Acute chemical pulmonary edema with inhaled nitrogen dioxide intoxication

Abstract

Nitrogen dioxide is released by the interaction of some metals with nitric acid. Inhalation intoxication with nitrogen dioxide leads to chemical pulmonary edema. This study presents the case of a patient who had acute inhalation exposure to an unidentified brown gaseous substance (presumably nitrogen dioxide) when he etched a metal product with nitric acid. Twenty-four hours after contact with the gas, he manifested signs of intoxication, such as chest pain, tachypnea, and decreased saturation. Laboratory tests revealed hemoconcentration, hyperfermentemia, and arterial hypoxemia. The X-ray image of the entire lung surface revealed a sharp increase and deformation of the pulmonary pattern due to the vascular component. The diagnosis was T65, i.e., toxic effect of other and unspecified substances. With treatment, the patient’s condition improved. On day 4 after therapeutic exposure, with decreased oxygen fraction in the inhaled gas mixture to 0.3, the saturation increased to 98%, and tachypnea disappeared. On day 6, with ongoing treatment (oxygen therapy, use of antioxidants, antihypoxants, anti-inflammatory, and antibacterial drugs), the inflammatory reaction stopped, the rheological properties of the blood improved, and the gas composition of arterial blood normalized, i.e., the oxygenation index was 436, which indicated the disappearance of arterial blood oxygenation disorders. During the radiological examination, the normal radiological picture of the lungs was determined. Thus, on day 6 after the start of therapy, signs of intoxication were completely stopped. Specific changes in the lungs during radiation research techniques, hemoconcentration, inflammation, and hypoxemia during laboratory blood tests should be considered prognostic signs of chemical pulmonary edema. As a pathogenetic therapy, treatment must be supplemented with drugs that stop the cascade of free radical oxidation reactions (acetylcysteine and sodium thiosulfate). Individuals exposed to nitrogen dioxide should be considered a high-risk group for lung damage and hospitalized for dynamic observation for at least 2 days. Taking into account the genotoxic effects of nitrogen dioxide, affected patients should be classified as at risk of developing neoplasms and undergo further dynamic monitoring.

Keywords

nitric acid / acetylcysteine / inflammation / nitrogen dioxide / nitrogen dioxide intoxication / inhalation intoxication / free radical oxidation / chemical pulmonary edema / aerogematic barrier

References

[1] Tiunov LA, Golovko NYa, Galkin BN, Barinov VA. Biokhimicheskie mekhanizmy toksichnosti oksidov azota. Uspekhi sovremennoi biologii. 1991;111(5):738–750. (In Russ.).

[2] Тиунов Л.А., Головко Н.Я., Галкин Б.Н., Баринов В.А. Биохимические механизмы токсичности оксидов азота // Успехи современной биологии. 1991. Т. 111, № 5. С. 738–750.

[3] Basharin VA, Chepur SV, Tolkach PG, et al. Toksikologiya produktov goreniya polimernykh materialov: uchebnoe posobie. Saint Petersburg: Levsha; 2022. 104 p. (In Russ.).

[4] Башарин В.А., Чепур С.В., Толкач П.Г., и др. Токсикология продуктов горения полимерных материалов: учебное пособие. Санкт-Петербург: Левша, 2022. 104 с.

[5] Korshunov AV, Kovaleva SV, Gladyshev VP. Vliyanie kontsentratsii azotnoi kisloty na sostav produktov ee vosstanovleniya pri vzaimodeistvii s med’yu. Bulletin of the Tomsk Polytechnic University. 2004;307(3):86–89. (In Russ.).

[6] Коршунов А.В., Ковалёва С.В., Гладышев В.П. Влияние концентрации азотной кислоты на состав продуктов ее восстановления при взаимодействии с медью // Известия Томского политехнического университета. 2004. Т. 307, № 3. С. 86–89.

[7] Gembitskii EV, Bogdanov NA, Safronov VA. Ostrye i khronicheskie otravleniya azotnoi kislotoi i okislami azota. Leningrad: Meditsina, 1974. 159 p. (In Russ.).

[8] Гембицкий Е.В., Богданов Н.А., Сафронов В.А. Острые и хронические отравления азотной кислотой и окислами азота. Ленинград: Медицина, 1974. 159 с.

