NEJM 9/9/99 - Severe Lung Injury after Exposure to Chloramine Gas from Household Cleaners

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http://www.nejm.org/content/1999/0341/0011/0848b.asp

The New England Journal of Medicine -- September 9, 1999 -- Vol. 341, No. 11

Severe Lung Injury after Exposure to Chloramine Gas from Household Cleaners

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To the Editor:

The inhalation of the noxious fumes associated with the mixing of household

cleaners can lead to pulmonary irritation and pneumonitis. Household ammonia

(3 to 10 percent aqueous NH3) and bleach (5 percent NaOCl) are two of the

most common cleaning agents. Combining them releases chloramine gas, which

is a combination of monochloramines (NH2Cl) and dichloramines (NHCl2). When

inhaled, chloramines react with the moisture of the respiratory tract to

release ammonia (NH3), hydrochloric acid (HCl), and oxygen free radicals.

Typically, exposures to low concentrations of chloramines produce only mild

respiratory tract irritation. In higher concentrations, the combination of

hydrochloric acid, ammonia, and oxygen free radicals may cause corrosive

effects and cellular injury, resulting in pneumonitis and edema. (1,2,3,4)

Emergency tracheostomy was required in a patient because of upper-airway

compromise induced by chloramine gas. The patient, a previously healthy

53-year-old woman, was cleaning a walk-in freezer at her workplace with

over-the-counter liquid ammonia and bleach. The door to the freezer was

closed, and there was no air exchange with the outside. Approximately 30

minutes after beginning to clean, she noted shortness of breath and called

911. Over the next three hours, she had increased tightness of the throat

and became unable to speak above a whisper. Despite aggressive use of

nebulized albuterol, racepinephrine, and intravenous steroids, her symptoms

progressively worsened. Rapid-sequence intubation was attempted but was

unsuccessful because of swelling of the upper airway. Emergency tracheostomy

was performed. The initial chest radiograph was unremarkable, but radiologic

evidence of pneumonitis developed over the next four hours (Figure 1). At

the time the second radiograph was obtained, the arterial-blood gas showed a

pH of 7.23, partial pressure of carbon dioxide of 49 mm Hg, and partial

pressure of oxygen of 102 mm Hg while the patient was breathing 100 percent

oxygen with assisted ventilation. The patient received supportive care. Her

tracheostomy was removed within five days, and she was discharged from the

hospital within seven days.

Although it occurs infrequently, exposure to chloramine gas represents a

substantial risk when household cleaners containing bleach and ammonia are

mixed. As the course of our patient illustrates, upper-airway irritation can

compromise the airway and require emergency tracheostomy.

A. Tanen, M.D.

Kimberlie A. Graeme, M.D.

Raschke, M.D.

Good Samaritan Regional Medical Center

Phoenix, AZ 85006

References

1. Gapany-Gapanavicius M, Molho M, Tirosh M. Chloramine-induced pneumonitis

from mixing household cleaning agents. BMJ 1982;285:1086.

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2. Reisz GR, Gammon RS. Toxic pneumonitis from mixing household cleaners.

Chest 1986;89:49-52.

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3. Pascuzzi TA, Storrow AB. Mass casualties from acute inhalation of

chloramine gas. Mil Med 1998;163:102-4.

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4. Mrvos R, Dean BS, Krenzelok EP. Home exposures to chlorine/chloramine

gas: review of 216 cases. South Med J 1993;86:654-7.

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