
at
minimal
during
changes
six-ear
volunie,
toxic
study2
with
isolated
iruhalatiomus
in
folloxx’-
findings
with
of
only
emid
compre-
systemnatically
1mm the
no’
ptilino-
report
volume
has
chlori
of
prestiit
residual
1 mllvr)
-
rationis
actually
cohoorts.
1)atients
to uline
u-orkers
pre’is
repo)rt
is difficult
to) explain
the different
exposure
conditio
)ns
vie\Ved
FE\’
mnoiihe’l
o.xisoseol
studies56
for
testing
up
co)ncent
that
results,l,10I5
degree
only
tie’
iii
high
reports
four
period.
at the
not
the
follow-up
of age
precluded
eXI)osed
Of
challenge
iateol
tested
12 vo’.ors tI’ter oxposuro
to (-illo)rimoo’ gos.
One in’eatio ommoitis coma1 too0)3W illll;llatio)II
od 1
mug/mill of mnttilao’holino
of the
reactivity
gas
sUl)jects
air
(Table
the
35 years
to chlorine
gas.
function
function
airway
dentally’
more
exposure
found
at least
number
multivariate
of the
with
were
exposure
with
1 50
Units)
demon-
pulmonary
pulmonary
associated
those
The
for
on
and
0.03)
=
24 hours
controlling
trapping
0.004)
standard
(Breath
to) methacholine
(p
(p
50
DOSE
responses
older
obstructio)n
0.03)
=
obtained
of air
of Loll fromml baseline
didn’t-s
0
this
mnay reflect
on r respective
l)LIt
that
redtictioiis
in
(ho’drocarbomus,
reI’csi(lual
amnmiio)ilia,
D1s1sS1oN
Our
findings
suggest
high
concentrations
term
respiratory
dental
air
of chlorine
to
trap)i11g.
we
with
67
with
an
expected
given
study
population.
13 subjects
reactivity
increase
the
age
In
tested
in
and
‘
reactive
airways
degree
o)fairflow
obstruction
observed
The
immediately
loss
cohort
12 had
was
directly
and
volume
iii
the
the
at o’xposmmro.
Snookimmg
Ioistoor
have
Table
addressed
6, we
evaluated
of follow-up)
review
the
shortpulmonary
this
the
and
type
(N=5)
:37.8
r
Noo.
±
9.4
42. 1 ± 12.2
1 (13)
Es
2
(2.5)
1 (2(i)
five
Cmorro-nt
5
(6.3)
4
2
(25)
1 (20)
of
Day
risk
of
to) the
that
1 CXII,
No.
Day 1 Pi-i’st
FE\’,
FE\’AC
.
76.5±15.1
ratio
10.6
92.4±
15.0
TLC
106.2±27.7
115.1±12.1
FRC
106.9±20.9
117.0±
variables
aro
In
o-ategorio.-
series
that
have
(at least
one
year
tPFT’s:
acci-
as
individuals
0.93
0:36
±29.6
0.57
0.52
15.6
0.40
studies
ouma6mi.mS
in
1(4.1
0.31
1.4
68.7±
136.9±36.0
case
1.0
91.9±37.5
69.3±
154:3±58.8
other
0.67
(81))
RV
helps
0.48
(%)
infiltrates
‘as
.
chlorine-exposed
that
p\tit1t
(l)
our
long-term
changes
(N S)
VU
of
six other
S0(X
Pro’olk’trd
Nevem’
*(‘oom)tjl)L300015
that
<SWk
exposure.
the
12
Gas
the
from
at Year
of Exposure
of our
airway
related
o)hservatio)n
findings
Age
of 20
that
air trapping
hours
Pmeoliett-oi
12
contrasted
that
Volume
24
i10Si(iu1al \olimmoot it loam’ 12
of their
increased
and
an important
together
year
volume
found
an
following
of residual
represents
us to) piece
we
methacholine
having
at
characteristics
addition,
Residual
Within
of
tested
residual
Charaiteristics*
to Chlorine
period
be
Clinical
as
in residual
should
height
at year
to) inhaled
12-year
percent
Between
4-Relationship
and
acci-
maiuifests
80
Table
to long-
decline
those
finding
to)
that
acutely
below
This
lead
found
the
of
volume
value.
mi/yr
gas
a progressive
percent
a residual
predicted
We
during
noted
exposure
may
gas
chlorine
However,
observatio)n,
having
short-term
complications.
exposure
volume
that
variables
are
t-xl)rt-sseol
exI)resseol
as
as
the
tue frt’oiue’no.-
iiot’ao)
±
S I)
svhule
(1o’rco-mot of total
smobjeets).
individual
o percemot
iueasmmros
1)redictd
except
of’ 1)1mlmI0oh1m’Y himu-tion
,om’e .Lll expresso-’ol
for tiu- FEV,/V(
: ratio.
