The effect of wet cupping on reactive airway dysfunction syndrome (RADS) caused by early exposure to chlorine gas: A randomized clinical trial.

The sudden onset of asthmalike symptoms and persistence of airway reactivity following an acute exposure to an irritant gas or vapor has been termed reactive airways dysfunction syndrome (RADS). A mixture of sodium hypochlorite (bleach, 40%) and hydrochloric acid (18%) is commonly used as a household cleaning solution in our region. From this mixture, chlorine gas is produced, which can cause airway damage and ensuing RADS. Here we describe findings of patients with RADS due to this cleaning mixture, and determine factors associated with a favorable outcome. Data were collected retrospectively on 55 symptomatic patients presenting to our emergency department after inhalation exposure to a mixture of bleach and hydrochloric acid. Symptoms, past medical and smoking history, details of the exposure, initial peak expiratory flow rate (PEFR) and oxygenation, and acute reversibility of airways obstruction were documented. All patients met previously defined criteria for the diagnosis of RADS, but did not undergo methacholine challenge testing and bronchoalveolar lavage or histopathologic study. Fifty patients were followed over the course of 3 mo. The majority of exposures (64%) occurred in the bathroom or kitchen. Only 21 of 55 (38%) patients showed an improvement in PEFR of 15% or greater following two β2-agonist inhalation treatments. In follow-up, 48 patients (87%) improved clinically and functionally (FEV1). Seven patients (13%) deteriorated, with ARDS developing in two, one of whom died from respiratory failure. Advanced age, initial low PEFR, exposure in a small enclosed area, use immediately after mixing, and prolonged short- and long-term exposures were associated with a poorer prognosis. This descriptive study is the largest case series in the literature of RADS developing after exposure to a bleach–hydrochloric acid mixture. The optimum acute treatment and long-term outcomes for patients with RADS due to this combination still need to be determined.

RADS after exposure to a riot-control agent: a case report.

Chlorine is one of the most common substances involved in toxic inhalation. As with all irritant gases, the airway injuries caused by chlorine gas may result in clinical manifestations similar to those of asthma. In this study, we investigated the effect of nebulized sodium bicarbonate (NSB) on the treatment and quality of life (QoL) of victims exposed to chlorine gas. Forty-four consecutive patients with reactive airways dysfunction syndrome (RADS) due to chlorine inhalation (40 females and 4 males, age range 17–56 yr) were included in this study. Patients were placed in control and treatment groups in a sequential odd–even fashion based on their order of presentation. Treatment of all patients included corticosteroids and nebulized short-acting β2-agonists. Then the control group (n = 22) received nebulized placebo (NP), and the NSB group (n = 22) received NSB treatment (4 cm3 of 4.20% sodium bicarbonate solution). A quality of life (QoL) questionnaire and pulmonary function tests (PFTs) were performed before and after treatments in both groups. The most common symptoms were dyspnea (82%) and chest tightness (82%). Baseline characteristics of both groups were similar. Compared to the placebo group, the NSB group had significantly higher FEV1 values at 120 and 240 min (p < .05). Significantly more improvement in QoL questionnaire scores occurred in the NSB group compared to the NP group (p < .001). Thus, NSB is a clinically useful treatment, as tested by PFTs and QoL questionnaire, for patients with RADS caused by exposure to chlorine gas.

An irritant, a non-corrosive chemical that causes a nonimmunologic, inflammatory reaction upon direct contact with the respiratory system may be the source of an acute inhalational injury. In contrast to allergy, an irritant response does not entail a preceding period of latency where there is interaction between an allergen and a person’s immune system. Features that characterize allergic occupational asthma and non-allergicintroduction Acute inhalational injuries comprise a spectrum of respiratory disorders with clinical manifestations mainly determined by the part of respiratory tract that becomes damaged. Clinical outcomes from acute inhalational injuries include upper airway damage, acute tracheobronchitis, reactive airways dysfunction syndrome (RADS), bronchiolitis obliterans, and/or acute respiratory distress syndrome. Expression of the pathological and clinical manifestations from the exposure depends on features of the inciting agent, exposure considerations and host/genetic distinctiveness (1). There can be a mixture of clinical manifestations when more than one anatomical site is affected; when there is a mixture of gases; or, when there are repeated inhalation exposures (2). Non-occupational inhalation accidents originate from fires and explosions, volcanic eruptions, industrial disasters, accidents involving trains orrine gas affects 20 workers during the evening shift of a magnesium production plant that utilizes chlorine gas during the production process.

