Airway Respiratory Irritants

Table of Contents

Aliases

Respiratory irritant, airway injury, respiratory injury, chemical respiratory injury, toxic inhalation

Patient Care Goals

Rapid recognition of the signs and symptoms of confirmed or suspected airway respiratory irritants.

Patient Presentation

Inclusion Criteria

  1. Inhalation of a variety of gases, mists, fumes, aerosols, or dusts may cause irritation or injury to the airways, pharynx, lung, asphyxiation, or other systemic effects
  2. Inhaled airway/respiratory irritant agents will interact with the mucus membranes, upper and lower airways based on solubility, concentration, particle size, and duration of exposure
  3. The less soluble and smaller the particle size of the agent the deeper it will travel into the airway and respiratory systems the inhaled toxic agent will go before reacting with adjoining tissues thus causing a greater delay in symptom onset

Signs and Symptoms

  1. As the type, severity and rapidity of signs and symptom onset depends on agent, water solubility, concentration, particle size, and duration of exposure, the below signs and symptoms are often overlapping and escalating in severity
  2. Many airway and respiratory irritant agents have “warning properties” such as identifiable or unpleasant smells or irritation to eyes or airways
  3. Some agents do not have clear warning properties and will often have delayed onset of any sign or symptom:
    1. Unusual odor /smell
    2. Tearing or itchy eyes
    3. Burning sensation and burns to the nose, pharynx and respiratory tract
    4. Sneezing
    5. General excitation
    6. Cough
    7. Chest tightness
    8. Nausea
    9. Shortness of breath /dyspnea
    10. Wheezing
    11. Stridor
    12. Dyspnea on exertion
    13. Dizziness Upper
    14. Change in voice
    15. Airway obstruction include laryngospasm and laryngeal edema
    16. Pulmonary edema (non-cardiogenic)
    17. Seizures
    18. Cardiopulmonary arrest
  4. High water solubility/highly irritating (oral/nasal and pharynx, particle size greater than 10 micrometers)
    1. Acrolein
    2. Ammonia
    3. Chloramine
    4. Ethylene oxide
    5. Formaldehyde
    6. Hydrogen chloride
    7. Methyl bromide
    8. Sodium azide
    9. Sulfur dioxide
  5. Intermediate water solubility (bronchus and bronchiole, particle size 5 to 10 micrometers)
    1. Chlorine
  6. Low water solubility/less irritating (alveolar, particle size less than 5 micrometers)
    1. Cadmium fume
    2. Fluorine
    3. Hydrogen sulfide (rotten egg odor; olfactory fatigue
    4. Mercury fume
    5. Mustard gas (also delayed blistering skin manifestations)
    6. Nickel carbonyl
    7. Ozone
    8. Phosgene
  7. Asphyxia agents (two categories)
    1. Oxygen deprivation below 19.5% oxygen atmosphere (“simple asphyxiants”)
      Any gas that reduces oxygen fraction or displaces oxygen from the inspired air

