Treatment of Chemical Inhalation Burn from Chlorine Bleach
Immediately remove the patient from the chlorine exposure source, ensure fresh air, administer 100% oxygen via high-flow mask or endotracheal tube without delay, and activate emergency medical services for any respiratory symptoms. 1
Immediate First Aid and Decontamination
Remove from exposure and begin oxygen therapy immediately:
- Move the patient to fresh air and away from the chlorine source to prevent continued exposure 2, 1
- Remove all contaminated clothing, shoes, and jewelry to prevent trapped chemicals from causing further injury 2
- If there is any skin contact with liquid bleach, irrigate the affected area with copious amounts of running water for at least 15 minutes 2
- Do not delay oxygen therapy - administer 100% oxygen via high-flow mask immediately, even before diagnostic confirmation 1
Oxygen Therapy (Primary Treatment)
High-flow oxygen is the cornerstone of treatment for chlorine inhalation injury:
- Administer 100% normobaric oxygen via high-flow mask or endotracheal tube as front-line treatment 1
- Continue oxygen therapy for 6-12 hours until symptoms resolve and any carboxyhemoglobin levels normalize (if co-exposure to carbon monoxide from combustion is suspected) 1
- If mechanical ventilation is required due to respiratory failure, provide 100% FiO2 1
Rationale: Chlorine gas is a potent pulmonary irritant causing acute damage to both upper and lower respiratory tracts, potentially leading to acute respiratory distress syndrome (ARDS) 3, 4, 5. High-flow oxygen helps maintain adequate oxygenation and may reduce inflammatory injury.
Emergency Medical Evaluation
Activate EMS immediately if any of the following are present:
- Difficulty breathing, shortness of breath, or respiratory distress 2, 1
- Hemoptysis (coughing up blood) 3
- Facial burns or singed nasal hairs suggesting inhalation injury 6
- Soot around nose or mouth 6
- Stridor or hoarseness indicating upper airway involvement 6
Hospital-Level Management
For patients requiring hospitalization:
- Maintain mechanical ventilation if ARDS develops, with lung-protective strategies 3, 5
- Monitor for pneumomediastinum, a rare but serious complication requiring high index of suspicion, especially in younger patients 7
- Be aware that chlorine inhalation can cause persistent necrotic shedding of respiratory mucosa and potential airway stenosis requiring tracheostomy or stent placement in severe cases 8
- Consider extracorporeal membrane oxygenation (ECMO) for refractory hypoxemia in severe cases, though this carries significant risk 5
Monitoring for Complications
Key complications to anticipate:
- ARDS can develop rapidly after chlorine exposure and may require prolonged mechanical ventilation (typically improving by day 6 in survivors) 3
- Reactive airways dysfunction syndrome (RADS) may occur as a subacute complication 4
- Acute non-cardiogenic pulmonary edema 4
- Late airway stenosis (developing weeks to months post-injury) requiring surgical intervention 8
Common Pitfalls to Avoid
- Do not delay oxygen therapy while waiting for diagnostic tests or transfer 1
- Do not underestimate household chlorine exposures - mixing bleach with acids (such as toilet bowl cleaners) is a common cause of dangerous chlorine gas generation 4
- Do not miss pneumomediastinum on chest imaging in mechanically ventilated patients, as this significantly worsens prognosis 7
- The severity of initial symptoms may not predict long-term complications; even patients who initially improve may develop delayed airway stenosis requiring follow-up 8
Special Considerations
Pediatric patients:
- Have higher mortality risk with inhalation injury, particularly those <48 months of age 5
- Require aggressive early intervention as hemodynamic and pulmonary instability can progress rapidly 5
- Should receive 100% oxygen starting at the first aid stage 1
Prognosis factors: