AN UNUSUAL CAUSE OF AN UNUSUAL CAUSE OF ACUTE LUNG INJURYACUTE LUNG INJURY

C.Vignesh KumarC.Vignesh KumarToxicologyToxicology

CASE HISTORYCASE HISTORY• 42 year old female, a k/c/o Carcinoma 42 year old female, a k/c/o Carcinoma

cervix on radiotherapycervix on radiotherapy• Exposure to fire inside radiotherapy Exposure to fire inside radiotherapy

unit for about an hourunit for about an hour• Presented with acute onset Presented with acute onset

breathlessness since the exposure with breathlessness since the exposure with productive coughproductive cough

• No loss of consciousness, Seizures, Skin No loss of consciousness, Seizures, Skin burnsburns

CASE HISTORYCASE HISTORY• Diagnosed to have Carcinoma Cervix Diagnosed to have Carcinoma Cervix

and on EBRT for the past 5 monthsand on EBRT for the past 5 months• Admitted in IOG for Intracavitary RTAdmitted in IOG for Intracavitary RT• No other comorbid illnessNo other comorbid illness• Married, Divorcee, NulliparaMarried, Divorcee, Nullipara• Family history: Not contributoryFamily history: Not contributory

EXAMINATIONEXAMINATION• Conscious, Oriented, AfebileConscious, Oriented, Afebile• Dyspneic, TachypneicDyspneic, Tachypneic• Oral cavity: Saliva with soot particlesOral cavity: Saliva with soot particles• No skin burnsNo skin burns• No CyanosisNo Cyanosis• Pulse : 110/minPulse : 110/min• BP : 110/70BP : 110/70

EXAMINATIONEXAMINATION• CVS : NADCVS : NAD• RS : B/L extensive rhonchi & ralesRS : B/L extensive rhonchi & rales• P/A : NADP/A : NAD• CNS : NFNDCNS : NFND

SPUTUMSPUTUM

INVESTIGATIONSINVESTIGATIONS• O2 Saturation: 78% in room airO2 Saturation: 78% in room air 92% with oxygen92% with oxygen• CBC & Peripheral Smear: Microcytic CBC & Peripheral Smear: Microcytic

hypochromic Anaemiahypochromic Anaemia• RFT : WNLRFT : WNL• LFT : WNLLFT : WNL• ECG : Sinus TachycardiaECG : Sinus Tachycardia

Arterial Blood GasArterial Blood Gas• pH : 7.439pH : 7.439• pO2 : 55.5 mm HgpO2 : 55.5 mm Hg• pCO2 : 41.7 mm HgpCO2 : 41.7 mm Hg• HCO3 : 27.6HCO3 : 27.6• BE : 3.5BE : 3.5• O2 Saturation : 89.9%O2 Saturation : 89.9%

CHEST X-RAYCHEST X-RAY

TREATMENTTREATMENT• Bed RestBed Rest• Oxygen by MaskOxygen by Mask• Intravenous AntibioticsIntravenous Antibiotics• Intravenous SteroidsIntravenous Steroids• BronchodilatorsBronchodilators

CT CHESTCT CHEST

INVESTIGATIONSINVESTIGATIONS• Sputum C/S : Klebsiella (ESBL)Sputum C/S : Klebsiella (ESBL) Sensitive to Cephalosporins, Sensitive to Cephalosporins,

AmikacinAmikacin

• USG Abdomen : Normal studyUSG Abdomen : Normal study

FOLLOW UP X-RAYS (DAY 4)FOLLOW UP X-RAYS (DAY 4)

FOLLOW UP X-RAYS (DAY 7)FOLLOW UP X-RAYS (DAY 7)

FOLLOW UP X-RAYS (DAY FOLLOW UP X-RAYS (DAY 11)11)

COURSE OF ILLNESSCOURSE OF ILLNESS• Clinical ImprovementClinical Improvement• Radiological improvementRadiological improvement• Steroids taperedSteroids tapered• Discharged after 13 daysDischarged after 13 days