      1. Argon
      2. Carbon dioxide
      3. Ethane
      4. Helium
      5. Methane
      6. Natural gas (e.g. heptane, propane)
      7. Nitrogen
      8. Nitrogen dioxide (delayed symptom onset)
    2. Chemical interfering with oxygen delivery of utilization (“chemical asphyxiants”)
      1. Carbon monoxide [see Carbon Monoxide/Smoke Exposure guideline]
      2. Cyanide [see Cyanide Exposure guideline]
      3. Hydrogen sulfide
  8. Inhalants of abuse
    1. These agents or substances are a diverse class of substances that include volatile solvents, aerosols, and gases
    2. These chemicals are intentionally inhaled to produce a state that resembles alcohol intoxication with initial excitation, drowsiness, lightheadedness, and agitation
    3. The abusers of these inhaled agents are often called huffers, sniffers, baggers, or snorters
      1. These individuals often present after inhaling an aerosol or gas with a loss of consciousness and the presence of the aerosol can or residue/paint around or in the mouth, nose, and oral pharynx
    4. Common household products that are used as inhalants of abuse
      1. Volatile solvents
        1. Paint remover
        2. Degreasers
        3. Dry-cleaning fluids
        4. Gasoline
        5. Lighter fluid
        6. Correction fluid
        7. Felt tip markers
        8. Glue
      2. Cosmetic/paint spray
        1. Deodorant spray
        2. Vegetable oil spray
        3. Fabric protector spray
        4. Spray paint
      3. Propellants/asphyxiants/nitrous oxide
        1. Propane gas
        2. Balloon tanks (helium)
        3. Computer keyboard cleaner
        4. Ether
        5. Halothane
        6. Chloroform
        7. Butane
        8. Propane
        9. Whipped cream dispensers
  1. Riot Control Agents [see Riot Control Agent guideline]
  2. A prototype agent is identified with each region of the effected airway respiratory track for mild to moderate exposures, as severe concentrated exposures of many of these agents overlap in signs and symptoms – the deeper the symptoms are in the respiratory track and the slower the rate of symptom onset the less water soluble the airway respiratory irritant
    1. Nasal and oral pharynx irritation – highly water-soluble agents (ammonia)
    2. Bronchial irritation (chlorine)
    3. Acute pulmonary edema/deep alveolar injury – poorly water soluble (phosgene)
    4. Direct neurotoxin (hydrogen sulfide)
    5. Asphyxia agent with additional symptoms (nitrogen dioxide – Silo Filler’s disease)
    6. Inhalants of abuse (volatile solvents, cosmetics/paints, propellants/asphyxiants/nitrous oxide)
    7. Riot control agents [see Riot Control Agents guideline]
    8. Anticholinesterase inhibitors [see Acetylcholinesterase Inhibitors guideline]
  3. Ammonia
    1. Immediate detection of unique sharp smell
    2. Nasal pharyngeal burning/irritation sensation
    3. Ocular tearing and irritation
    4. Sneezing
    5. Altered mental status – Sleepy to agitated
    6. Cough
    7. Shortness of breath
    8. Chest tightness
    9. Bronchospasm wheezing
    10. Change in voice
    11. Upper airway obstruction includes laryngospasm and laryngeal edema
    12. Corneal burns or ulcers
    13. Skin burns
    14. Pharyngeal, tracheal, bronchial burns
    15. Dyspnea/tachypnea
    16. High concentrations and or protracted exposure may develop non-cardiac pulmonary edema
    17. Esophageal burns
  4. Chlorine
    1. All the above (Ammonia)
    2. Increased likelihood of the following
    3. Bronchiole burns
    4. Bronchospasm wheezing
    5. Non-cardiac pulmonary edema develops within 6 to 24 hours of higher exposures
  5.  Phosgene
    1. Often have none of the above symptoms for first half hour to several hours then are much milder until more severe lower respiratory tract symptoms develop
      1. Only warning is report of “fresh mowed hay” odor
      2. Mild airway irritation or drying
      3. Mild eye irritation
      4. Fatigue
      5. Chest tightness
      6. Dyspnea/tachypnea
      7. Significant delay up to 24 hours for
        1. Exertional dyspnea
        2. Bronchospasm wheezing
        3. Hypoxia
        4. Severe non-cardiac pulmonary edema
        5. Cardiopulmonary arrest
  6. Hydrogen sulfide – A direct neurotoxin and is rapidly absorbed through lung generating systemic effects
    1. Distinctive rotten egg smell which rapidly causes olfactory fatigue/loss of sense of smell
    2. Cough
    3. Shortness of breath
    4. Rapid alternations in cognition or consciousness
    5. Bronchiole and lung hemorrhage/hemoptysis
    6. Non-cardiac pulmonary edema
    7. Hydrogen sulfide is known as the “knock down” gas because of near immediate and sudden loss of consciousness with high concentrations
    8. Asphyxia
    9. Death
  7. Nitrogen dioxide (also called Silo Filler’s disease)
    1. Heavier than air displacing oxygen from low lying areas and closed spaces causing direct asphyxia
    2. Low concentrations may cause
      1. Ocular irritation
      2. Cough
      3. Dyspnea/tachypnea
      4.  Fatigue
    3. High concentrations:
      1. Altered mental status including agitation
      2. Cyanosis
      3. Vomiting
      4. Dizziness
      5. Loss of consciousness
      6. Cardiopulmonary arrest
  8. Inhalants of abuse (e.g. felt tip markers, spray paint)
    1. Physical presences of paint or residue on individual from the inhaled agent
    2. Slurred speech
    3. Altered mental status (excitation, drowsiness to unconsciousness)
    4. Loss of consciousness
    5. Cardiac dysrhythmias
    6. Cardiopulmonary arrest