CHEST
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21610/ on 06/18/2017
I 97
I 4 I APRIL,
1990
823
Table 5-Relationship
Between
Airway
Response
to
Methacholine
Challenge
at Year 12 and Clinical
Characteristics*
Within
24 Hours
ofExposure
to
Chlorine
Gas
ance,
o)r
the
ii)
persons
elastic
older
has
been
recoil
of the
35
years
of age,
be
largely
than
found
to
co)llapse.#{176}’ Presuming
Niethacholin
e Cllallemlge
the
mechanics
nations
Poositive
Negative
(N=5)
Ageat
exposure.
Smoking
yr
hishor;
1)dltme
(N=8)
33.7±5.5
48.7±9.6
0.004
Never
.
.
1 (13)
.
Ex
3 (61))
6 (75)
CLmrre’mlt
2 (40)
1 (13)
1 CXR,
Day
0.42
(%)
No.
Infiltrates
.
.
3
.
0.23
(:38)
FEy
75.8±29.5
FEV/VC
ratio
59.8±
14.5
First,
chlorine
gas
recoil
would
result
effect
on
normal
expansion
0.48
74.9±6.7
0.03
olar
V(:
96.3±21.4
96.0±22.8
0.86
them
airway
LIV
183.9±60.6
125.0±26.5
0.03
Maintaining
126.4±20.7
99.2±17.6
0.03
FRC
permit
128.3±5.6
99.9±
variai)les
*(‘o,,Jti,)m300mos
categoric
variables
are
are
(.xpresso(I
exl)ressed
as
as tile
tue
mucan
freoiuencv
± SI)
(percent
so bile
esis
subjects).
tPF”I’s:
as
a
individual
I)t’rco’mot
measures
prt-olicteol
ni I)mmlmlloonarY function
eX(’(’pt
for the
are
FEVA’C
gas,
tll expressed
patholo)gic
sloughing
ratio.
intense
sulfur
dioxide,
and
responsible
for
clinical
significance
remains
in tir
function
as we11
of the
l)y
airways.
gases.
injury
of
the
in
Table
6-Reports
volume
tiO)fl
with
extensive
ob-
bronchiolitis
volume
strength,
ofAccidental
result
chest
Exposure
for
that
sve observed
among
workers.
However,
the mechanism(s)
without
remains
the
from
compli-
wall
to Chlorine
the
Gas
in Which
the
to)
relatively
an
high
the
Accident,
of
Referemce
-
Exposed
Foollonved-up
Folloow-up
Time,
2()8
3.3
1.3
156
11
1.7
Lo)ngshooreman,
156
59
Yoork (:it
sui)wa\;’
Filtration
traimi,”
plant,#{176}
12
7.0
35
18
1.2
histologic
confirma-
for
of
high
(38
percent
prevalence
Subjects
in
this
of
Were
positive
Freight
traim,#{176}
of subjects
smoking
Followed
in
upfor
this
is
given
cohort,
at Least
Fimmlction
it is
One
Year
Tests
.
Not
End
obtailled
Not
, FRC
Not
oohtained
Not
ooiotaimied
Airway
RV (7/18)
56
5.0
145
61)
6.0
Nornlal
from Inhalation
FE!I
spiroometr
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21610/ on 06/18/2017
I RV
Gas
(3/12)
Noot reported
Normal
PF’Ts
with
boss oof 1 nol.5’r
lumig volimnies
of Chlorine
resistance
amid
J RV (5/7 tested)
FEy, (5/10 tested)
1 RV (3/12)
o)htaineol
56
Sequelae
of Fodioeo’-up
Noormnal
FEy
(5/18)
Noot rep.tortoi
Pulmonary
re-
cohort
tested),
Initial
and
824
finding
airway
exposed
our
I
fecompatioonal,’’
airway
fibrosis
‘
1 .6-2.9
1(X)
acute
decline
in residual
expo)sed
construe-
FEy
Freight
and
cases,
peribronchial
our
prevalence
methacholine
yr
Loongshoretnan,
New
the expoinflamma-
accounting
Puinuomiary
.
following
airway
some
persistent
Noo. ool Subjects
Type
be-
speculative.
Although
SOn5C5
an
killed
by persistent
The
account
tion,
the
by
Animals
in
is followed
fibrosis.
extensive
bronchiectasis,
Thus,
volume
tiO)I1
chest
injury
hypoth-
to chlorine
is followed
.
bn)nchitis,
and
latter
ofexposure
six months
persistent
comld
suggests
and
airway
inflammation
po)stmorten)
the
svhich
would
in a reduced
demonstrate
n
extensive
that
cause
volumes
and
to have
found
stiffening
and
lung
and
weeks
were
studies
muscles
two
sure
is determined
of the
residual
muscle
volume
expirato)ry
wall,
in either
other
in chronic
residual
characteristics
increase
tween
20
result
pressure-volume
reductions
volume
by
in residual
may
Since
strength
the
be
and
exhalation.