Reactive Airway Disease after Chlorine Gas Exposure

ObjectivesThis study was conducted to report the course of an accidental release of chlorine gas that occurred in a factory in Gumi-si, South Korea, on March 5, 2013. We describe the analysis results of 2 patients hospitalized because of chlorine-induced acute health problems, as well as the clinical features of 209 non-hospitalized patients.MethodsWe analyzed the medical records of the 2 hospitalized patients admitted to the hospital, as well as the medical records and self-report questionnaires of 209 non-hospitalized patients completed during outpatient treatment.ResultsImmediately after the exposure, the 2 hospitalized patients developed acute asthma-like symptoms such as cough and dyspnea, and showed restrictive and combined pattern ventilatory defects on the pulmonary function test. The case 1 showed asthma-like symptoms over six months and diurnal variability in peak expiratory flow rate was 56.7%. In case 2, his FEV1 after treatment (93%) increased by 25% compared to initial FEV1 (68%). Both cases were diagnosed as chlorine-induced reactive airways dysfunction syndrome (RADS) on the basis of these clinical features. The most frequent chief complaints of the 209 non-hospitalized patients were headache (22.7%), followed by eye irritation (18.2%), nausea (11.2%), and sore throat (10.8%), with asymptomatic patients accounting for 36.5%. The multiple-response analysis of individual symptom revealed headache (42.4%) to be the most frequent symptom, followed by eye irritation (30.5%), sore throat (30.0%), cough (29.6%), nausea (27.6%), and dizziness (27.3%).ConclusionsThe 2 patients hospitalized after exposure to chlorine gas at the leakage site showed a clinical course corresponding to RADS. All of the 209 non-hospitalized patients only complained of symptoms of the upper airways and mucous membrane irritation.

Introduction: Chlorine gas inhalation is a toxic respiratory irritant associated with high lung complications. Despite its wide industrial and domestic applications such as bleaching detergents, there is no specific treatment for chlorine gas poisoning yet and common standard treatments are mostly supportive. In this regard, this study aimed to find a new treatment for this pathogenesis from the perspective of Persian medicine (PM).&#x0D; Materials and methods: In this review study, at first, we searched the etiologies and clinical symptoms associated with chlorine gas poisoning in modern medicine and then compared them with similar etiologies and symptoms in valuable Persian medical manuscripts. Then we reviewed the proposed treatments for similar illnesses from the point of view of PM.&#x0D; Results: The pathology of lung damage caused by inhalation of chlorine gas is reactive airway dysfunction syndrome (RADS), which leads to dyspnea, hypoxemia, respiratory tract obstruction, pneumonia, pulmonary edema, and finally acute respiratory distress syndrome (ARDS). In a comparative study, it seems that this pathology has the closest similarity with the Persian term“Varme-e-harr riye”. The treatment strategy for this syndrome in PM is bloodletting at the first and then the application of cold-temperament foods and medications to improve the lungs.&#x0D; Conclusion: According to the compatibility of acute pulmonary edema caused by chlorine inhalation and “varam-e-harr riye” in PM, it seems that wet cupping can be considered as a suggested primary and emergency treatment for this pathology in future clinical studies.

Reactive airway dysfunction syndrome (RADS) is a type of non-immunologically mediated asthma-like disease. It usually occurs after a massive exposure to an irritating substance in the atmosphere in the form of smoke, fumes, gases, and vapor. Unlike bronchial asthma, there is no latency to the symptoms seen in RADS. A number of agents are known to cause RADS, but tile dust, as an etiological agent, has not been previously reported. We report a 45-year-old male laborer, who presented with an acute onset of cough, chest tightness, breathlessness, and audible wheeze after his first time exposure to porcelain tile dust within 5 hours of exposure. Lab tests, including, chest X-ray, electrocardiogram, air blood gas analysis, and serum IgE, were unremarkable. Spirometry showed a mild obstruction [forced expiratory volume in 1 second (FEV1)=72% of predicted], while the bronchodilator reversibility test was significant(14% increase in FEV1 above the baseline).Bronchial biopsy revealed a chronic inflammatory reaction with lymphocytic and plasma cell infiltration and more importantly a striking absence of eosinophils. To the best of our knowledge, this is the first reported case of RADS as a result of exposure to tile dust (porcelain ceramics).