Patient Management

  1. Don appropriate PPE – respiratory protection critical
  2. Remove patient from the toxic environment
    1. Remove the patient’s clothing that may retain gases or decontaminate if liquid or solid contamination
    2. Flush irrigated effected/burned areas
  3. Rapidly assess the patient’s respiratory status, mental status, and oxygenation
  4. Administer (humidified if available) oxygen
  5. Establish intravenous access (if possible)
  6. Apply a cardiac monitor (if available)
  7. Continuous and ongoing patient reassessment is critical

Assessment

  1. Make sure the scene is safe as many gases are heavier than air and will build up in low lying areas. This is especially true of hydrogen sulfide and it’s ”knock down” effect of the initial unprotected responder and subsequence casualties associated with unprotected rescuers attempting to safe the first downed responder
  2. Consider BSI or appropriate PPE
  3. Remove patient from toxic environment
  4. Decontaminate
  5. Assess ABCD and if indicated, expose the patient and then cover the patient to assure retention of body heat
  6. Vital signs which include temperature
  7. Place cardiac monitor and examine rhythm strip for arrhythmia potentials (consider 12-lead EKG)
  8. Check blood glucose Level
  9. Monitor pulse oximetry and ETCO2 for respiratory decompensation
  10. Perform carboxyhemoglobin (CO) monitoring, if available
  11. Identify specific suspected agent if possible
  12. Pertinent cardiovascular history or other prescribed medications for underlying disease
  13. Patient pertinent history
  14. Patient physical examination

Treatment and Interventions

  1. Assure a patent airway
  2. Administer oxygen and if hypoventilation, toxic inhalation or desaturation noted, support breathing
    1. Maintain the airway and assess for airway burns, stridor, or airway edema and if indicated, perform intubation early (recommendation to avoid extraglottic airways – cricothyrotomy may be required in rarer severe cases
    2. Non-invasive ventilation techniques.
      1. Use continuous positive airway pressure (CPAP) for severe respiratory distress or impending respiratory failure
      2. Use bag-valve-mask (BVM) ventilation in the setting of hypoventilation, respiratory failure or arrest
  3. Albuterol 5 mg nebulized (or 6 puffs metered dose inhaler) should be administered to all patients in respiratory distress with signs of bronchospasm either by basic life support BLS or ALS providers. This medication should be repeated at this dose with unlimited frequency for ongoing distress
  4. Ipratropium 0.5 mg nebulized should be given up to 3 doses, in conjunction with albuterol
  5. Initiate IV access for infusion of lactated Ringer’s or normal saline and obtain blood samples in effort to record pre-treatment levels associated with EMS management (e.g. glucose, lactate, cyanide)
  6. Fluid bolus (20 mL/kg, max of 2 L) if evidence of hypoperfusion
  7. If the patient is experiencing significant pain, administer IV/IO analgesics
  8. Eye irrigation early
  9. Treat topical chemical burns [see appropriate Toxins and Environmental section guideline(s)]
  10. In severe respiratory irritation, in particular hydrogen sulfide, with altered mental status and no improvement with removal from the toxic environment, administer oxygen as appropriate with a target of achieving 94-98% saturation – consider consultation for transfer to a hyperbaric oxygen therapy

Notes – Airway Irritants