CHLORINE GAS INHALATION

Chlorine gas is a pulmonary irritant with intermediate water solubility that causes
acute damage in the upper and lower respiratory tract. Occupational exposures
constitute the highest risk for serious toxicity from high-concentration chlorine (see
the image below). Mixing of chlorine bleach (sodium hypochlorite) with ammonia or
acidic cleaning agents is a common source of household exposure. As with all
poisons, the dose determines the toxicity. Exposure to low concentrations of
chlorine for prolonged periods may have destructive effects, as might very shortterm exposure to high concentrations.
Chest radiograph of a 36-year-old chemical worker Chest radiograph of a 36-yearold chemical worker 2 hours post-exposure to chlorine inhalant. She had severe
resting dyspnea during the second hour, diffuse crackles/rhonchi on auscultation,
and a partial pressure of oxygen of 32 mm Hg breathing room air. The radiograph
shows diffuse pulmonary edema without significant cardiomegaly.
Signs and symptoms
Symptoms may vary depending on the degree of exposure. Exposure possibilities
include acute low levels, acute high levels, and chronic low levels.
Low-level (3-5%, 1-15 ppm) acute exposure
Most poisonings fall into this category and are caused by household exposure to
low-concentration cleaning products. Manifestations are as follows:
Eye tearing, nose and throat irritation
Sneezing
Excess salivation
General excitement or restlessness
High-level (20%, >30 ppm) acute exposure
In addition to the symptoms seen with low-level exposure, high-level exposure may
result in the following:
Dyspnea: Upper airway swelling and obstruction may occur
Violent cough
Nausea and vomiting (with the smell of chlorine in emesis)
Lightheadedness
Headache
Chest pain or retrosternal burning
Muscle weakness
Abdominal discomfort

Dermatitis (with liquid exposure): Corneal burns and ulcerations may occur from
splash exposure to high-concentration chlorine products
Esophageal perforation

Chronic exposure
Manifestations of chronic exposure include the following:
Acne (chloracne)
Chest pain
Cough
Sore throat
Hemoptysis

Findings on physical examination may include the following:

Tachypnea
Cyanosis (most prevalent during exertion)
Tachycardia
Wheezing
Intercostal retractions
Decreased breath sounds
Rales (pulmonary edema)
Nasal flaring
Aphonia, stridor, or laryngeal edema
Ulceration or hemorrhage of the respiratory tract
Rhinorrhea
Lacrimation, salivation, and blepharospasm
Chloracne or tooth enamel corrosion (with chronic exposure)
Redness, erythema, and chemical burns to the skin from dose-dependent
exposure to liquid
Diagnosis
Studies in patients with significant exposure to chlorine gas may include the
following:

Pulse oximetry
Serum electrolyte, blood urea nitrogen (BUN), and creatinine levels
Arterial blood gases
Chest radiography
Electrocardiogram (ECG)
CT scan of the chest
Ventilation-perfusion scan
Pulmonary function testing
Laryngoscopy or bronchoscopy

Abnormalities include hypoxia (from bronchospasm or pulmonary edema) and

metabolic acidosis. The metabolic acidosis may be hyperchloremic (non-anion gap).
Chest radiograph findings are frequently normal initially but later may show
nonspecific abnormalities, pulmonary edema, pneumonitis, mediastinal free air,
myocardial depression or signs of ARDS.
Management
The most important aspect of treating patients exposed to chlorine gas is the
provision of good supportive care, as follows:
Supplemental oxygen (humidified if possible) as necessary
Fluid restriction and diuretics for impending pulmonary edema
PEEP in patients with noncardiogenic pulmonary edema
Beta2 agonists and other bronchodilators as necessary for bronchospasm
Nebulized lidocaine for analgesia and reduction of cough
Consider nebulized sodium bicarbonate
Consider inhaled or parenteral corticosteroids
Copious saline irrigation for skin or eye exposures
Consider admission and observation for the following patients, even if they are
initially asymptomatic, as they are at increased risk of progression to respiratory
failure:
Patients exposed to large concentrations in an enclosed environment
Patients with underlying respiratory or cardiovascular disease
Children