Reactive Airways Dysfunction Syndrome in Housewives Due to a Bleach–Hydrochloric Acid Mixture

Abstract

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 beta(2)-agonist inhalation treatments. In follow-up, 48 patients (87%) improved clinically and functionally (FEV(1)). 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.

Acute Inhalation Injury

“…Exposure victims develop respiratory symptoms in the minutes or hours that follow and persistent bronchial hyperresponsiveness after the inhalation incident. Repeated exposures may cause similar pathology [14,[37][38][39][40].…”

“…Hydrochloric acid, which is highly soluble in water, predominantly targets the epithelia of the ocular conjunctivae and upper respiratory mucus membranes. Similarly, hypochlorous acid is highly water soluble and has an injury pattern similar to hydrochloric acid, which may account for the toxicity of elemental chlorine and hydrochloric acid to the human body [13][14][15].…”

Nebulized Lidocaine as an Alternative Therapy for Reactive Airway Dysfunction Syndrome

“…The most frequently reported agents are chlorine, toluene di-isocyanate, oxides of nitrogen and sodium hypochlorite (bleach, 40%), which is also a common agent that is widely used for indoor cleaning in rural regions [2,3]. Non-specific bronchial hyperresponsiveness is characteristic of the disease.…”

Histopathological Study of Short and Long-Term Pulmonary Effects of Nebulized Sodium Bicarbonate Treatment in Chlorine Gas Exposured Rats

“…Combination of NaOCl and HCl produces large amounts of bubbles and chlorine gas. 3 Chlorine gas is a pulmonary irritant gas with intermediate water solubility that causes acute injury in the lower and upper respiratory tracts. This gas has a yellowishgreen color and a bitter odor.…”

“…6 HCl and oxygen radicals O -are responsible for chlorine gas toxicity. [1][2][3] Decrease in ventilated air, non-allergic hypersensitivity, mucosal inflammation in lymphocytes, and epithelial basal membrane thickening have been reported following the acute exposure to high doses of chlorine gas. 7 Some clinical studies mention that use of nebulized sodium bicarbonate (NSB) in emergency patients exposed to chlorine gas has beneficial effects in treating the respiratory problems.…”