CONSTITUENTS OF SMOKECONSTITUENTS OF SMOKE• Heated AirHeated Air• Suspended solids, LiquidsSuspended solids, Liquids• GasesGases• FumesFumes• Aerosols , VapoursAerosols , Vapours

COMBUSTION PRODUCTSCOMBUSTION PRODUCTSWood,CottonWood,Cotton CO,Acrolein,Methane, CO,Acrolein,Methane,

Formaldehyde, Formaldehyde, Acetaldehyde,Acetaldehyde,

PetroleumPetroleum CO,Acrolein, Acetic acid, CO,Acrolein, Acetic acid, Formic acidFormic acid

PlasticsPlastics CN,HCl,NH3,Phosgene,NitroCN,HCl,NH3,Phosgene,Nitrogen gen oxides,Aldehyde,Chlorineoxides,Aldehyde,Chlorine

WoolWool CO, CN, Phosgene, ChlorineCO, CN, Phosgene, ChlorineRubberRubber H2S, SO2H2S, SO2

COMBUSTION PRODUCTSCOMBUSTION PRODUCTS• Simple asphyxiants- CO2Simple asphyxiants- CO2• Chemical asphyxiants- CO,HCN,H2S, Chemical asphyxiants- CO,HCN,H2S, Oxides of Oxides of

NitrogenNitrogen• Irritants Irritants

IRRITANTSIRRITANTS• High water solubility -Acrolein, SO2,High water solubility -Acrolein, SO2, NH3, HCl NH3, HCl • Intermediate solubility -Chlorine, Intermediate solubility -Chlorine, IsocyanateIsocyanate• Low water solubility -Oxides of Low water solubility -Oxides of

NitrogenNitrogen PhosgenePhosgene

SOOTSOOT• CarbonCarbon• Adsorbed acids, Aldehydes,Adsorbed acids, Aldehydes,• Sulphur dioxideSulphur dioxide• Hydrogen chlorideHydrogen chloride• ChlorineChlorine• PhosgenePhosgene

FACTORS AFFECTING FACTORS AFFECTING RESPIRATORY TRACT INJURYRESPIRATORY TRACT INJURY

• Water solubilityWater solubility• ConcentrationConcentration• Duration of ExposureDuration of Exposure• Particle SizeParticle Size• Respiratory RateRespiratory Rate• Absence of protective reflexesAbsence of protective reflexes• Preexisting diseasePreexisting disease

PATHOGENESISPATHOGENESIS• Reactive Oxygen speciesReactive Oxygen species• Inflammatory MediatorsInflammatory Mediators• Increased Microvascular PermeabilityIncreased Microvascular Permeability• Denaturation of Proteins, Nucleic acidDenaturation of Proteins, Nucleic acid• Deactivation of SurfactantDeactivation of Surfactant• Impaired mucociliary clearanceImpaired mucociliary clearance• Impaired phagocytosisImpaired phagocytosis

CLINICAL FEATURESCLINICAL FEATURES• Voice changeVoice change• StridorStridor• RhonchiRhonchi• RalesRales• TachypneaTachypnea• TachycardiaTachycardia• CNS manifestations (R/O Alcoholism, Head CNS manifestations (R/O Alcoholism, Head

injury)injury)

INVESTIGATIONSINVESTIGATIONS• ABGABG• Carboxyhemoglobin levelsCarboxyhemoglobin levels• Methemoglobin levelsMethemoglobin levels• Chest X rayChest X ray• Pulmonary Function TestsPulmonary Function Tests• Xenon Ventilation StudiesXenon Ventilation Studies

MANAGEMENTMANAGEMENT• Airway managementAirway management• Beta 2 agonistsBeta 2 agonists• CorticosteroidsCorticosteroids• Mechanical VentilationMechanical Ventilation• Chest PhysiotherapyChest Physiotherapy• Therapeutic BronchoscopyTherapeutic Bronchoscopy

MANAGEMENTMANAGEMENT• Hyperbaric OxygenHyperbaric Oxygen

• Cyanide AntidoteCyanide Antidote

• Methylene BlueMethylene Blue

THANK YOUTHANK YOU