[9] Basharin VA, Chepur SV, Tolkach PG, et al. Toksikologiya pul’monotoksikantov: uchebnoe posobie. Saint Petersburg: Levsha; 2021. 87 p. (In Russ.).

[10] Башарин В.А., Чепур С.В., Толкач П.Г., и др. Токсикология пульмонотоксикантов: учебное пособие. Санкт-Петербург: Левша, 2021. 87 с.

[11] Basharin VA, Chepur SV, Shchegolev AV, et al. The role and place of respiratory support in the treatment regimens for acute pulmonary edema caused by inhalation of toxic substances. Russian Military Medical journal. 2019;340(11):26–32. (In Russ.). DOI: 10.17816/RMMJ81664

[12] Башарин В.А., Чепур С.В., Щёголев А.В., и др. Роль и место респираторной поддержки в схемах терапии острого лёгочного отека, вызванного ингаляционным воздействием токсичных веществ // Военно-медицинский журнал. 2019. Т. 340, № 11. С. 26–32. DOI: 10.17816/RMMJ81664

[13] GNIII VM MO RF. Metodicheskie rekomendatsii po terapii dykhatel’noi nedostatochnosti u porazhennykh otravlyayushchimi i vysokotoksichnymi veshchestvami na ehtapakh meditsinskoi ehvakuatsii. Saint Petersburg; 2016. 55 p. (In Russ.).

[14] ГНИИИ ВМ МО РФ. Методические рекомендации по терапии дыхательной недостаточности у поражённых отравляющими и высокотоксичными веществами на этапах медицинской эвакуации. Санкт-Петербург, 2016. 55 с.

[15] Meulenbelt J, Sangster B. Acute nitrous oxide intoxication: clinical symptoms, pathophysiology and treatment. Neth J Med. 1990;37 (3-4):132–138.

[16] Meulenbelt J., Sangster B. Acute nitrous oxide intoxication: clinical symptoms, pathophysiology and treatment // Neth J Med. 1990. Vol. 37, Nо. 3-4. P. 132–138.

[17] Sherbasov KA, Basharin VA, Marysheva VV, et al. Experimental estimation of efficiency of antihypoxants at toxic pulmonary edema caused by nitrogen oxide (IV). Reviews on Clinical Pharmacology and Drug Therapy. 2016;14(2):65–68. (In Russ.). DOI: 10.17816/RCF14265-68

[18] Шербашов К.А., Башарин В.А., Марышева В.В., и др. Экспериментальная оценка эффективности антигипоксантов при токсическом отеке легких, вызванном оксидом азота(IV) // Обзоры по клинической фармакологии и лекарственной терапии. 2016. Т. 14, № 2. С. 65–68. DOI: 10.17816/RCF14265-68

[19] Lindvall T. Health effects of nitrogen dioxide and oxidants. Scand J Work Environ Health. 1985;11(S3):10–28.

[20] Lindvall T. Health effects of nitrogen dioxide and oxidants // Scand J Work Environ Health. 1985. Vol. 11, Nо. S3. P. 10–28.

[21] Yaroshetsky AI, Gritsan AI, Avdeev SN, et al. Diagnostics and intensive therapy of Acute Respiratory Distress Syndrome (Clinical guidelines of the Federation of Anesthesiologists and Reanimatologists of Russia). Russian Journal of Anesthesiology and Reanimatology. 2020;(2):539. (In Russ.). DOI: 10.17116/anaesthesiology20200215

[22] Ярошецкий А.И., Грицан А.И., Авдеев С.Н., и др. Диагностика и интенсивная терапия острого респираторного дистресс-синдрома (клинические рекомендации Общероссийской общественной организации «Федерация анестезиологов и реаниматологов») // Анестезиология и реаниматология. 2020. № 2. С. 5–39. DOI: 10.17116/anaesthesiology20200215

[23] Moroz VV, Golubev AM, Kuzovlev AN. Pulmonary edema: Classification, mechanisms of development, diagnosis. General Reanimatology. 2009;(1):83–88. (In Russ.).

[24] Мороз В.В., Голубев А.М., Кузовлев А.Н. Отек легких: классификация, механизмы развития, диагностика // Общая реаниматология. 2009. № 1. С. 83–88.

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