Inhalation of a range of agents can result in airway inflammation and/or irritation. This may result in occupational asthma or reactive airways dysfunction syndrome. Reactive airways dysfunction syndrome follows a single large exposure to a chemical agent but is now frequently embraced under the wider term of irritant-induced asthma, a term that also includes asthma due to persistent, lower dose irritant exposures. Bronchial hyperresponsiveness is a hallmark of both occupational asthma and reactive airways dysfunction syndrome, although some patients with occupational asthma may occasionally have typical clinical features without increased bronchial hyperresponsiveness. Following removal of the causal agent in occupational asthma, bronchial hyperresponsiveness generally returns towards normal over a 2-year period, although some individuals demonstrate increased bronchial hyperresponsiveness for longer. Measurement of specific bronchial hyperresponsiveness to the primary causal agent in occupational asthma is used diagnostically but not for assessing prognosis. Bronchial hyperresponsiveness to inhaled methacholine can be measured across individual workshifts to assess work-related change. It may also be measured at the end of a work period when exposure has occurred, and compared with values following a period away from work. There have been no direct, systematic comparisons of changes in methacholine responsiveness in the diagnosis of occupational asthma compared with the more frequently used serial peak flow measurements. Patients with reactive airways dysfunction syndrome classically exhibit non-specific bronchial hyperresponsiveness, which can be readily measured by evaluating responses to inhaled methacholine. Bronchial hyperresponsiveness in reactive airways dysfunction syndrome can persist for many years after initial exposure and serial changes can be used to assess recovery and subsequent disability over time.

Host susceptibility to indoor air pollution

The clinical features of acute chlorine gas inhalation, and its management are reviewed. Current medical views on the chronic effects of an acute overwhelming exposure on lung function (reactive airways...

The RCN Learning Zone is a FREE online service to help RCN members with their continuing professional development and professional portfolio management. The RCN Learning Zone can be found at www.rcn.org.uk/members/learningzone.php This practice profile is based on NS689 Hazeldine V (2013) Pharmacological management of acute asthma exacerbations in adults. Nursing Standard. 27, 33, 43-49. I care for many people with coexisting conditions, including asthma, in a nursing and residential care home. The CPD article helped me to change practice in this setting. Although the prevalence of asthma is slowly declining, it affects an estimated 3.8 million people in the UK. There have been advances in diagnosing and managing asthma, but exacerbations remain a problem, and early recognition of such exacerbations can save lives. Where I work, several service users experience asthma and other respiratory pathologies. All service users are monitored regularly using the National Early Warning Score (NEWS) observation chart, which includes temperature, pulse, blood pressure, respiratory rate, peripheral oxygen level and consciousness measurements. These parameters are measured routinely in the nursing and residential care home and recorded on clinical charts. It was interesting to read that the signs and symptoms of an acute asthma exacerbation can include cough, wheeze, dyspnoea, chest tightness and variable airflow obstruction. Patients with asthma and other respiratory conditions could be monitored more effectively using a peak expiratory flow (PEF) meter. PEF meters are low cost, portable, and easy to use. Using this meter, along with the NEWS observations, allows for greater monitoring of asthma and other respiratory conditions. Individuals with asthma ideally require a recorded PEF from within the last two years for comparison purposes. This would help nurses to determine if a service user was experiencing an acute asthma exacerbation. A series of PEF readings were taken for service users, initially only for those with asthma, to record baseline levels. PEF can be used with a traffic light system, and this is how it is used at the care home: Red (danger) – PEF less than 50% of the individual’s personal best indicates a medical alert. Advice should be obtained as soon as possible. At the care home, the service user’s GP or nurse practitioner responds as appropriate. Yellow (caution) – PEF 50-79% of the individual’s personal best indicates that the asthma is worsening. Medical review of the service user should be obtained. At the care home, the GP or nurse practitioner responds as appropriate. Green (safe) – PEF 80-100% of the individual’s personal best indicates that the asthma is under control and that the person should continue to be monitored. The rapid assessment of a service user during an asthma exacerbation is important. At the care home, individuals with asthma usually only develop exacerbations when they have an acute illness, such as a chest infection or pneumonia. Monitoring PEF and using the NEWS observation chart will help to improve the care I give NS