result
response
the
abnormality
residual
is supported
reduction
initial
to
Although
a characteristic
feature
of lung
short-term
exposure
to this agent
no)XiouS
observed
the
l)elieved
cases.
physiologic
reduced
sul)jects
as other
The
that
the
represent
following
may
were
of the
of this
unclear,
served
and
pesticides)
16 percent
and
epithelia,
inflammatory
peribronchi-
during
studies7
hours
their
a nearly
Alternatively,
bronchioles
specimens
of airsvay
its tethering
permitting
at low lung
W7ithin
likely:
by
to closure
Animal
the
recoil
to) maintain
the
in tw’() humans#{176} suggest
is more
increase
capacity.
exhalation
VO)luflle.
sttidies
total
of
continued
by
elastic
in mild
patency
induced
could
result
stiffen
resistant
airway
residual
lung
expla-
in residual
injury
while
may
airway
affected
roentgenographically
volume
volumes
may
to be more
TIA:
0.005
that
possible
tending
at total
not
increased
residual
damage
fibrosis
two
that
The
airways,
at low lung
acute
has
reduction
in mild
lung.
in a low
small
wall,
fibrosis
the
volume
by
gas
parenchymal
result
O)f
chlorine
observed
diffuse
may
In healthy
residual
determined
chest
the
interstitial
elastic
86.6±24.2
17.5
for
volume.
patency
Day 1 PFTst
the
O)f
exist
inapparent
(%)
Noo.
that
lung.
(Schwartz,
Smith,
in RV
Lakshminarayan)
consistent
with
trolling
for
trapping
pulmonary
testing
These
opment
ofair
be
of
hyperreactivity.
more
had
to
might
the
likely
to) respond
exposure.
to
observed
gas.
In the
absence
tests
and
gas,
it is difficult
to
al)normalities,
the
to) the
these
The
In
aI)sence
the
exact
temporal
to
appears
remains
early
reactive
gas
ofthese
of air
airways
exposure;
events
needs
2 Charan
of accidental
chlorine
TA,
upton
5,
21
prove
22
the
inhaiatiom
in pulnloonary
DD.
functioon.
Reba
RC,
respiratoory
Rev
RT, Spicer
functioon.
Arch
Effects
WS.
Emoviron
with
56:430-42
clinicopathooloogic
J. Fatal
chlorine
coorrelatioon.
pooisoning:
Am
pulmonary
VoL
1922;
effect
the
omi
disease
gases.
Br
folloaving
J
Meol
193.3;
I)lmlnlonar
effects
in
of gas
6:57 1-74
pooisonin
Iletterl.
ii.
Am
\V-ill
Rev
L.anct-t
1984;
JL,
J,
ilo-Im
Occmmp
Nleoi
II.
Lumug fmmnctiomu
Respir
Dis
1986;
134:
NIR.
1959;
BC,
Respir
staml(lards
Dis
197!;
fimmictiomi
predictioon
Cotes
JE.
for
10.3:57-67
tests:
noormal
oof noornial
results.
Cigarette
(tramisfer
snooking
factor).
Aol
and
Rev
Respir
1
ER,
for airsvavs
inhalationo
Spiromnetric
Rev
79:457-67
Blo-ecker
test
LC.
the
capacity
11)5:30-4
oof spi-
119:8.31-38
Rospiratorv
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difl’usiiug
screemling
Am
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omo staml(lar(lizatiomo
1979;
Joiinson
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Docker
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Niasoomo P A
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\Vare
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Jil,
muetilacia)-
82:1.5-8
Bostoml,
in six
B,
Bumrroows
24
capacity
cities.
I.eboowitz
J
25
oof
Respir
Dis
MD,
Mass:
Little
Brown
&
oof chlorine
26
DS,
in health);
Rev
Respir
Camilli
AE,
Fav
ME,
vo)lumne
expiratoory
expiratorv
Kimiasewit-s
1987;
Clicksherg
white,
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198.5;
Knudson
vo)lunle
nevem
131:51
RJ.
in
in oma
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1-21)
i.omgitusecootul
ill
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isO)lated
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JF. The
Nlurrav
Am
iml forced
M\’u
camce
BC,
oof forced
vital
U.S.
cilanges
Owens
Ferris
I)istriinmtioon
amld forced
CT,
Andersoon
reductioon
WM
residual
in
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voolionie.
signifiAn
Rev
136:1377-80
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lummig. Philadelphia,
Pa:
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Saumnders
1986
Leith
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1967;
report
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1971;
ooecurrence
J Clin Pathooi
Lancet
tileir
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adomlts. Am Rev Respir
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A,
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(;anso’
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Vest
Kooski
Chathamu
Go;
Parker
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the
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following
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1969;
chlorimie
4:152-54
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led
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Respir
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ation
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Unfortunately,
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suggest
trapping
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findings
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that
24 hours
hyperreactivity
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found
5 Joovmier
However,
after conthe degree
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27
we
initial
on
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Sparrow
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D,
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J
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