PURPOSE: Chlorine is a chemical with widespread industrial use. Chlorine gas was used as a weapon in the first World War with devastating consequences. More recently, attempts at weaponizing chlorine have been made during attacks with vehicle borne improvised explosive devices (VBIEDs) in Iraq. We report our experience with the care of nine patients who suffered acute respiratory distress syndrome (ARDS) following chlorine gas exposure.
METHODS: On January 28th, 2007, nine patients were admitted to the intensive care unit (ICU) of Ibn Sina Hospital, a United States Army Combat Support Hospital (CSH), following exposure to chlorine gas after a VBIED attack. Data from mechanical ventilator settings and measurements, arterial blood gases, and clinical records for nine patients were reviewed and extracted.
RESULTS: All patients were adult males who arrived to our facility within approximately eight hours of the incident. Only one patient had suffered significant thoracic trauma from the blast. All patients developed ARDS by the first hospital day with a mean partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) ratio (P:F) of 101 and a mean oxygenation index (OI) of 28.5. Eight of nine patients were placed on airway pressure release ventilation due to refractory hypoxemia. All were treated with inhaled albuterol and fluticasone; three patients received intravenous corticosteroids during their hospitalization. Eight patients survived to discharge from the ICU while breathing without assistance. The ninth patient died following 21 days of mechanical ventilation after developing ventilator associated pneumonia. Of the survivors, the mean days requiring mechanical ventilation were 8.1 (range, 2–16). At the time of discharge from the ICU, survivors had a mean P:F of 211 (range, 152–265) and OI of 7.0 (range, 4.8–8.7).
CONCLUSION: Intense exposure to chlorine gas can result in profound hypoxemia and ARDS. With supportive care, patients may demonstrate rapid improvement.
CLINICAL IMPLICATIONS: In cases of ARDS following chlorine gas exposure, early supportive care with mechanical ventilation should be pursued. Inhaled beta-agonists and corticosteroids are treatments that deserve consideration.
DISCLOSURE: David Bell, No Financial Disclosure Information; No Product/Research Disclosure Information