To characterize asthma symptoms, pulmonary function, and responsiveness to beta 2-agonist stimulation, and in vitro beta 2-receptor density and cyclic adenosine 3',5'-monophosphate (cAMP) response throughout the menstrual cycle in women with premenstrual asthma (PMA); and to examine the effect of exogenous estradiol administration on asthma symptoms, pulmonary function and responsiveness, and beta 2-receptor density and function in these women. Open-label, longitudinal, 9-week study. A university clinical research center. Seventeen women with mild to moderate asthma, of whom 14 completed the study. Every morning on awakening during the entire 9-week study, each subject completed visual analog scales for asthma symptomatology (cough, wheezing, breathlessness, chest tightness) and measured and recorded her peak expiratory flow rate (PEFR) with a peak flow meter. Also measured at various times throughout the menstrual cycle were dyspnea index scores, pulmonary function (PEFR, forced expiratory volume in 1 sec [FEV1]), pulmonary response to subcutaneous terbutaline, T lymphocyte beta 2-receptor density (Bmax) and function (cAMP), and estradiol, progesterone, and catecholamine concentrations, both with and without exogenous estradiol administration. At the time of enrollment, only 5 subjects reported premenstrual worsening of asthma symptoms, but all 14 had greater than 20% decrease in PEFR and/or increase in symptoms premenstrually during the study. Significant differences (p < 0.05) existed in asthma symptoms and PEFR between day 13 (highest estradiol concentrations) and day 26 (lowest estradiol concentrations) of the menstrual cycle. Asthma symptoms and dyspnea index scores were significantly improved (p < 0.05) after estradiol administration compared with baseline (premenstrual period without exogenous estrogen). Pulmonary response to terbutaline, beta 2-receptor density and function, and catecholamine concentrations were not significantly altered after estradiol administration, but the trend was toward significant differences (0.05 < p < 0.2) in pulmonary function tests (PEFR, FEV1). Even asthmatics not previously aware of PMA may experience premenstrual worsening of asthma symptoms and/or PEFR. Estradiol is associated with a significant improvement in asthma symptoms and dyspnea index scores. This ameliorating effect does not appear to be related to beta 2-receptors.

To study the clinical presentation, pulmonary functions and outcomes in subjects who were accidentally exposed to chlorine gas. Prospective observational study of 64 patients who sustained acute accidental exposure to chlorine gas during a leak in the chlorination system of the public bathing pool of a temple. The major presenting symptoms and signs included acute dyspnoea (100%), chest discomfort (100%), cough (97%), eye irritation (88%), giddiness (72%), vomiting (46%), and heaviness in the head (44%); tachycardia (100%), tachypnoea (96%) and polyphonic wheezing (28%). All patients were managed in the emergency room with humidified oxygen inhalation and beta-2 agonist nebulisation and 52 were discharged within six hours. Twelve patients were severely affected and required hospitalisation; three of them were admitted into the intensive care unit. Three patients developed pulmonary oedema six to eight hours following admission. Pulmonary function testing (n = 12) at presentation revealed obstructive defect in eight and mixed obstructive-cum-restrictive defect in four patients. The mean duration of hospital stay was 5.1 +/- 2.1 days. None of the patients died. Reactive airway dysfunction syndrome (RADS) was observed in three of the 12 hospitalised patients, who complained of manifested persistent cough that lasted for three months period following discharge. Serial pulmonary functions recovered to normal range by the end of the six months in all patients and remained so at one-year follow-up. Acute exposure to chlorine gas is an uncommon, but important public health hazard and can cause RADS, acute lung injury and pulmonary function abnormalities, which are reversible on prompt and appropriate management.

Peak flow meters are essential tools in the management of asthma. Many types are on the market. A computer-driven piston pump is normally not available for evaluation of the various meters. Comparison with values from a pneumotachograph is an accepted way of testing peak flow meters. This study aims at comparing 11 peak flow meters, for accuracy and linearity. Seven adult peak flow meters were tested: Miniwright with an equidistant scale (Clement Clarke); Personal Best (Healthscan); Wright Pocket fdE (Ferraris); Vitalograph (Vitalograph); Assess (Healthscan); Pocket Peak flow meter (Micro Medical); and Truzone (Monaghan). Furthermore, four low-range (LR) peak flow meters were tested: LR Miniwright with equidistant scale (Clement Clarke); LR Personal Best (Healthscan); LR Wright Pocket (LR Ferraris); and LR Pocket peak flow meter (LR Micro Medical). Two test series were performed: in the first one, a peak flow meter was connected downstream in series with a Fleisch #4 pneumotachograph. One subject performed 50 partial forced expiratory manoeuvres through this ensemble. In the second series, 50 adult patients and 25 healthy children performed sequential maximal forced expiratory manoeuvres on each peak flow meter, and on the pneumotachograph. A ranking system was devised for the various parameters of agreement of the meters with the pneumotachograph. Substantial differences in the quality of the adult meters were found. The adult peak flow meters with the closest agreement to the pneumotachograph were Personal Best and Micro Medical. In the low-range peak flow meters, the lowest differences were seen in the LR Personal Best and LR Micro Medical.