Via Research Recognition Day Program VCOM-Carolinas 2025

Case Reports

Chlorine-Induced Chemical Pneumonitis from Pool Shock that Progressed to Acute Respiratory Distress Syndrome (ARDS)

Erik Benson, OMS-III, Dr. Lynn Campbell, DO, FACOEP, FACEP Edward Via College of Osteopathic Medicine - Carolinas Spartanburg, SC

Introduction

Figures & Tables

Discussion

References • The high solubility of calcium hypochlorite causes a gradient of injury with a predominance for the large airways. • The presentation of these cases is largely dependent on the potency of the exposure. • Supportive treatment remains mainstay of care. • Glucocorticoids have shown promise in animal studies & showed improved this patient but remain controversial. • This patient was a good candidate for BiPAP and intubation was avoided. Conclusions • Supplemental oxygen, nebulized bronchodilators, steroids, followed by BiPAP, can be effective in managing chlorine induced ARDS without resorting to intubation. • Patient improvement with noninvasive positive pressure ventilation supported cardiac output and decreased risks associated with intubation. • Patient improvement with steroids supports conclusions drawn from numerous studies in animals. • Greater exploration of efficacy of steroids in chemical induced ARDS is warranted. 1. Agency for Toxic Substances and Disease Registry. ATSDR MMG for Calcium Hypochlorite and Sodium Hypochlorite. 2. Matos AM, De Oliveira RR, Lippi MM, Takatani RR, Filho WDO. Use of noninvasive ventilation in severe acute respiratory distress syndrome due to accidental chlorine inhalation: a case report. Brazilian Journal of Intensive Care. 2017;29(1):105-110. doi:10.5935/0103-507X.20170015 3. White CW, Martin JG. Chlorine gas inhalation: Human clinical evidence of toxicity and experience in animal models. Proc Am Thorac Soc. 2010;7(4):257-263. doi:10.1513/pats.201001-008SM 4. Wang J, Zhang L, Walther SM. Administration of Aerosolized Terbutaline and Budesonide Reduces Chlorine Gas-Induced Acute Lung Injury. Journal of Trauma - Injury, Infection and Critical Care. 2004;56(4):850-862. doi:10.1097/01.TA.0000078689.45384.8B 5. Demnati R, Martin JG, Plaa G, Malo JL. Effects of Dexamethasone on Functional and Pathological Changes in Rat Bronchi Caused by High Acute Exposure to Chlorine Effects of Dexamethasone on Functional and Pathological Changes in Rat Bronchi Caused by High Acute Exposure To. Vol 45.; 1998. https://academic.oup.com/toxsci/article abstract/45/2/242/1653902

Figures: Chest radiographs obtained on the initial ED presentation & repeat visit 12 hours later.

• Calcium Hypochlorite Ca(ClO) 2 is a crystalline solid which is a component of many domestic and commercial cleaning products. • Exposure can be by skin contact, ingestion or inhalation. When aerosolized patients can present with a variety of symptoms such as ocular and mucosa irritation, dyspnea, tachypnea, cough and often hypoxia. • Management is supportive with supplemental oxygen, bronchodilators and steroids in severe cases. • Exposures can lead to acute respiratory distress syndrome (ARDS) which is often classified by its severity as seen in Table 1. • Infrequent cases and limited research constrain treatment guidelines. Patient History: 20-year-old male, Non-smoker with no significant medical history presents to emergency department (ED) with shortness of breath & chest pain after he accidently inhaled pool shock chemicals while treating a swimming pool. ED Course: Vitals signs were 99/67 mmHg, 61 beats per minute (bpm), 22 breaths per minute (RR), pulse ox 94% on room air (RA). Lung auscultation was clear. Electrocardiogram showed normal sinus rhythm & chest radiograph (CXR) showed coarse infiltrates without consolidation. Patient was treated with supplemental oxygen, nebulized ipratropium/albuterol breathing treatments & 4 hours of observation per poison control recommendations prior to discharge. 2 nd ED Visit: He returned 12 hours after being discharged for worsening symptoms along with nausea & vomiting. Vital signs: 99/54 mmHg, 108 bpm, RR 18 , 86% RA. Lung auscultation remained clear despite repeat CXR showing diffuse infiltrates & bilateral alveolar opacities, found to be consistent with chemical pneumonitis. Further Treatment: Supplemental O 2 , nebulized ipratropium/albuterol and IV methylprednisolone → Admission Inpatient Course: Pt developed acute respiratory distress syndrome (ARDS) and required bilevel positive airway pressure (BiPAP) for 2 days prior to being weaned off oxygen. He was then discharged home with inhaled albuterol, budesonide, and oral methylprednisolone. Case Presentation

Figure 2. CXR on Day 2

Figure 1. CXR on Day 1

Table 1. ARDS Classification based off of partial pressure of oxygen (PaO2) ratio to fraction of inspired oxygen (FiO2)

ARDS Severity

PaO 2 :FiO 2 500 200-300 200-100 ≤ 100

Normal

Mild

Moderate

Severe

Table 2. Patient’s Arterial Blood Gas Results

PaO 2 :FiO 2 Ratio

Time pH pO 2

SpO 2

FiO 2

Flow Rate

Day 1 14:06 7.38 73 mmHg 95% - 347.62 Room Air Day 2 02:15 7.41 52 mmHg 87% 28% 185.71 2 Day 2 20:42 7.41 62 mmHg 92% 36% 172.22 4 Day 3 04:50 7.39 129 mmHg 99% 45% 286.67 BiPAP a BiPAP Settings: 8 Brmeainths , 8 cmH 2 O Inspiratory Positive Airway Pressure, and 6 cmH 2 O Expiratory Positive Airway Pressure

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